The Evidence Behind Centralization of Aortic Care: A Scoping Review

Background Centralization of aortic care has been proposed to improve outcomes in abdominal aortic aneurysm (AAA) repair, but its effects may vary according to treatment modality, procedural complexity, and system organization. This scoping review examined the evidence on volume-outcome relationships, failure to rescue (FtR), surgeon and center volume, and integrated models of aortic care. Methods PubMed/MEDLINE was searched from inception to April 29th, 2026. Search terms combined centralization, AAA, hospital volume, surgeon volume, volume–outcome, failure to rescue (FtR), open aortic repair (OSR), endovascular aneurysm repair (EVAR), and ruptured AAA. A narrative synthesis was performed. Results Evidence for an inverse volume–outcome relationship was strongest and most consistent for OSR, in both elective and ruptured AAA. In an analysis of the International Consortium of Vascular Surgery, mortality after intact OSR was 6.0% in the lowest-volume quartile versus 3.6% in the highest, and after ruptured OSR 44.2% versus 30.2%. Lower surgeon volume was also associated with worse OSR outcomes in several studies. Most studies identified approximate center-level thresholds of 10–20 repairs/year. FtR after OSR consistently favored higher-volume centers. By contrast, EVAR showed a more heterogeneous and less reproducible association between center volume and early mortality, particularly in ruptured AAA, although some studies reported lower FtR in higher-volume centers. More limited thoracoabdominal data suggested clearer volume effects in more complex procedures. Conclusions Centralization appears most strongly supported for OSR and emergency AAA care. Better outcomes are likely achieved in services combining open expertise, endovascular capability, structured emergency pathways, and effective peri-operative rescue capacity.