Editor's Choice – Optimal Threshold for the Volume–Outcome Relationship After Open AAA Repair in the Endovascular Era: Analysis of the International Consortium of Vascular Registries

Salvatore T. Scali, Adam Beck, Art Sedrakyan, Jialin Mao, Christian Alexander Behrendt, Jonathan R. Boyle, Maarit Venermo, Rumi Faizer, Marc Schermerhorn, Barry Beiles, Zoltan Szeberin, Nikolaj Eldrup, Ian Thomson, Kevin Cassar, Martin Altreuther, Sebastian Debus, Amundeep Johal, Martin Bjorck, Jack L. Cronenwett, Kevin Mani

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


OBJECTIVE: As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice.

METHODS: This was an observational study of OARs performed in 11 countries (2010 - 2016) within the International Consortium of Vascular Registry database (n = 178 302). The primary endpoint was post-operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement.

RESULTS: In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n = 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n = 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% - 5.2%] vs. ≥ 13 procedures/year 3.1% [95% CI 2.8% - 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact + ruptured) decreased significantly (2010 - 2013 = 35.7; 2014 - 2016 = 29.8; p < .001). Only 23% of centres (n = 240/1 065) met the ≥ 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%).

CONCLUSION: An annual centre volume of 13 - 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes.

Original languageEnglish (US)
Pages (from-to)747-755
Number of pages9
JournalEuropean Journal of Vascular and Endovascular Surgery
Issue number5
Early online dateMar 12 2021
StatePublished - May 2021

Bibliographical note

Funding Information:
Data source for Germany was the RDC of the Federal Statistical Office and Statistical Offices of the Länder (Diagnosis Related Groups, Statistics), survey years 2010 – 2016, own calculations.

Publisher Copyright:
© 2021 European Society for Vascular Surgery


  • Open AAA repair
  • Threshold
  • Volume–Outcome
  • Outcome Assessment, Health Care/standards
  • Prospective Studies
  • Hospital Mortality
  • Hospitals, Low-Volume/organization & administration
  • Humans
  • Middle Aged
  • Male
  • Reference Values
  • Hospitals, High-Volume/standards
  • Benchmarking/standards
  • Aortic Aneurysm, Abdominal/mortality
  • Registries/statistics & numerical data
  • Internationality
  • Postoperative Complications/epidemiology
  • Aged, 80 and over
  • Female
  • Vascular Surgical Procedures/adverse effects
  • Aged

PubMed: MeSH publication types

  • Observational Study
  • Multicenter Study
  • Journal Article


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