ARTICLE IN PRESS JID: YMSY [m5G;June 6, 2018;13:58] Surgery 000 (2018) 1–6 Contents lists available at ScienceDirect Surgery journal homepage: www.elsevier.com/locate/surg A nationwide study of treatment modalities for thoracic aortic injury ✩, ✯✯ Young-Ji Seo, Sarah E. Rudasill, Yas Sanaiha, Esteban Aguayo, Katherine L. Bailey, Vishal Dobaria, Peyman Benharash ∗ Division of Cardiac Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA a r t i c l e i n f o Article history: Accepted 9 April 2018 Available online xxx a b s t r a c t Background: Thoracic aortic injuries have traditionally been associated with high morbidity and mor- tality. Thoracic endovascular aortic repair has emerged as a suitable alternative to open repair, but its impact at a national level remains ill defined. This study aimed to analyze the national trends of patient characteristics, outcomes, and resource utilization in the treatment of thoracic aortic injuries. Methods: Patients admitted with thoracic aortic injuries from 2005–2014 were identified in the National Inpatient Sample. Patients were identified as undergoing thoracic endovascular aortic repair, open surgery, or nonoperative management. The primary outcome was in-hospital mortality, while secondary outcomes included complications and costs. Multivariate regressions accounting for characteristics of the patients and injury characteristics were used to determine predictors of mortality and changes in cost. Results: Of the 11,257 patients admitted for thoracic aortic injuries, 33% received thoracic endovascular aortic repair, 8% open surgery, and 59% nonoperative management. Thoracic endovascular aortic repair had the great largest growth in case volume (P < .001). Compared to open surgery, thoracic endovascular aortic repair patients had greater rates of concomitant brain (17 vs 26%, P = .01), pulmonary (21 vs 33%, P < .001), and splenic injuries (2 vs 4%, P = .031). In-hospital mortality was greater for open surgery (odds ratio = 3.06, P = .003) and nonoperative management (odds ratio = 4.33, P < .001) than thoracic endovascular aortic repair. Over time, mortality rates for thoracic endovascular aortic repair decreased (P = .002), but increased for open surgery (P = .04). Interestingly, total costs with thoracic endovascular aortic repair increased (P = .004), while they decreased for open surgery (P = .031). Conclusion: Our findings indicate the rapid adoption of thoracic endovascular aortic repair over open surgery for management of thoracic aortic injuries. Thoracic endovascular aortic repair is associated with lower mortality rates, but it has greater costs not otherwise explained by other patient factors. © 2018 Elsevier Inc. All rights reserved. Introduction Despite a low incidence, thoracic aortic injuries (TAIs) caused by trauma remain a substantial cause of morbidity and mortal- ity. 1 Based on limited single-institution series, 80% of TAIs result in immediate mortality, 2 often caused by shearing forces from the sudden deceleration of motor vehicles and falls. 3-5 Open surgical repair requiring thoracotomy, single-lung ventilation, and car- diopulmonary bypass has been the standard treatment for TAIs since 1959. 4 This major operative procedure, however, is associated ✩ Presented at the 13th Annual Academic Surgical Congress in Jacksonville, FL, January 30 to February 1, 2018. ✯✯ The authors have no conflicts of interest to disclose. ∗ Corresponding author at Peyman Benharash, MD, UCLA Division of Cardiac Surgery, Los Angeles, CA 90095. E-mail address: pbenharash@mednet.ucla.edu (P. Benharash). with high rates of complications and mortality, especially given the frequency of concomitant injuries in TAI patients. 6 Thoracic endovascular aortic repair (TEVAR) is a less invasive approach that deploys prefitted grafts in the thoracic aorta, thus avoiding thoracotomy and single-lung ventilation. 3 The technique was first utilized for the treatment of TAIs in 1997 and gained FDA approval for the first commercial graft in 2005. 7,8 Since that time, multiple institutional studies have reported lower mortality rates for patients undergoing TEVAR relative to open surgical repair. 9-16 In addition to decreased mortality, patients undergoing TEVAR ex- perience lower rates of complications, including paraplegia, pneu- monia, acute renal failure, and postoperative infection. 10, 14-17 Although the use of TEVAR for the treatment of TAI has sup- planted open repair at institutions with endovascular expertise, adoption of this technology and its impact on other treatment modalities at a national level remain ill defined. Resource utiliza- tion for various modalities is rarely reported, and studies report- https://doi.org/10.1016/j.surg.2018.04.015 0039-6060/© 2018 Elsevier Inc. All rights reserved. Please cite this article as: Y.-J. Seo et al., A nationwide study of treatment modalities for thoracic aortic injury, Surgery (2018), https://doi.org/10.1016/j.surg.2018.04.015