The Association Between Hospital Volume and Failure-to-rescue for Open Repairs of Juxtarenal Aneurysms

BACKGROUND Nationwide variation in mortality by hospital volume exists after open repairs of complex abdominal aortic aneurysms (AAAs). This study assessed whether rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) better explain lower mortality rates among higher-volume hospitals. METHODS Using the 2004-2018 Vascular Quality Initiative, we identified all patients who underwent open repairs of elective or symptomatic abdominal aortic aneurysms, where the proximal clamp sites were at least above one renal. We divided patients into hospital quintiles by annual volume and compared risk-adjusted outcomes. Multivariable logistic regressions adjusted for patient characteristics, operative factors, and hospital volume to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue. RESULTS We identified 3566 patients who underwent open repairs of elective or symptomatic complex AAAs (median age 71 years, 29% female, 4.1% African American, 48% Medicare insurance). Unadjusted rates of 30-day postoperative mortality were 5.0%, overall complications were 44%, and failure-to-rescue were 10%. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with their specific rates of failure-to-rescue varying from 12% to 22%. On adjusted analyses, the risk-adjusted mortality rate was 2.5 times greater among lower-volume hospitals relative to higher-volume hospitals (7.4% vs 3.0%, P<0.01). While risk-adjusted complication rates were similar between these hospital groups (30% vs 27%, P=0.06), failure-to-rescue rates were 2.3 times greater among lower-volume hospitals relative to their higher-volume counterparts (6.3% vs 2.7%, P=0.02). CONCLUSIONS Higher-volume hospitals have lower mortality rates after open repairs of complex AAAs because they better "rescue" patients after postoperative complications. Both understanding the clinical mechanisms underlying this association and the regionalization of these surgeries may improve patient outcomes.