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• W3028834690 abstract "We appreciate the excellent comment by Botes et al. The highlighted improvements in abdominal aortic aneurysm (AAA) repair in the United Kingdom give evidence of the value of real-world data use, and the authors should be congratulated for being a part of this outstanding success of ongoing changes in vascular services in Great Britain. Widespread adoption of endovascular aneurysm repair (EVAR)1Beck A.W. Sedrakyan A. Mao J. Venermo M. Faizer R. Debus E.S. et al.International Consortium of Vascular RegistriesVariations in abdominal aortic aneurysm care: a report from the International Consortium of Vascular Registries.Circulation. 2016; 134: 1948-1958Crossref PubMed Scopus (165) Google Scholar, 2Budtz-Lilly J. Venermo M. Debus E.S. Behrendt C.A. Altreuther M. Beiles B. et al.Editor's choice—assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.Eur J Vasc Endovasc Surg. 2017; 65: 13-20Abstract Full Text Full Text PDF Scopus (86) Google Scholar and the ongoing centralization of AAA repairs3Budtz-Lilly J. Björck M. Venermo M. Debus E.S. Behrendt C.A. Altreuther M. et al.Editor's choice—the impact of centralisation and endovascular aneurysm repair on treatment of ruptured abdominal aortic aneurysms based on international registries.Eur J Vasc Endovasc Surg. 2018; 56: 181-188Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 4Trenner M. Kuehnl A. Salvermoser M. Reutersberg B. Geisbuesch S. Schmid V. et al.Editor's choice—high annual hospital volume is associated with decreased in hospital mortality and complication rates following treatment of abdominal aortic aneurysms: secondary data analysis of the nationwide German DRG statistics from 2005 to 2013.Eur J Vasc Endovasc Surg. 2018; 55: 185-194Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar can be seen as the cause of improvements in both intact and ruptured AAA repairs. Whereas EVAR rates and hospital volume are broadly consented to be indicators of process or structure quality, respectively, the weekend effect seems to be a more complex measurement of quality in vascular care. However, some evidence suggests that both changes in EVAR rates and centralization of vascular services are associated with outcome of patients operated on at the weekend. Botes et al correctly point out differences from a similar study by Ambler et al.5Ambler G. Mariam N. Sadat U. Coughlin P. Loftus I. Boyle J. Weekend effect in non-elective abdominal aortic aneurysm repair.BJS Open. 2017; 1: 158-164Crossref PubMed Google Scholar Comparison between the studies appears challenging as Ambler et al limited their analyses to nonelective infrarenal AAA, whereas we also included ruptured thoracic and thoracoabdominal aortic aneurysms to reflect treatment reality during off-hours as ruptured aortic aneurysms respect neither anatomic nor infrastructural borders. However, we adjusted the multivariable analyses accordingly and additionally performed a propensity score matching to account for possible confounders (eg, for case mix effects). Second, there are likely to be differences in patient selection, illustrated, for instance, by differences in the proportion of women (26.1%-36.9% in Germany among ruptured aortic aneurysms vs 17.4% in the United Kingdom among all nonelective intact and ruptured AAAs) and EVAR rates (35.0% in Germany vs 26.9% in the United Kingdom). Third, multiple factors might have influenced the surgeon's experience with EVAR technique in urgent or emergent situations, and there is evidence that the situation in the United Kingdom is different from other countries.6Karthikesalingam A. Vidal-Diez A. Holt P.J. Loftus I.M. Schermerhorn M.L. Soden P.A. et al.Thresholds for abdominal aortic aneurysm repair in England and the United States.N Engl J Med. 2016; 375: 2051-2059Crossref PubMed Scopus (103) Google Scholar Last, it can be difficult to compare national health systems without adjusting for substantial differences in vascular maintenance. Thus, it is not surprising that a publicly funded and administered health care system in the United Kingdom works well in terms of centralization. Against this, the German health care system is different and to some degree comparable to the conditions in the United States, where various studies prove a weekend effect in urgent care. Certainly, there are reports demonstrating a volume-outcome association for elective AAA repair in Germany,4Trenner M. Kuehnl A. Salvermoser M. Reutersberg B. Geisbuesch S. Schmid V. et al.Editor's choice—high annual hospital volume is associated with decreased in hospital mortality and complication rates following treatment of abdominal aortic aneurysms: secondary data analysis of the nationwide German DRG statistics from 2005 to 2013.Eur J Vasc Endovasc Surg. 2018; 55: 185-194Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar but the question remains whether aortic ruptures can also be centralized and if the rapid adoption of EVAR has an impact on outcomes of open surgical repair (OSR). In line with prior international reports showing increasing mortality rates after OSR,2Budtz-Lilly J. Venermo M. Debus E.S. Behrendt C.A. Altreuther M. Beiles B. et al.Editor's choice—assessment of international outcomes of intact abdominal aortic aneurysm repair over 9 years.Eur J Vasc Endovasc Surg. 2017; 65: 13-20Abstract Full Text Full Text PDF Scopus (86) Google Scholar our study showed a strong weekend effect for OSR but not for EVAR of aortic ruptures.7Behrendt C.A. Sedrakyan A. Schwaneberg T. Kölbel T. Spanos K. Debus E.S. et al.Impact of weekend treatment on short-term and long-term survival following urgent repair of ruptured aortic aneurysms in Germany.J Vasc Surg. 2019; 69: 792-799Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar In conclusion, we believe that the widespread adoption of EVAR might be associated with improved outcomes after elective procedures where a centralization is viable, but this development might also lead to worse outcomes after OSR in urgent or emergent situations. To transfer patients with ruptures might negatively affect outcomes because some 20% will die without receiving definite repair.8Mell M.W. Wang N.E. Morrison D.E. Hernandez-Boussard T. Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm.J Vasc Surg. 2014; 60: 553-557Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Regarding “Impact of weekend treatment on short-term and long-term survival after urgent repair of ruptured aortic aneurysms in Germany”Journal of Vascular SurgeryVol. 69Issue 4PreviewBehrendt et al1 should be congratulated on their work identifying worse in-hospital survival rates for patients treated for ruptured abdominal aortic aneurysm (rAAA) at the weekend in Germany. The “weekend effect” has received much attention since 2001, when it was first described in a population of Canadian patients undergoing repair of rAAA. Full-Text PDF Open Archive" @default.
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