Beyond Volume Metrics: Outcomes of Open Abdominal Aortic Aneurysm Repair in a Small-to-Medium Volume Hospital-Challenging the Centralization Paradigm: A Single-Centre Retrospective Analysis.

Background/Objectives: Centralisation of open abdominal aortic aneurysm (AAA) repair is widely advocated, but supporting evidence often conflates institutional volume with individual surgeon expertise. We report outcomes of open AAA repair at a small- to medium-volume centre and assess the contributions of surgeon experience, multidisciplinary perioperative care, and supervised surgical teaching. Methods: Retrospective analysis of all consecutive patients undergoing open AAA repair between January 2017 and December 2023. Endovascular procedures were excluded. The primary endpoint was 30-day all-cause mortality. Secondary endpoints included perioperative morbidity, acute kidney injury (AKI), length of stay, and overall survival. Results: A total of 195 patients underwent open AAA repair (162 elective; 33 urgent/emergency), with a mean of 27.9 cases annually. Mean age was 70.2 years (SD 8.1), and 85.6% were male. Thirty-day mortality was 1.5% overall (3/195) and 1.2% (2/162) for elective cases, with no significant difference between elective and urgent/emergency cases (1.2% vs. 3.0%; p = 0.430). No perioperative strokes occurred; myocardial infarction occurred in three patients (1.5%). Median operative time was 261 min (IQR 210-320), reflecting systematic supervised teaching in approximately 95% of cases. AKI occurred in 10.3%; clinically significant renal insufficiency at 30 days occurred in 5.1%, and no patient required permanent renal replacement therapy. The perioperative reintervention rate was 9.2%, and median hospital stay was 8 days (IQR 7-12). At a mean follow-up of 62.3 months (SD 25.1), overall mortality was 7.7% and aneurysm-related mortality 1.0%. Kaplan-Meier estimated overall survival was 98.5%, 95.8%, and 89.0% at 1, 3, and 7 years, respectively. Conclusions: Favourable outcomes can be achieved at small- to medium-volume centres through concentrated surgeon expertise, structured teaching, and a high-functioning multidisciplinary team. These findings support a more nuanced assessment of open AAA repair that considers surgeon experience, team performance, and demonstrated outcomes rather than institutional volume alone.