Perspective:

The quintile cut-points from this analysis are every bit as important as the model findings and conclusions, which suggest that lower perioperative mortality could be achieved through concentration of open AAA repair at high-volume centers. Defining ‘high volume’ would affect access and provider availability, while reduction of open repair volume at ‘mid-volume’ centers would potentially affect ability to offer open repair for symptomatic or ruptured AAA (where patient transfer may be unsafe) as experience diminishes. Although the authors allude to mortality reductions observed in the United Kingdom through similar approaches in the discussion, differences in health systems and scale might make implementation in the United States more complex, particularly if the redistribution of volume leads to delays in repair. Concentration of open repairs at high-volume centers would also concentrate training in open surgical repair, potentially reducing the pool of surgeons able to offer this technique. Lack of anatomic data is a major limitation of this study and prevented adjustment for aneurysm diameter, extent, and other factors related to risk and selection.