National outcomes in acute aortic dissection: influence of surgeon and institutional volume on operative mortality.

BACKGROUND: Despite clinical and technical advances, acute aortic dissection carries high operative mortality. This study was designed to establish whether this is influenced by institution and surgeon volume. METHODS: Outcomes of 5,184 patients (mean age, 60.3 years; 65.9% male) diagnosed with acute aortic dissection from the Nationwide Inpatient Sample from 2003 to 2008 were analyzed with risk-adjustment for preoperative comorbidity using multivariate logistic regression analysis. RESULTS: Overall operative mortality was 21.6%, with similar preoperative patient risk profile across institutions and individual surgeons. A strong inverse relationship was observed between operative mortality and both institution and surgeon volume: surgeons who averaged less than 1 aortic dissection repair annually had a mean operative mortality of 27.5%, compared with 17.0% for those averaging 5 or more annually (odds ratio, 1.78; 95% confidence interval, 1.39 to 2.29; p < 0.001). This was similar to the relationship seen between institution volume and mortality: operative mortality was 27.4% in institutions performing 3 or fewer acute aortic dissections a year, compared with 16.4% in those performing more than 13 annually (p < 0.001). Nationally, operative mortality decreased steadily from 23% in 1998-2000 to 19% in 2005-2008, with no significant decrease in patient risk profile. CONCLUSIONS: Patients undergoing emergency repair of acute aortic dissection by lower-volume surgeons and centers have approximately double the risk-adjusted mortality of patients undergoing repair by the highest volume care providers. Routine involvement, whenever feasible, of teams experienced in acute aortic dissection repair may be a strategy to reduce operative mortality and major morbidity.

Endovascular repair of thoracic aortic tears.

BACKGROUND: Standard treatment of traumatic thoracic aortic transection (TTAT) is open repair by left thoracotomy with or without the use of partial cardiopulmonary bypass. However, open repair is associated with high rates of morbidity and mortality, particularly in multiply injured trauma patients. We reviewed our experiences of endovascular repair of acute TTAT. METHODS: Between February 2001 and February 2006, 30 patients (male 24, female 6, mean age 43 years) who had sustained severe blunt trauma with multiple injuries (mean injury severity score = 42) underwent endovascular repair for TTAT. Devices used included commercially available proximal abdominal aortic extension cuffs and thoracic stent-grafts. Either low dose or no systemic heparin was used. Arterial access was obtained by femoral-iliac cutdown (n = 19) or completely percutaneous through the femoral artery (n = 11). Mean follow-up was 11.6 months (range, 1 to 48 months). RESULTS: Technically success was achieved in 100% of patients, as determined by angiographic and computed tomographic (CT) scan exclusion of TTAT. Mean operating time was 132 minutes. Mean blood loss was 300 cm3. Three patients had complications: 1 iliac artery rupture, 1 cerebellar stroke, and 1 partial stent collapse. There were 2 perioperative deaths. There were no instances of procedure-related paralysis. Clinical and CT follow-up did not reveal evidence of endoleak, stent migration, or late pseudoaneurysm formation. CONCLUSIONS: The adaptation of commercially available stent-graft devices to treat TTAT is technically feasible, and can be performed with low rates of morbidity and mortality. The long-term durability of endovascular repair of TTAT remains unknown, but early and midterm results appear promising.