title: Regionalization of Emergent Vascular Surgery for Patients With Ruptured AAA Improves Outcomes.
abstract: Safe and efficient endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) requires advanced infrastructure and surgical expertise not available at all US hospitals. The objective was to assess the impact of regionalizing r-AAA care to centers equipped for both open surgical repair (r-OSR) and EVAR (r-EVAR) by vascular surgeons.
  
  
  
  A retrospective review of all patients with r-AAA undergoing open or endovascular repair in a 12-hospital region. Patient demographics, transfer status, type of repair, and intraoperative variables were recorded. Outcomes included perioperative morbidity and mortality.
  
  
  
  Four hundred fifty-one patients with r-AAA were treated from 2002 to 2015. Three hundred twenty-one patients (71%) presented initially to community hospitals (CHs) and 130 (29%) presented to the tertiary medical center (MC). Of the 321 patients presenting to CH, 133 (41%) were treated locally (131 OSR; 2 EVAR) and 188 (59%) were transferred to the MC. In total, 318 patients were treated at the MC (122 OSR; 196 EVAR). At the MC, r-EVAR was associated with a lower mortality rate than r-OSR (20% vs 37%, P = 0.001). Transfer did not influence r-EVAR mortality (20% in r-EVAR presenting to MC vs 20% in r-EVAR transferred, P > 0.2). Overall, r-AAA mortality at the MC was 20% lower than CH (27% vs 46%, P < 0.001).
  
  
  
  Regionalization of r-AAA repair to centers equipped for both r-EVAR and r-OSR decreased mortality by approximately 20%. Transfer did not impact the mortality of r-EVAR at the tertiary center. Care of r-AAA in the US should be centralized to centers equipped with available technology and vascular surgeons.
authors.affiliation: *The Vascular Group, The Institute for Vascular Health and Disease, Department of Surgery and Division of Vascular Surgery, Albany, NY †Albany Medical College/Albany Medical Center Hospital, Albany, NY.
authors.forename: Courtney J
authors.initials: CJ
authors.lastname: Warner
authors.forename: Sean P
authors.initials: SP
authors.lastname: Roddy
authors.forename: Benjamin B
authors.initials: BB
authors.lastname: Chang
authors.forename: Paul B
authors.initials: PB
authors.lastname: Kreienberg
authors.forename: Yaron
authors.initials: Y
authors.lastname: Sternbach
authors.forename: John B
authors.initials: JB
authors.lastname: Taggert
authors.forename: Kathleen J
authors.initials: KJ
authors.lastname: Ozsvath
authors.forename: Steven C
authors.initials: SC
authors.lastname: Stain
authors.forename: R Clement
authors.initials: RC
authors.lastname: Darling
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000601:surgery*; D006764:Hospitals, Community / Q000706:statistics & numerical data; D006801:Humans; D012040:Regional Health Planning / Q000379:methods*; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000458:organization & administration*