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Page 4 of 5 Tanaka et al. Vessel Plus 2023;7:28 https://dx.doi.org/10.20517/2574-1209.2023.108

HOSPITAL/SURGEON CASE VOLUMES
There is a clear relationship between hospital volume and operative mortality after open TAAA repair. A
US-based study using Nationwide Inpatient Sample, including 1,542 patients and 20% of US hospitals,
demonstrated a near doubling of operative mortality after open TAAA repair at the low-volume hospitals
(median annual case: 1) compared to that of high-volume hospitals (median annual case: 12) (27% vs. 15%,
[14]
P < 0.001) . This study also showed a similar relationship in surgeon volume-operative mortality (low-
volume surgeon: median annual case of 1; high-volume surgeon: median annual case of 7; operative
[13]
mortality 26% vs. 11%, < 0.001) .

Similarly, a recent study using the Vascular Quality Initiative database evaluated the impact of hospital
volume on operative mortality after endovascular TAAA repair in 2,115 patients from 118 centers . The
[15]
study demonstrated that centers with low and medium quantile volumes (mean annual case: 3.6 and 9.3)
had higher 30-day mortality rates compared to the high-volume hospitals (mean annual case: 22.7)
(unadjusted 30-day mortality 5.1%, 6.5%, 2.2%, respectively, P = 0.002). Of note, for complex fenestrated-
branched EVAR, there is a learning curve, even after 300 cases . Preoperative planning of fenestrations and
[16]
[17]
cannulation of branch vessels represent a significant portion of the learning curve with these devices .
Thus, if the patient with TAAA was suitable to be treated by either of the procedures, it may be reasonable
to be treated using the approach that the treating institution is more proficient and experienced in.
However, if the institution is not well experienced with either open or endovascular aortic repair, stable
TAAA patients should be referred to an experienced aortic center for the patient’s benefit.

SUMMARY
For patients with stable TAAA, it is recommended to refer them to experienced aortic centers. Open
surgical TAAA repair should be considered in patients with connective tissue disorders, younger age (less
than 50 years old), and ruptured hemodynamically unstable TAAA. Endovascular TAAA repair should be
considered in patients with sarcopenia, advanced age, renal dysfunction, and lung dysfunction, if they have
suitable anatomy. The two approaches should remain complementary.

DECLARATIONS
Authors’ contributions
Responsible for the overall concept and design of this paper: Tanaka A, Smith HN, Estrera AL
Responsible for writing and research: Tanaka A, Smith HN
Reviewed and approved the final version: All three authors

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Estrera AL is a consultant for WL Gore, CryoLife, Edwards Life Science, and Terumo Aortic.
The other authors have no disclosures.