Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Ann Thorac Surg. 2019 Nov;108(5):1299-1306. doi: 10.1016/j.athoracsur.2019.06.047. Epub 2019 Aug 7.
As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection.
Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality.
Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend < .001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P < .001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P < .001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P < .001).
This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.
随着外科手术死亡率的降低和血管内治疗的应用增加，胸主动脉夹层修复术的量效关系尚不清楚。我们描述了胸主动脉夹层手术和血管内治疗的量效关系。
在美国，在 2010 年至 2014 年间，在七个全民支付州住院患者管理数据库中确定了 18 岁以上接受胸主动脉夹层修复的患者。根据修复类型将患者分为以下几组：A型夹层的手术修复（TAAD）、B 型夹层的手术修复（TBAD）和血管内修复（TEVAR）。分层逻辑回归模型评估了医院量与住院死亡率之间的关系。
总体住院死亡率为 13.4%（6650 例中的 890 例），TAAD 后最高（2918 例中的 463 例，15.9%），其次是 TBAD（1934 例中的 270 例，14.0%）和 TEVAR（1798 例中的 157 例，8.7%）。TAAD 和 TBAD 的调整后住院死亡率存在量效关系（P趋势<.001），但 TEVAR 则不然（P趋势=.11）。TAAD 的调整后住院死亡率差异最大（每年少于 3 例：21%，95%置信区间，18%至 24%；每年 11 例或更多：12%，95%置信区间，8%至 16%；P<.001）和 TBAD（每年少于 2 例：18%，95%置信区间，15%至 22%；每年 11 例或更多：9%，95%置信区间，5%至 12%；P<.001），而 TEVAR 在四分位数之间没有差异。与三个较低的容量四分位数相比，每年进行 26 次或更多的整体胸主动脉夹层修复的中心的调整死亡率较低（P<.001）。
这项研究表明，在主动脉夹层的整体修复中，高容量医院的死亡率较低，对于 TAAD 和 TBAD 的手术修复分别持续存在，但对于 TEVAR 则不然。随着血管内技术的进步和实践模式的相应改变，分析应侧重于理解胸主动脉夹层的手术量、死亡率和获得治疗之间的平衡。
