Objective

Contemporary data on outcomes in open thoracoabdominal aortic aneurysm (TAAA) repair are limited to reports from major aortic referral centers showing excellent outcomes. This study aimed to characterize the national experience of open TAAA repair using national outcomes data, with a primary focus on the association of hospital volume with mortality and morbidity.

Methods

The Nationwide Inpatient Sample was queried from 1998 to 2011, and all patients with a diagnosis of TAAA who underwent open operative repair were included. These patients were further stratified into tertiles based on the operative volume of the institution that performed the operation: low volume (LV), <3 cases/y; medium volume (MV), 3 to 11 cases/y; and high volume (HV), ≥12 cases/y. Baseline demographics as well as perioperative outcomes were compared between these groups. Multivariable logistic regression was performed to determine predictors of operative mortality and morbidity. Subgroup analyses were performed for patients presenting for elective surgery and for those presenting for urgent and emergent surgery.

Results

Overall operative mortality was 21% for the entire cohort. Operative mortality was higher at LV (26%) and MV (21%) centers compared with HV centers (15%; P < .001). This difference was similar in both elective surgery (LV, 18%; MV, 14%; HV, 12%; P < .001) and urgent and emergent surgery (LV, 34%; MV, 30%; HV, 19%; P < .001). Furthermore, rates of blood transfusion and acute renal failure were significantly lower in the HV group. Multivariable analysis revealed that compared with the HV group, patients operated on at LV centers (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.7-2.1; P < .001) and MV centers (OR, 1.5; 95% CI, 1.4-1.7; P < .001) had at least 1.5 times the odds of in-hospital mortality. The HV group also had significantly lower odds of dying in the subgroup analyses of both elective surgery and urgent and emergent surgery. Increasing TAAA volume was associated with increased use of distal aortic perfusion (OR, 1.03; 95% CI, 1.02-1.03; P < .001).

Conclusions

Patients with TAAA in the United States operated on at HV centers have significantly lower mortality and morbidity compared with patients operated on at lower volume centers. Consideration of referral to HV centers may be warranted, but further research is required to justify this conclusion.

中文翻译：

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增加的医院容量与胸腹主动脉瘤修复术后死亡率的降低有关。

客观的

目前关于开放式胸腹主动脉瘤 (TAAA) 修复结果的数据仅限于来自主要主动脉转诊中心的报告显示出良好的结果。本研究旨在使用国家结果数据描述开放性 TAAA 修复的国家经验，主要关注医院数量与死亡率和发病率的关联。

方法

查询1998年至2011年全国住院患者样本，纳入所有接受开放手术修复的TAAA患者。根据进行手术的机构的手术量，将这些患者进一步分为三等分：低体积 (LV)，<3 例/年；中等体积 (MV)，3 至 11 例/年；和高容量 (HV)，≥12 例/年。比较这些组之间的基线人口统计学以及围手术期结果。进行多变量逻辑回归以确定手术死亡率和发病率的预测因素。对择期手术和急诊手术的患者进行了亚组分析。

结果

整个队列的总体手术死亡率为 21%。LV (26%) 和 MV (21%) 中心的手术死亡率高于 HV 中心 (15%; P  < .001)。这种差异在择期手术（LV，18%；MV，14%；HV，12%；P  < .001）和急诊手术（LV，34%；MV，30%；HV，19%；P  < .001)。此外，HV 组的输血率和急性肾功能衰竭率显着降低。多变量分析显示，与 HV 组相比，患者在 LV 中心（优势比 [OR]，1.9，95% 置信区间 [CI]，1.7-2.1；P  < .001）和 MV 中心（OR，1.5； 95% CI，1.4-1.7；P < .001) 至少是院内死亡率的 1.5 倍。在择期手术和急诊手术的亚组分析中，HV 组的死亡几率也显着降低。TAAA 体积的增加与远端主动脉灌注的使用增加有关（OR，1.03；95% CI，1.02-1.03；P  < .001）。

结论

在美国，在 HV 中心接受手术的 TAAA 患者与在低容量中心接受手术的患者相比，死亡率和发病率显着降低。考虑转诊到 HV 中心可能是必要的，但需要进一步研究来证明这一结论。