Centralisation of Abdominal Aortic Aneurysm Repair - We Can No Longer Ignore the Benefits!

Wanhainen, Anders; Haulon, Stéphan; Kolh, Philippe

doi:10.1016/j.ejvs.2020.08.008

Cited by 11 publications

(7 citation statements)

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“…The volume-outcome relationship after AAA surgery is well documented and a strong argument in favor of centralization of aortic care to high-volume institutions. 14 However, it still attracts some debate, especially after minimally invasive endovascular interventions for which standard quality metrics, as in-hospital mortality, might not represent the optimal performance indicators. Indeed, improved outcomes after EVAR in the modern endovascular era should be evaluated in the context of long-term repair durability, 15 and benefits of endovascular procedures (even more so for complex repairs as with use of IBD) when performed in high-volume institutions may extend well beyond the immediate postoperative period.…”

Section: Discussionmentioning

confidence: 99%

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry

et al. 2021

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Objective To evaluate early and follow-up outcomes following bilateral use of iliac branch devices (IBD) for aortoiliac endografting and assess the impact of center volume. We used data from the pELVIS international multicentric registry. Methods For the purpose of this study, only those patients receiving concomitant bilateral IBD implantation were analyzed. To assess the impact that procedural volume of bilateral IBD implantation could have on early and follow-up outcomes, participating institutions were classified as Site(s) A if they had performed >10 and/or >20% concomitant bilateral IBD procedure, otherwise they were classified as Site(s) B. Endpoints of the analysis included early (ie, 30-day) mortality and morbidity, as well as all-cause and aneurysm-related mortality during follow-up. Additional endpoints that were evaluated included IBD-related reinterventions, IBD occlusion or stenosis requiring reintervention (ie, loss of primary patency), and IBD-related type I endoleak. Results Overall, 96 patients received bilateral IBD implantation (out of 910 procedures collected in the whole pELVIS cohort), of whom 65 were treated at Site A (ie, Group A) and 31 were treated at Site(s) B (ie, Group B). In total, only 1 death occurred within 30 days from bilateral IBD implantation, and 9 patients experienced at least 1 major complication without any significant difference between subjects in Group A versus those in Group B (10.8% vs 6.5%, p=0.714). In the overall cohort, the 2-year freedom from IBD-related type I endoleaks and IBD primary patency were 96% and 92%, respectively; no significant differences were seen in those rates between Group A or Group B (95% vs 100%, p=0.335; 93% vs 88%, p=0.470). Freedom from any IBD-related reinterventions was 83% at 2 years, with similar rates between study groups (85% vs 83%, p=0.904). Conclusions Within the pELVIS registry, concomitant bilateral IBD implantation is a safe and feasible technique for management of aortoiliac aneurysms in patients with suitable anatomy. Despite increased technical complexity, effectiveness of the repair is satisfactory with low rates of IBD-related adverse events at mid-term follow-up. Procedural volume does not seem to affect technical or clinical outcomes after bilateral use of IBD, which remains a favorable treatment option in selected patients.

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Section: Discussionmentioning

confidence: 99%

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry

et al. 2021

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“…This of course comes as a surprise, as one of the main arguments supporting the centralization of H&N services is the need to improve all of patients' outcomes, including flap success rate. In other specialties, the association between volume and outcomes is very clear and has already led to reconfiguration of services (i.e., vascular surgery) (6).…”

Section: Discussionmentioning

confidence: 99%

“…This of course means that outcomes might improve up to a certain volume level, after which any further increase has a detrimental effect (5). On other occasions, achievement of acceptable outcomes might plateau after a certain case volume and remain unchanged thereof (6).…”

Section: Review Articlementioning

confidence: 99%

The impact of volume and surgical throughput on outcomes in head and neck reconstruction: a systematic review

Kyzas¹

2022

Front Oral Maxillofac Med

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Background: Microvascular free tissue transfer is the standard of care for head and neck reconstruction.It is suggested that the volume of cases/surgical throughput might be linked to better free flap outcomes, following the pattern of other surgical disciplines. However, the literature evidence is unclear.Methods: I performed a PRISMA-guided systematic review (PROSPERO CRD206975). Reports were identified using a search algorithm in MEDLINE/EMBASE. I have included articles in English, irrespective of the study design. I compared the free flap success rate between high-volume units (>50/year) and lowvolume units (<50/year). An attempt to record secondary outcomes (mortality, readmissions, complications, return to theatre) was also made. Eligible studies were assessed for quality using the GRADE method.Results: I identified 27 eligible studies. Distribution between high and low volume units was equal (12 vs. 11 studies). The remaining 4 studies were multicenter and revealed no difference between included units.Flap cases/year ranged from 8 to 280. Free flap success rate ranged from 89% to 100% (average 95%) with no differences between units. Very limited data were available on the secondary outcomes (mortality, readmissions, complications, return to theatre). The quality of the eligible studies was suboptimal, and the threat of selective reporting bias was present.Discussion: This systematic review revealed that the reported free flap success rate is similar between high and low volume units. Despite suboptimal study quality, this review calls for caution when outcomes are used as a justification for centralizing H&N services, as literature doesn't seem to support this as strongly is in other surgical disciplines.

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“…The volume-outcome relationship after AAA surgery is well documented, [15][16][17][18][19] although it remains a focus of ongoing controversy and active research. [20][21][22] Because repair of intact AAA is a prophylactic intervention, it is crucial to determine the optimal organization of services that delivers the safest care possible.…”

Section: Discussionmentioning

confidence: 99%

Association Between Hospital Volume and Failure to Rescue After Open or Endovascular Repair of Intact Abdominal Aortic Aneurysms in the VASCUNET and International Consortium of Vascular Registries

et al. 2021

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Objective: To investigate the association between hospital volume and failure to rescue (FtR), after open repair (OAR), and endovascular repair (EVAR) of intact abdominal aortic aneurysms (AAA) among centers participating in the VASCUNET and International Consortium of Vascular Registries. Summary of Background Data: FtR (ie, in-hospital death following major complications) is a composite end-point representing the inability to treat complications effectively and prevent death. Methods: Using data from 8 vascular registries, complication and mortality rates after intact AAA repair were examined (n = 60,273; EVAR-43,668; OAR-16,605). A restricted analysis using pooled data from 4 countries (Australia, Hungary, New Zealand, and USA) reporting data on all postoperative complications (bleeding, stroke, cardiac, respiratory, renal, colonic ischemia) was performed to identify risk-adjusted association between hospital volume and FtR. Results: The most frequently reported complications were cardiac (EVAR-3.0%, OAR-8.9%) and respiratory (EVAR-1.0%, OAR-5.7%). In adjusted analysis, 4.3% of EVARs and 18.5% of OARs had at least 1 complication. The overall FtR rate was 10.3% after EVAR and 15.7% after OAR. Subjects treated in the highest volume centers (Q4) had 46% and 80% lower odds of FtR after EVAR (OR = 0.54; 95% CI = 0.34–0.87; P = 0.04) and OAR (OR = 0.22; 95% CI = 0.11–0.44; P < 0.001) when compared to lowest volume centers (Q1), respectively. Colonic ischemia had the highest risk of FtR for both procedures (adjusted predicted risks, EVAR: 27%, 95% CI 14%–45%; OAR: 30%, 95% CI 17%–46%). Conclusions: In this multi-national dataset, FtR rate after intact AAA repair with EVAR and OAR is significantly associated with hospital volume. Hospitals in the top volume quartiles achieve the lowest mortality after a complication has occurred.

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Centralisation of Abdominal Aortic Aneurysm Repair - We Can No Longer Ignore the Benefits!

Cited by 11 publications

References 11 publications

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry

The impact of volume and surgical throughput on outcomes in head and neck reconstruction: a systematic review

Association Between Hospital Volume and Failure to Rescue After Open or Endovascular Repair of Intact Abdominal Aortic Aneurysms in the VASCUNET and International Consortium of Vascular Registries

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