Hospital Volume and Outcomes after Elective Abdominal Aortic Aneurysm Repair: A Systematic Review and Dose-Response Meta-Analysis.

BACKGROUND

Procedural volume has been associated with outcomes after abdominal aortic aneurysm (AAA) repair, yet the magnitude and shape of the volume-outcome relationship remain uncertain. This systematic review and dose-response meta-analysis evaluated the association between hospital and surgeon procedural volume and outcomes following elective AAA repair.

METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched from inception to February 9, 2026. Studies evaluating the association between procedural volume and outcomes after elective AAA repair were included. Dose-response meta-analyses were performed using restricted cubic spline models to assess potential linear and nonlinear associations between procedural volume and outcomes.

RESULTS

Eleven observational studies were analyzed. Higher hospital procedural volume was significantly associated with lower overall mortality, with a predominantly linear relationship (n = 202,212; β = -0.0102, P = 0.011). Hospitals at the 90th percentile of procedural volume had 35% lower odds of mortality compared with those at the 10th percentile (odds ratio: 0.65; 95% confidence interval: 0.44-0.96). A significant inverse association was also observed between hospital volume and failure-to-rescue after open repair (n = 60,096; β = -0.0407, P = 0.0006), although the P90 versus P10 contrast was not statistically significant due to wide confidence intervals.

CONCLUSION

Higher hospital procedural volume is associated with lower mortality after elective AAA repair and reduced failure-to-rescue after open repair. These findings suggest that institutional experience plays an important role in outcomes after AAA repair, supporting strategies aimed at centralizing care in higher-volume centers.