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The Impact Of Annual Surgeon Volume On Outcomes Following Thoracic Endovascular Aortic Repair For Blunt Thoracic Aortic Injury
Sai Divya Yadavalli, MD1, Tim J. Mandigers, MD1, Vinamr Rastogi, MD1, Christina L. Marcaccio, MD, MPH1, Sophie X. Wang, MD1, Sara L. Zettervall, MD, MPH2, Benjamin W. Starnes, MD2, Hence JM Verhagen, MD PhD3, Marc L. Schermerhorn, MD1.
1BIDMC, Boston, MA, USA, 2University of Washington, Seattle, WA, USA, 3Erasmus University Medical Center, Rotterdam, Netherlands.

Objectives: Higher center volumes have been shown to be independently associated with improved perioperative mortality following TEVAR for blunt thoracic aortic injury (BTAI), though the effect of surgeon volumes has not been studied. Methods: We identified VQI patients who underwent TEVAR for BTAI between 2013-2022. Annual surgeon volumes were measured as the number of TEVARs (for any pathology) performed
over a one-year period preceding each procedure and were categorized into quintiles. Surgeons in the first volume quintile were considered as low volume (LV) and the highest quintile as high volume (HV), with the middle three quintiles considered medium volume (MV). Cases that did not have data for the preceding one-year period were excluded. Multilevel logistic regression models were used to evaluate the effect of surgeon volumes on in-hospital outcomes, accounting for annual center volumes and random effects for center to account for the clustering of multiple patients within the same center.Results: We studied 968 TEVARs for BTAI (25% by LV surgeons [0/1 repair], 54% by MV surgeons [2-8 repairs], 21% by HV surgeons [≥9 repairs]). With increasing surgeon volumes, there were no differences in SVS aortic injury grade, Glasgow Coma Score, and Injury Severity Score (p-trend>.05). However, with increasing surgeon volume, we observed lower rates of perioperative mortality (LV vs MV vs HV: 11% vs 7.1% vs 5.4%; p-trend=.014), postoperative complications (39% vs 32% vs 29%;p-trend=.025) and stroke (6.1% vs 3.1% vs 2.0%;p-trend=.01). Compared with low surgeon volume, medium and high surgeon volumes were associated with lower perioperative mortality (MV vs LV: aOR 0.44 [95%CI:0.23-0.87];p=.018); HV vs LV: aOR 0.37 [0.14-0.96];p=.041 | Table), while accounting for the impact of center volume. MV and HV were also associated with lower odds of postoperative stroke and with a trend for lower odds of any postoperative complication. Conclusion: Following TEVAR for BTAI, higher surgeon volume was associated with lower perioperative mortality and postoperative complications, specifically postoperative stroke. Given these results, efforts should be directed towards determining a minimum threshold of TEVAR cases per surgeon per year that will ensure adequate training and likely improve outcomes following TEVAR for BTAI.

Table I. Outcomes following TEVAR for BTAI stratified by annual surgeon volume
Low surgeon volume(0/1 repair)(N=244)Medium surgeon volume(2-8 repairs)(N=519)High surgeon volume (9 repairs)(N=205)Medium volume vs Low volume(N=519)High volume vs Low volume(N=205)
Unadjusted rates (%)Adjusted outcomesOR [95% CI]p-value
Perioperative death127.15.40.48 [0.25-0.93]0.37 [0.14-0.95]
Aortic related mortality7. [0.19, 1.1]0.77 [0.25-2.4]
Any Complication3932290.66 [0.44-1.0]0.61 [0.35-1.1]
Stroke6. [0.10-0.69]0.25 [0.07-0.91]
Acute Kidney Injury2217160.70 [0.44-1.1]0.55 [0.30-1.04]
Postoperative Dialysis4. [0.21-1.4]1.1 [0.35-3.3]
Spinal Cord Ischemia2. [0.13-2.5]0.99 [0.16-6.2]
Bowel Ischemia1. [0.18-4.3]3.2 [0.54-19]
Leg Ischemia2. [0.10-1.6]1.4 [0.34-5.7]
Pulmonary Complications2118160.83 [0.52-1.3]0.81 [0.43-1.5]
Cardiac Complication1. [0.51-6.6]0.83 [0.13-5.4]
Reintervention during index admission3. [0.33-2.7]0.62 [0.12-3.3]
*This model was corrected for age, sex, center volume (based on number of traumatic TEVAR cases), ISS >25 (yes/no binary variable), renal dysfunction (eGFR <60), left subclavian revascularization/occlusion, Glasgow Coma Score

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