Outcomes before and after initiation of an acute aortic treatment center.
BACKGROUND
Acute aortic syndromes remain life-threatening. Time is of the essence, as mortality rises with increasing time after the acute episode. The aim of this report is to show changes in practice and outcomes after the establishment of an acute aortic treatment center (AATC) to expedite the care of acute aortic syndromes in a major metropolitan area with the belief that "door to intervention time under 90 minutes" reduces mortality and morbidity from acute aortic disease.


METHODS
A database of patients admitted with acute aortic disease (Type A and B aortic dissections, acute thoraco-abdominal aortic aneurysms, acute and ruptured abdominal aortic aneurysms) for 1 year prior to initiation (2007) and 1 year after initiation of the pathway (AATC) in 2008 was developed. Comorbidities were scored according to Society of Vascular Surgery criteria. Anatomic and functional outcomes were determined and categorized by Society of Vascular Surgery reporting criteria. Multivariate analysis was performed for categorical outcomes and Cox proportional hazard analyses for time-dependent outcomes.


RESULTS
Six hundred twenty-one patients reported with aortic disease to the cardiovascular services; 306 patients were considered to have acute disease. When compared with the year before the AATC was instituted, there was a 30% increase in the total number of admissions and a 25% increase in acute pathology after setting up the AATC (P = .02). There was a two-fold increase in thoracic aortic dissections admitted to the service. Initiation of the treatment pathway resulted in a highly significant 64% reduction in time to definitive therapy (526 ± 557 vs 187 ± 258 minutes, mean ± SD pre-AATC vs AATC; P = .0001). Comorbidity scores were equivalent between the two cohorts. Despite the increase in acuity, mortality (4% vs 6%) and morbidity (41% vs 45%) rates were unchanged, and there was a significant decrease in intensive care unit length of stay (5 vs 4 days, pre-AATC cohort vs the AATC cohort), but total hospital length of stay (11 vs 10 days) was unchanged. There was no correlation between deaths within 30 days and length of stay in the intensive care unit.


CONCLUSIONS
Establishment of a multidisciplinary AATC pathway was associated with a 30% increase in volume, 64% reduction in time to definitive treatment, improved throughput with reduced intensive care unit time, and maintained clinical efficacy despite an increase in acute admissions. These results suggest the concept be further evaluated.
Davies
Mark G
MG
Methodist DeBakey Heart and Vascular Center, Department of Cardiovascular Surgery, The Methodist Hospital, 6550 Fannin-Smith Tower, Ste. 1401, Houston, Texas 77030, USA. MDavies@tmhs.org
Younes
Houssam K
HK
Harris
Patricia W
PW
Masud
Faisal
F
Croft
Bryan A
BA
Reardon
Michael J
MJ
Lumsden
Alan B
AB
D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000601:surgery*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000601:surgery*; D019091:Critical Pathways; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D006757:Hospital Units / Q000458:organization & administration*; D006801:Humans; D015993:Life Tables; D008297:Male; D010360:Patient Transfer; D011183:Postoperative Complications; D012017:Referral and Consultation; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000458:organization & administration