P. Tripodi, G. Mestres and V. Riambau

Vascular Surgery Division

Cardiovascular Institute, Hospital Clínic of Barcelona

On Behalf of Catalan Vascular Group-Catalan Health Service

NONE

1.Background and Context

2.Objectives

3.Patients and Methods

4.Results

5.Summary

1.Background and Context

2.Objectives

3.Patients and Methods

4.Results

5.Summary

As surgeons performed higher annual volumes of elective open AAA repairs, significantly

lower mortality rates were demonstrated. Surgeons wishing to perform elective AAA

repairs should achieve a minimum case volume of 13 repairs per annum.

J Vasc Surg 2007

Higher annual operation volumes are associated with significantly lower

mortality in both elective and ruptured AAA repair. This suggests that

AAA surgery should be performed only at higher-volume centres.

Elective Ruptured

15 rAAAs per annum45 eAAAs per annum

• AAA repair should only be performed in hospitals

performing at least 50 elective cases per annum,

whether by open repair or EVAR. Level 2c,

Recommendation B.

EJVES 2011

EJVES 2019

• Is a political decision

• Is a health organization

model

• Does it represent a real

health value?

• Is it the right model to go

and expand?

AAA repair should only be performed in hospitals

performing at least 30 elective cases per

annum, whether by open repair or EVAR

Centralization was completed on July 2015

7 543 825 inhabitants and a density of 234 inhabitants/km²

22 Hospitals withVS. capabilities

Low complexity

10 Hub for Level IIIHigh Complexity: AAA, Carotids , endo DTAA

5 Hub for Level IV

Very High Complexity:

Ao dissection, Open DTAA, ATAA, Cardiac S.

requirements

1.Background and Context

2.Objectives

3.Patients and Methods

4.Results

5.Summary

• To analyze the impact of centralization

– in-hospital mortality

– length of stay (LoS) in elective and urgent repair of AAA

• Secondary endpoints include

– In-hospital Mortality and LoS in high volume centers

1.Background and Context

2.Objectives

3.Patients and Methods

4.Results

5.Summary

Dec 2017Jan 2008

Jul 20152nd Doc 09/215

7.5 year period

P1: Pre-centralization

2.5 year period

P2: Post-centralization

Jul 20141st Doc 09/2014

Feb 2013Starting meeting

Jun 2015implemented

1.Background and Context

2.Objectives

3.Patients and Methods

4.Results

5.Summary

*http://catsalut.gencat.cat/ca/proveidors-professionals/registres-catalegs/registres/cmbd/

Hospital Discharge

Minimum Basic Data Set (HDMBD)*

2008-2017

ICD9-CM

441.4 (iAAA) 441.3 (rAAA)

38.44, 39.25 (OR) 39.71 (EVAR)

4298 registries

-62 (Cleaning unclear records)

42363802 iAAA and 434 rAAA

P1

3046P2

1190

Co-morbidities All (N=4236) Before Centralization

(N=3046)

After Centralization

(N=1190)

P

Value

N (% ) N (% ) N (% )

Age (mean ± SD years) 72.95±8.27 72.71±8.27 73.45±8.58 .010

Sex (male) 4077 (96.2%) 2939 (96.5%) 1138 (95.6%) .187

Smoking history 1677 (39.6%) 1204 (39.5%) 473 (39.7%) .895

Alcoholism or other drugs addiction 145 (3.4%) 93 (3.1%) 52 (4.4%) .034

Hypertension 2396 (56.6%) 1725 (56.6%) 672 (56.5%) .924

Dyslipemia 2046 (48.3%) 1382 (45.4%) 665 (55.9%) <.001

Diabetes Mellitus 726 (17.1%) 502 (16.5%) 224 (18.8%) .069

Coronary disease 903 (21.3%) 647 (21.2%) 256 (21.5%) .846

Chronic renal failure 524 (12.4%) 338 (11.1%) 186 (15.6%) <.001

Hemodialysis 115 (2.7%) 84 (2.8%) 31 (2.6%) .783

Chronic pulmonary disease 1017 (24.0%) 739 (24.3%) 278 (23.4%) .538

Carotid stenosis 136 (3.2%) 94 (3.1%) 42 (3.5%) .462

Other aneurysms 463 (10.9%) 304 (10.0%) 159 (13.4%) .002

Type of AAA Before centralization After centralization P

All AAA (N=4236) 274 (9.0%) 68 (5.7%) <.001

iAAA (N=3802) 113 (4.1%) 20 (1.9%) .001

rAAA (N=434) 161 (52.8%) 48 (37.2%) .003

Treatment Type of AAA Before centralization After centralizatio p

EVAR 75 (4.1%) 37 (4.1%) .968

iAAA 33 (1.9%) 12 (1.5%) .412

rAAA 42 (38.9%) 25 (28.7%) .138

OR 199 (16.3%) 31 (11.0%) .026

iAAA 80 (7.8%) 8 (3.3%) .014

rAAA 119 (60.4%) 23 (54.8%) .499

Before centralization (SD) After centralization(SD) P

EVAR 8.14 (10.70) 6.89 (10.68) .004

iAAA 7.45 (8.60) 5.84 (7.65) < .001

rAAA 19.06 (25.28) 16.83 (23.15) .526

OR 14.08 (17.76) 13.69 (24.60) .759

iAAA 13.05 (13.28) 12.78 (20.24) .799

rAAA 19.43 (31.71) 18.86 (41.52) .920

Mortality Length of stay

Before

centralization

After

centralization

P Before centralization

(SD)

After centralization

(SD)

P

All AAA

(N=3933)

241 (8.7%) 67 (5.7%) < .001 10.41 (13.91) 8.53 (15.51) < .001

iAAA

(N=3523)

93 (3.8%) 20 (1.9%) .004 9.42 (10.87) 7.42 (12.12) < .001

rAAA

(N=410)

148 (52.3%) 47 (37.0%) .004 19.13 (27.77) 17.72 (30.4) .643

1.Background and Context

2.Objectives

3.Patients and Methods

4.Results

5.Summary

• Centralization significantly improves in-hospital mortality after repair of iAAA and rAAA

• Centralization has a significant impact on in-hospital mortality after elective OR

• For elective cases, LoS significantly improves after centralization, especially for

elective EVAR cases

• For high-volume centers, Mortality and LoS significantly improve after centralization

• These results support the hypothesis that AAA procedures have better outcomes after

centralization in high-volume centers.

P. Tripodi, G. Mestres and V. Riambau

Vascular Surgery Division

Cardiovascular Institute, Hospital Clínic of Barcelona

On Behalf of Catalan Vascular Group-Catalan Health Service