Hospital Volume Association With Abdominal Aortic Aneurysm Repair Mortality

HomeCirculationVol. 140, No. 15Hospital Volume Association With Abdominal Aortic Aneurysm Repair Mortality Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBHospital Volume Association With Abdominal Aortic Aneurysm Repair MortalityAnalysis of the International Consortium of Vascular Registries Salvatore T. Scali, MD, Adam W. Beck, MD, Art Sedrakyan, MD, PhD, Jialin Mao, MD, MS, Maarit Venermo, MD, PhD, Rumi Faizer, MD, Marc Schermerhorn, MD, Barry Beiles, MB BCh, FRACS, Zoltán Szeberin, MD, PhD, Nikolaj Eldrup, MD, PhD, Ian Thomson, MBChB, FRACS, Kevin Cassar, MD, FRCS(Ed), Martin Altreuther, MD, Christian-Alexander Behrendt, MD, Sebastian Debus, MD, PhD, Jonathan R. Boyle, MBChB, MD, FRCS, Amundeep Johal, PhD, Martin Bjorck, MD, PhD, Jack Cronenwett, MD and Kevin Mani, MD, PhD Salvatore T. ScaliSalvatore T. Scali Salvatore T. Scali, MD, FACS, RPVI, Division of Vascular Surgery and Endovascular Therapy, PO Box 100128, Suite NG-45, Health Science Center, 1600 SW Archer Rd, Gainesville, FL 32610. Email E-mail Address: [email protected] Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville (S.T.S.). , Adam W. BeckAdam W. Beck Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham (A.B.). , Art SedrakyanArt Sedrakyan Healthcare Policy and Research, Weill Cornell Medical College, New York, NY (A.S., J.M.). , Jialin MaoJialin Mao Healthcare Policy and Research, Weill Cornell Medical College, New York, NY (A.S., J.M.). , Maarit VenermoMaarit Venermo Department of Vascular Surgery, Helsinki University Hospital, Finland (M.V.). , Rumi FaizerRumi Faizer Division of Vascular Surgery, University of Minnesota, Minneapolis (R.F.). , Marc SchermerhornMarc Schermerhorn Division of Vascular Surgery and Endovascular Therapy, Beth Israel Deaconess Medical Center, Boston, MA (M.S.). , Barry BeilesBarry Beiles Australasian Vascular Audit, Australasian Society for Vascular Surgery, Melbourne, Australia (B.B.). , Zoltán SzeberinZoltán Szeberin Department of Vascular Surgery, Semmelweis University, Budapest, Hungary (Z.S.). , Nikolaj EldrupNikolaj Eldrup Department of Cardio-Thoracic and vascular Surgery, Aarhus University Hospital Skejby, Denmark (N.E.). , Ian ThomsonIan Thomson Department of Surgery, University of Otago, Dunedin, New Zealand (I.T.). , Kevin CassarKevin Cassar Department of Surgery, Faculty of Medicine and Surgery, University of Malta (K.C.). , Martin AltreutherMartin Altreuther Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway (M.A.). , Christian-Alexander BehrendtChristian-Alexander Behrendt Department of Vascular Medicine, Working Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (C.-A.B., S.D.). , Sebastian DebusSebastian Debus Department of Vascular Medicine, Working Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (C.-A.B., S.D.). , Jonathan R. BoyleJonathan R. Boyle Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, United Kingdom (J.R.B.). , Amundeep JohalAmundeep Johal Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom (A.J.). , Martin BjorckMartin Bjorck Department of Surgical Sciences, Uppsala University, Sweden (M.B., K.M.). , Jack CronenwettJack Cronenwett Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (J.C.). and Kevin ManiKevin Mani Department of Surgical Sciences, Uppsala University, Sweden (M.B., K.M.). Originally published7 Oct 2019https://doi.org/10.1161/CIRCULATIONAHA.119.042504Circulation. 2019;140:1285–1287Abdominal aortic aneurysm (AAA) management has undergone significant changes because of broad dissemination of endovascular repair (EVAR),1 with significant variation in AAA care between countries.2 An inverse relationship between hospital volume and postoperative open surgical repair (OSR) mortality for intact AAA (iAAA) has been reported based on administrative data3; however, center volume association may vary between countries because of differences in patient selection, geography, and healthcare systems. The hypothesis of this analysis was that a volume-outcome relationship would be present in a large contemporary, multinational dataset that included both iAAA and ruptured AAA (rAAA) repair.Data on primary AAA procedures from 2010 to 2016 were prospectively collected in vascular surgical registries from 11 countries (Australia, Denmark, Germany, Hungary, Finland, Malta, New Zealand, Norway, Sweden, the United Kingdom, and the United States) and submitted to the Medical Device Epidemiology Network for analysis. Details regarding registries, including coverage and validity, have been published previously.1,2 This study was approved by Weill Cornell Medicine Institutional Review Board (No. 1511016772). No informed consent was needed because all patient data were obtained from existing registry effort.Hospital annual volumes for EVAR and OSR were calculated separately, averaged across years, and volume quartiles were created among 4 groups (intact/ruptured EVAR, intact/ruptured OSR). Generalized linear mixed models were adjusted for age, sex, comorbidities (diabetes mellitus, cardiac history, and renal dysfunction [creatinine ≥1.7 mg/dL]), procedure year, aneurysm size, and registry and hospital random effects.A total of 178 860 patients were analyzed. EVAR was used in 68.0% of iAAA and 27.9% of rAAA repairs. Overall mean age was 73.2 years; 15.3% of patients were women. Comorbidity frequency included cardiac disease (41.6%), diabetes mellitus (16.2%), and renal dysfunction (5.0%). Crude in-hospital mortality was 1.0% for iAAA with EVAR, 4.7% for iAAA with OSR, 23.1% for rAAA with EVAR, and 37.1% for rAAA with OSR.Median case volumes varied between countries (range for EVAR from a low of 7 cases in Germany to 76 in Denmark; range for OSR: Germany 4, Denmark 86). Proportions treated with EVAR increased significantly from 2010 to 2013 (iAAA, 64.7%; rAAA, 23.7%) to 2014 to 2016 (iAAA, 72.4%; rAAA, 34.0%; P<0.001). Concurrently, mean OSR number per center decreased (from 36.4 to 29.8 cases/year; P<0.0001), whereas the mean EVAR volume increased from 43.2 to 45.4 cases/year (P<0.0001).In both crude and risk-adjusted analysis, no volume effect on in-hospital or 30-day mortality was identified after EVAR for either iAAA or rAAA; however, there was a significant volume-outcome relationship after OSR for both (Figure). A significant reduction in mortality was identified when we compared the highest to lowest volume quartiles for OSR of iAAA (quartile 4, 3.6% versus quartile 1, 6.0%; odds ratio, 0.62 [95% CI, 0.40–0.98]; P=0.04), as well as for OSR of rAAA (quartile 4, 30.2% versus quartile 1, 44.2%; odds ratio, 0.41 [95% CI, 0.29–0.58]; P<0.0001). Sensitivity analyses demonstrated consistent results.Download figureDownload PowerPointFigure. Risk-adjusted analysis of volume-outcome impact on in-hospital mortality after EVAR and open repair of intact and ruptured abdominal aortic aneurysms.A and B, Risk-adjusted mortality outcomes for intact and ruptured EVAR by annual hospital volume quartile. No significant volume effect on in-hospital mortality is identified. C and D, In contrast, a significant inverse relationship was demonstrated between increasing hospital volume and postoperative in-hospital mortality outcome after open repair of both intact and ruptured abdominal aortic aneurysms. Odds ratio for in-hospital mortality is presented with error bars representing the 95% CI. EVAR indicates endovascular repair; and Q, annual volume quartile.This contemporary multinational analysis identified consistently improved outcomes after OSR when performed at high-volume centers for both iAAA and rAAA. Risk-adjusted mortality decreased for each increase in volume quartile (Figure). Although no relationship between volume and early mortality was detected after EVAR, this does not preclude the presence of a volume-outcome relationship when assessing other long-term outcomes. EVAR has a higher risk of late failure than OSR, and adequate anatomic case selection and device implantation are key factors affecting long-term failure.The current Society for Vascular Surgery guidelines endorse a volume of ≥10 open AAA cases per year as a minimum aortic practice requirement.4 Assessing the current dataset, only 29% of centers achieved this recommendation during the study period. Interestingly, an analysis of the inflection point indicates that the volume-outcome relationship was highly significant up to 10 to 15 OSRs per year for iAAA repair, whereas the incremental benefit in improved outcome decreased beyond this threshold.Aortic repair volumes and associated mortality rates are often endorsed by stakeholders as inpatient quality indicators.5 Accordingly, vascular trainees are required to perform at least 30 OSR procedures during their residency or fellowship.4 The implication of greater proportions of AAA cases being treated with EVAR is a concordant decrease in OSR volumes. The unintended consequence of this is to create fewer centers with experienced surgeons who are able to competently train and perform OSR. As this practice proliferates across multiple countries, the systems of care needed to manage patients requiring OSR will invariably become more strained and require restructuring to sustain high-quality care delivery.Limitations of this study include its vulnerability to random and systematic data missingness, as well as incorrectly coded information among the different registries. Not all registries provide a comprehensive national perspective on AAA care, which limits the ability to perform detailed epidemiological analysis. Granular details about surgeon experience, as well as anatomic and patient physiological features, which are especially important for ruptured AAA cases, were not captured. However, this international collaboration includes several quality registries with >90% national or regional coverage of AAA repairs, which reduces the risk for systematic selection bias. Additionally, data regarding perioperative or 30-day mortality, which was the primary outcome of the current analysis, are highly valid.In conclusion, this international analysis underscores the importance of case volume and its effect on mortality after OSR for iAAA and rAAA. The decrease in OSR volumes resulting from increasing EVAR utilization will continue to reduce the number of centers with sufficient volumes to support contemporary training and credentialing thresholds. These findings have important consequences on hospital accreditation and care regionalization to improve overall AAA repair mortality outcomes internationally.AcknowledgmentsAll listed authors have provided data and assisted in the analysis, as well as the interpretation of results from the study. All authors have had the opportunity to review the submitted manuscript and agree to be responsible for its content.Sources of FundingThe project and efforts were funded in part by the US Food and Drug Administration through grant 1U01FD005478 (principal investigator: Dr Sedrakyan). Views expressed in the publication do not necessarily reflect the official policies of the Department of Health and Human Services, nor does any mention of trade names, commercial practices, or organization imply endorsement by the US government.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circEthics approval for the collection and analysis of vascular registry data was obtained on the basis of national regulations for each registry for this international collaborative project.Salvatore T. Scali, MD, FACS, RPVI, Division of Vascular Surgery and Endovascular Therapy, PO Box 100128, Suite NG-45, Health Science Center, 1600 SW Archer Rd, Gainesville, FL 32610. Email salvatore.[email protected]ufl.eduReferences1. Budtz-Lilly J, Venermo M, Debus S, Behrendt CA, Altreuther M, Beiles B, Szeberin Z, Eldrup N, Danielsson G, Thomson I, et al. Editor's choice: assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.Eur J Vasc Endovasc Surg. 2017; 54:13–20. doi: 10.1016/j.ejvs.2017.03.003CrossrefMedlineGoogle Scholar2. Beck AW, Sedrakyan A, Mao J, Venermo M, Faizer R, Debus S, Behrendt CA, Scali S, Altreuther M, Schermerhorn M, et al; International Consortium of Vascular Registries. Variations in abdominal aortic aneurysm care: a report from the International Consortium of Vascular Registries.Circulation. 2016; 134:1948–1958. doi: 10.1161/CIRCULATIONAHA.116.024870LinkGoogle Scholar3. Karthikesalingam A, Grima MJ, Holt PJ, Vidal-Diez A, Thompson MM, Wanhainen A, Bjorck M, Mani K. Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden.Br J Surg. 2018; 105:520–528. doi: 10.1002/bjs.10749CrossrefMedlineGoogle Scholar4. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, Mastracci TM, Mell M, Murad MH, Nguyen LL, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg. 2018; 67:2–77.e2. doi: 10.1016/j.jvs.2017.10.044CrossrefMedlineGoogle Scholar5. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, et al. Editor's choice: European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57:8–93. doi: 10.1016/j.ejvs.2018.09.020CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Alhajri N, Yin K, Locham S, Ou M and Malas M (2022) Low-volume hospitals are not associated with inferior outcomes after thoracic endovascular aortic repair, Journal of Vascular Surgery, 10.1016/j.jvs.2021.11.055, 75:4, (1202-1210), Online publication date: 1-Apr-2022. Tedjawirja V, Alberga A, Hof M, Vahl A, Koelemay M, Balm R, van den Akker P, Akkersdijk G, Akkersdijk G, Akkersdijk W, van Andringa de Kempenaer M, Arts C, Avontuur J, Bakker O, Balm R, Barendregt W, Bekken J, Bender M, Bendermacher B, van den Berg M, Berger P, Beuk R, Blankensteijn J, Bleker R, Blok J, Bode A, Bodegom M, van der Bogt K, Boll A, Booster M, Borger van der Burg B, de Borst G, Bos- van Rossum W, Bosma J, Botman J, Bouwman L, Brehm V, de Bruijn M, de Bruin J, Brummel P, van Brussel J, Buijk S, Buijs M, Buimer M, Burger D, Buscher H, Cancrinus E, Castenmiller P, Cazander G, Coester A, Cuypers P, Daemen J, Dawson I, Dierikx J, Dijkstra M, Diks J, Dinkelman M, Dirven M, Dolmans D, van Doorn R, van Dortmont L, Drouven J, van der Eb M, Eefting D, van Eijck G, Elshof J, Elsman B, van der Elst A, van Engeland M, van Eps R, Faber M, de Fijter W, Fioole B, Fokkema T, Frans F, Fritschy W, Fung Kon Jin P, Geelkerken R, van Gent W, Glade G, Govaert B, Groenendijk R, de Groot H, van den Haak R, de Haan E, Hajer G, Hamming J, van Hattum E, Hazenberg C, Hedeman Joosten P, Helleman J, van der Hem L, Hendriks J, van Herwaarden J, Heyligers J, Hinnen J, Hissink R, Ho G, den Hoed P, Hoedt M, van Hoek F, Hoencamp R, Hoffmann W, Hogendoorn W, Hoksbergen A, Hollander E, Hommes M, Hopmans C, Huisman L, Hulsebos R, Huntjens K, Idu M, Jacobs M, van der Jagt M, Jansbeken J, Janssen R, Jiang H, de Jong S, Jongbloed-Winkel T, Jongkind V, Kapma M, Keller B, Khodadade Jahrome A, Kievit J, Klemm P, Klinkert P, Koedam N, Koelemaij M, Kolkert J, Koning G, Koning O, Konings R, Krasznai A, Krol R, R, R, van der L, van der M, van J, van G, D, J, G, B, D, V, M, M, M, R, van der F, P, M, M, van de K, D, C, E, R, B, G, T, R, R, de van J, M, van M, van de R, W, S, C, J, A, de A, D, J, van R, D, V, A, B, J, H, A, van A, B, M, A, R, E, I, P, A, S, J, M, B, M, de J, A, van M, de R, E, B, P, van M, M, van H, van J, van P, D, M, A, P, F, F, V, O, M, G, C, A, H, L, R, de A, P, T, M, A, M, van der T, van S, D, R, R, G, J, J, B, M, M, T, The R, W, I, I, van R, R, E, M, K, R, R, A, Vahl A, E, H, M, S, H, B, C, E, B, van der R, M, van der J, van C, R, van der J, A, de B, C, G, M, B, P, de A, de D, de J, de M, van der C, E, de B, van L, van J, M, van de W, van V, van A, G, R, J, A, O, W, J, M, E, E, W, M, C, C, R, O, K, C and van M (2022) Mortality elective abdominal aortic aneurysm repair in Journal of Surgery, Online publication date: Alberga A, E, J, de Bruin J, Akkersdijk G, Geelkerken R, Hamming J, J, H, van den Akker P, Akkersdijk G, Akkersdijk W, van Andringa de Kempenaer M, Arts C, Avontuur A, Bakker O, Balm R, Barendregt W, Bekken J, Bender M, Bendermacher B, van den Berg M, Beuk R, Blankensteijn J, Bode A, Bodegom M, van der Bogt K, Boll A, Booster M, Borger van der Burg B, de Borst G, Rossum W, Bosma J, Botman J, Bouwman L, Brehm V, de Bruijn M, de Bruin J, Brummel P, van Brussel J, Buijk S, Buimer M, Buscher H, Cancrinus E, Castenmiller P, Cazander G, Cuypers P, Daemen J, Dawson I, Dierikx J, Dijkstra M, Diks J, Dinkelman M, Dirven M, Dolmans D, van Dortmont L, Drouven J, van der Eb M, Eefting D, van Eijck G, Elshof J, Elsman B, van der Elst A, van Engeland M, van Eps G, Faber M, de Fijter W, Fioole B, Fritschy W, Jin P, Geelkerken R, van Gent W, Glade G, Govaert B, Groenendijk R, de Groot H, van den Haak R, de Haan E, Hajer G, Hamming J, van Hattum E, Hazenberg C, Hedeman Joosten P, Helleman J, van der Hem L, Hendriks J, van Herwaarden J, Heyligers J, Hinnen J, Hissink R, Ho G, den Hoed P, Hoedt M, van Hoek F, Hoencamp R, Hoffmann W, Hoksbergen A, Hollander E, Huisman L, Hulsebos R, Huntjens K, Idu M, Jacobs M, van der Jagt M, Jansbeken J, Janssen R, Jiang H, de Jong S, Jongbloed-Winkel T, Jongkind V, Kapma M, Keller B, Jahrome A, Kievit J, Klemm P, Klinkert P, Koedam N, Koelemaij M, Kolkert J, Koning G, Koning O, Konings R, Krasznai A, R, R, van der L, van der M, van J, van G, D, J, G, B, D, V, M, M, M, van der F, P, M, M, van de K, D, C, E, R, B, T, R, de van J, M, van M, van de R, W, S, C, J, A, de A, D, van R, J, D, A, B, J, H, A, van A, B, M, A, R, E, P, A, S, J, B, M, de J, A, van M, de R, E, B, van M, M, van H, van J, van P, D, M, A, P, F, F, V, O, M, G, C, A, H, L, R, de A, P, T, M, A, M, van der T, van S, D, R, R, G, J, J, B, M, T, The R, W, I, I, van R, R, E, M, K, R, C, R, Vahl A, E, H, M, H, B, C, E, B, van der R, M, van der J, van van C, van der J, A, C, G, de B, M, B, P, de D, de J, de M, de A, van der C, E, de B, van L, van J, M, van V, van A, G, J, A, O, W, J, M, E, E, W, M, C, C, O, K, C and van M (2022) for Abdominal Aortic A European Journal of Vascular and Endovascular Surgery, Online publication date: C, J, G, M and (2022) of mortality in abdominal aortic aneurysm repair, Journal of Vascular Surgery, Online publication date: M, O, D, B, G, and A (2022) Repair of Abdominal Aortic Aneurysm in The Endovascular on The of 15 Journal of Surgical Online publication date: D, J, S, Schermerhorn M and A (2022) surgical quality in abdominal aortic aneurysm repair, Journal of Vascular Surgery, Online publication date: 1-Apr-2022. Scali S, Beck A, Sedrakyan A, Mao J, Behrendt C, Boyle J, Venermo M, Faizer R, Schermerhorn M, Beiles B, Szeberin Z, Eldrup N, Thomson I, Cassar K, Altreuther M, Debus S, Johal A, Bjorck M, Cronenwett J and Mani Editor's for the AAA Repair in the Endovascular of the International Consortium of Vascular European Journal of Vascular and Endovascular Surgery, Online publication date: H, J and of for and Mortality for Abdominal Aortic of Vascular Surgery, Online publication date: H, C, G, B, N, F, and outcomes of endovascular abdominal aortic aneurysm repair in patients for open surgical repair, Journal of Vascular Surgery, Online publication date: Boyle J, Mao J, Beck A, Venermo M, Sedrakyan A, Behrendt C, Szeberin Z, Eldrup N, Schermerhorn M, Beiles B, Thomson I, Cassar K, Altreuther M, Debus S, Johal A, S, Scali S, and Mani Editor's in Abdominal Aortic Aneurysm Repair by of International Consortium of Vascular Registries 2010 European Journal of Vascular and Endovascular Surgery, Online publication date: J, P, L, and and in the Journal of Online publication date: F, Behrendt C, K, Beck A, Beiles C, Boyle J, Mani K, R, M, M, J and The impact of on vascular registries and clinical in Vascular Surgery, Online publication date: M, Scali S, Mao J, Szeberin Z, Thomson I, Beiles B, D, Sedrakyan A, Eldrup N, Venermo M, Cassar K, Altreuther M, Boyle J, Behrendt C, Beck A and Mani Association Hospital Volume and to or Endovascular Repair of Abdominal Aortic in the and International Consortium of Vascular of Surgery, Online publication date: and in der of aortic in Online publication date: F, J, M, J, D, N, J, Mansour M, M, and repair perioperative outcomes a hospital volume association for abdominal aortic Journal of Vascular Surgery, Online publication date: Scali S, Martin A, D, S, J, B, P, R, and versus volume outcomes in contemporary Journal of Vascular Surgery, Online publication date: Behrendt C, A, T, Debus E, F, A, and M in to about the of abdominal aortic in and open Online publication date: C der in the of abdominal aortic data for a Online publication date: Mani K, and Wanhainen A EVAR a of European Journal of Vascular and Endovascular Surgery, Online publication date: Cronenwett J Research, and European Journal of Vascular and Endovascular Surgery, Online publication date: Wanhainen A and Mani The to aortic Journal of Medicine, Online publication date: Behrendt C, M and den der der of minimum and in the of abdominal aortic Online publication date: M, Wanhainen A, R, G, and Mani A review of the and for analysis of endovascular repair for intact aortic Journal of Vascular Surgery, Online publication date: L, Venermo M, Mani K, Wanhainen A and Schermerhorn M in abdominal aortic aneurysm management based on vascular registries, Journal of Medicine, Online publication date: Wanhainen A, and of Abdominal Aortic Aneurysm Repair No the European Journal of Vascular and Endovascular Surgery, Online publication date: G, J, D, Schermerhorn M, P, S, R, J, S, Scali S, G, L, Mell M, Malas M, B, D, M, Beck A, G, D, Sedrakyan A and The Vascular and An to for vascular Journal of Vascular Surgery, Online publication date: W, J and M Editor's in Abdominal Aortic Aneurysm of the Hospital for the European Journal of Vascular and Endovascular Surgery, Online publication date: A and Boyle J and are of EVAR European Journal of Vascular and Endovascular Surgery, Online publication date: K, P, Behrendt C, G, G, F, M, Debus S, A and of Abdominal Aortic Aneurysm and and Journal of Endovascular Therapy, Online publication date: B, F, S, H, W, and of the of abdominal aortic aneurysm in M, M, A, V, and A The of on and in Abdominal Aortic Aneurysm Alberga A, de Bruin J, F, E, J, van Herwaarden J, J, H, V, A, A, A, A, A, B, B, B, B, B, B, M B, B, B, B, B, B, B, B, B, B, B, J B, B, B, B, B, B, MA B, B, B, B, C, C, C, C, C, D, D, D, D, J D, D, M D, D, D, E, E, E, A F, F, F, F, F, F, G, G, G, G, H, H, H, H, H, H, H, H, H, H, H, H, H, H, H, H, M H, H, H, H, H, I, J, J, J, J, J, J, K, K, A K, K, K, K, K, K, K, K, K, K, K, K, K, K, L, L, L, L, L, L, L, L, MA L, L, L, L, L, M, M, M, M, M, M, M, M, M, M, M, M, N, N, N, N, N, J N, N, N, O, O, J O, P, P, P, P, P, P, P, P, P, A P, R, M R, R, R, A R, R, S, S, S, J S, S, A S, S, S, S, S, S, MA S, S, S, A S, S, S, S, S, S, S, S, S, S, S, S, S, T, T, M T, T, T, T, T, T, T, T, T, M T, T, T, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, V, M C W, W, W, W, W, W, W, W, W, J W, W, W, W, W, W, W, W, W, and (2022) of or Endovascular Abdominal Aortic Journal of Endovascular Therapy, Behrendt C, T, J, G, M, K, G, Debus S, and and after Endovascular Aneurysm Repair for Abdominal Aortic A Journal of Clinical Medicine, 140, 15 2019 Originally 2019 aortic and