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Invited Commentary
September 2016

Aortic Centers of ExcellenceShifting the Focus

Author Affiliations
  • 1Department of Surgery, Harbor University of California, Los Angeles Medical Center, Torrance
JAMA Surg. 2016;151(9):845. doi:10.1001/jamasurg.2016.0838

The Leapfrog initiative was created with the goal of improving in-hospital mortality for high-risk procedures, including elective abdominal aortic aneurysm (AAA) repair.1 The aim was to lower perioperative AAA mortality by at least 50% by referring patients to high-volume centers because high volume was felt to be a surrogate for low mortality. Buoyed by this initiative, aortic centers of excellence have sprung up throughout the country with the expectation of better outcomes. The study by Hicks and colleagues2 in JAMA Surgery appears to contradict the mortality benefit of high-volume centers. Instead, the authors reported that in-hospital mortality for elective AAA repair was primarily determined by patient-specific risk rather than hospital-level factors such as Leapfrog compliance (>50 AAA cases/year).2 Because prior studies have shown that aortic centers are more likely to perform endovascular AAA repair (EVAR) rather than open AAA repair (OAR), a potential byproduct of focusing on referral to high-volume centers is a decline in OAR. Alarmingly, Hicks et al2 noted a significant decline in hospitals that performed more than 25% of AAA repairs via OAR (only 18% by 2011). Undoubtedly, the consistently low in-hospital mortality associated with EVAR makes it an appealing treatment option. In fact, Hicks et al2 note a 6-fold higher in-hospital mortality for OAR. Thus, a knee-jerk conclusion from their study might be to push toward further OAR reduction. But such a view misses the mark. Endovascular AAA repair is not, as yet, a panacea. Endovascular AAA repair has yet to rid itself of troublesome endoleaks, need for reinterventions, and persistent (albeit low) risk of AAA rupture. Thus, long-term mortality for EVAR and OAR are similar. A limitation of the Hicks et al study2 was the lack of analysis of long-term survival.

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