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.