title: National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries.
abstract: Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally.
  
  
  
  Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality.
  
  
  
  Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P < .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P < .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P < .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P < .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P < .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P < .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P < .001), respiratory complications (47.5% vs 54.8%; P < .001), and shorter length of stay (18.4 vs 20.2 days; P = .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3).
  
  
  
  TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Klaas H J
authors.initials: KH
authors.lastname: Ultee
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
authors.forename: Victor
authors.initials: V
authors.lastname: Chien
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
authors.forename: Rodney P
authors.initials: RP
authors.lastname: Bensley
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Zettervall
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Hence J M
authors.initials: HJ
authors.lastname: Verhagen
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000328:Adult; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data / Q000639:trends*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality / Q000706:statistics & numerical data / Q000639:trends*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012307:Risk Factors; D013898:Thoracic Injuries / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D055815:Young Adult