Improved Outcomes of Endovascular Repair of Thoracic Aortic Injuries at Higher-Volume Institutions

Abstract

Abstract Background The use of thoracic endovascular aortic repair (TEVAR) has significantly improved the ability to treat traumatic aortic injuries (tTEVAR). We sought to determine whether a greater center volume correlated with better outcomes. Methods Vascular Quality Initiative data of TEVAR (2011-2017) for trauma were used in the present analysis. Using the distribution of the annual case volume at the participating centers, the sample was stratified into three terciles. In-hospital mortality at high-volume centers (HVCs) and low-volume centers (LVCs) was compared after adjustment for risk factors established in our previous Vascular Quality Initiative-based risk model containing age, gender, renal impairment, left subclavian artery involvement, and select concomitant injuries. Results A total of 619 tTEVAR cases were studied across 74 centers. HVCs (n = 184 cases) had performed ≥4.9 cases annually and LVCs (n = 220 cases) had performed ≤2.4 cases annually. Both crude mortality (4.4% vs 8.6%; P = .22) and adjusted odds of mortality (odds ratio, 0.44; 95% confidence interval, 0.18-1.09; P = .08) showed a trend toward better outcomes for tTEVAR performed at HVCs than at LVCs. The addition of center volume to our previous multivariate model significantly improved its discriminative ability (C-statistic, 0.90 vs 0.88; P = .02). The overall TEVAR volume (for all indications) was not associated with increased odds of mortality for tTEVAR (odds ratio, 0.46; 95% confidence interval, 0.17-1.20; P = .11), nor did it improve the model's discriminative ability. Conclusions Higher volume centers showed improved perioperative mortality after tTEVAR. The thoracic aortic trauma volume was more predictive than the overall TEVAR volume, suggesting that technical expertise is not the driving factor. Stable patients might benefit from transfer to a higher volume center before repair.