Bridging regional disparities in ruptured abdominal aortic aneurysm repair through a centralized system in South Korea: a ten-year nationwide analysis of fatal distance

Ruptured abdominal aortic aneurysm (rAAA) is a surgical emergency with a high mortality. Thus, it requires immediate intervention. While endovascular aneurysm repair (EVAR) has become the preferred approach, significant regional disparities remain in diagnosis, treatment accessibility, and outcomes. This study aimed to analyze rAAA repair trends in South Korea over a decade, highlighting inequities and proposing a centralized referral model. This retrospective cohort study analyzed patients who underwent rAAA repair between 2007 and 2016 using the national Health Insurance Review and Assessment Service (HIRA) database. Patients were identified using ICD-10 and procedural codes for EVAR and open surgical repair (OSR). Regional differences in diagnosis, repair rates, 30-day mortality, and referral patterns were analyzed to propose an optimized hospital network. Of 13,832 AAA repairs, 1,812 (13.1%) were for rAAA. EVAR increased from 30.8% in 2007 to 73.7% in 2016, surpassing OSR since 2012. rAAA repairs were concentrated in metropolitan areas (86.6%), showing significant patient influx to Seoul and Daegu (+16.9% and +13.1%, respectively), while low-volume regions exhibited patient efflux rates exceeding 20%. The 30-day mortality rate for rAAA repair was 13.5% nationally, showing evident regional disparities. Low-volume regions demonstrated less than two rAAA repairs per million people, suggesting a potential selective treatment bias. A 50-km referral system designating 28 vascular centers capable at least 4.5 rAAA repairs annually is proposed, considering transport networks and hospital distribution. National guidelines should implement a coordinated transfer system to ensure timely, equitable access to specialized care and improve survival outcomes.