• Joshua T Geiger, Christopher T Aquina, Antoinette Esce, Peng Zhao, Roan Glocker, Fergal Fleming, James Iannuzzi, Michael Stoner, and Adam Doyle.
• Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
• J. Vasc. Surg. 2021 Jan 1; 73 (1): 108-116.e1.

ObjectiveVolume-outcome relationships in surgery have been well established. Studies have shown that high-volume surgeons provide improved outcomes in performing open abdominal aneurysm repairs. The hypothesis of this study was that high-volume surgeons provide superior short-term and midterm outcomes of elective open aortic operations compared with low-volume surgeons.MethodsWe evaluated patients undergoing elective open abdominal aortic aneurysm repair, aortofemoral bypass, and aortomesenteric bypass by board-certified vascular surgeons using the New York Statewide Planning and Research Cooperative System database from 2002 to 2014. The Contal and O'Quigley technique was used to estimate a cut point objectively and provided an estimate of significance. A division using average yearly volumes (averaged during 3 years) of seven or more cases and fewer than seven cases per year returned the highest Q statistic, and this grouping was used to classify high-volume and low-volume provider groups. Rates of complications during index hospitalization, length of stay, 30-day survival, 90-day survival, 1-year survival, and cause of death were analyzed using mixed effect models.ResultsIn 118 hospitals during the 13-year period, 266 board-certified vascular surgeons performed 244 aortomesenteric bypasses, 4202 aortofemoral bypasses, and 6126 abdominal aortic aneurysm repairs. High-volume surgeons' rates of complications during index hospitalization, 30-day survival, 90-day survival, and 1-year survival were superior to those of low-volume surgeons. The Contal and O'Quigley technique returned an estimate of seven operations per year for optimal survival during 1 year. This cutoff is associated with an adjusted 1-year hazard ratio of 0.687 (P = .003), a 2.69% difference in 1-year all-cause survival (P = .003), and a 1.76-day reduction in the mean length of stay at index hospitalization (P < .001). Higher volume surgeons showed a 25.0%, 43.4%, 42.4%, 40.6%, and 45.0% reduction in postoperative rates of acute renal failure (P < .001), hemorrhage (P < .001), pulmonary failure (P < .001), sepsis (P < .001), and venous thromboembolism (P < .001), respectively. Abdominal abscess, acute renal failure, hemorrhage, myocardial infarction, and sepsis were associated with increased cardiovascular cause-specific mortality after open aortic operations (P < .001).ConclusionsThese data demonstrate that high-volume surgeons performing elective open aortic operations provide reduced complications and improved short-term and midterm survival compared with low-volume surgeons. Clinical and postoperative variables that are associated with increased cardiovascular cause-specific mortality are also identified. These data provide further evidence that elective open abdominal vascular surgery should be centralized to high-volume surgeons.Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

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