Feasibility and Added Value of Textbook Outcome and Failure to Rescue in Elective Juxtarenal Abdominal Aortic Aneurysm Repair: Insights from Two National Registries.

Abstract

Juxtarenal abdominal aortic aneurysms (JRAAAs) are anatomically complex and technically challenging to treat. Traditional metrics such as mortality or complication rates may not adequately reflect care quality. Composite measures such as failure to rescue (FTR) and textbook outcome (TO) offer a more comprehensive, patient centred assessment, capturing complication management and peri-operative course. TO reflects an ideal post-operative course, and FTR represents the proportion of patients who die after a major complication. This study assessed the feasibility and added value of TO and FTR as quality indicators in elective JRAAA repair using national registry data from the Netherlands and Sweden. This retrospective cohort study used prospectively collected data from the Dutch Surgical Aneurysm Audit (DSAA) and the Swedish Swedvasc registry. Patients undergoing elective JRAAA repair with open surgical repair (OSR) or complex endovascular aortic repair (cEVAR) between 2016 and 2023 were included. TO reflected an ideal post-operative course; FTR captured death after major complications (Clavien-Dindo ≥ IV). Multivariable logistic regression was used to assess associations between surgical approach and outcomes. The study included 1 925 patients from the Netherlands and 775 from Sweden. In the Dutch cohort, cEVAR was associated with statistically significantly lower FTR rates (1.6% vs. 4.3%; p < .001), 30 day mortality (2.6% vs. 6.1%; p < .001), and severe complications (5.8% vs. 14.8%; p < .001), and higher TO achievement (81.4% vs. 73.6%; p < .001) compared with OSR. No statistically significant differences in FTR (1.6% vs. 1.8%; p = .83) or TO (92.5% vs. 88.4%; p = .086) were found between OSR and cEVAR in the Swedvasc cohort. The main structural difference between the registries was the absence of re-admission data in Swedvasc. TO and FTR show future promise as standardised metrics to evaluate surgical quality in JRAAA repair. Their added value is conceptual and requires further validation. Registry differences and incomplete data remain limitations. Implementing key variables with standardised definitions will enable benchmarking and support international quality improvement.