From the Society for Clinical Vascular Surgery

A population-based analysis of endovascular versus

open thoracic aortic aneurysm repair
Babak J. Orandi, MD, MSc,a Justin B. Dimick, MD, MPH,b G. Michael Deeb, MD,c
Himanshu J. Patel, MD,c and Gilbert R. Upchurch Jr, MD,d Ann Arbor, Mich

Objective: The perioperative outcomes of open surgical and endovascular repair of intact thoracic aortic aneurysms (TAAs)
during the last 3 months of 2005 were compared using a national administrative database.
Methods: The Nationwide Inpatient Sample was used to identify patients undergoing open aneurysm repair (OAR) or
endovascular TAA repair (TEVAR) from October 1 to December 31, 2005. Patient demographic data, length of stay,
hospital charges, patient disposition, and mortality were examined. Where appropriate, univariate tests of association
used the ␹2 test, and multiple logistic regression analysis was used to determine predictors of in-hospital mortality,
complications, and discharge status.
Results: A total of 1030 patients underwent open TAA repair and 267 underwent TEVAR. There was no significant
difference in mortality between OAR and TEVAR (adjusted odds ratio [OR], 1.2; 95% confidence interval [CI],
0.73-2.12), although OAR patients were more likely to have cardiac, respiratory, and hemorrhagic complications.
Patients undergoing TEVAR were more likely to be discharged to home (adjusted OR, 6.37; 95% CI, 2.93-13.70) and
had a decreased length of stay (5.7 days vs 9.9 days; P ⴝ .0015). The differences in hospital charges and costs were not
significant.
Conclusion: Although further study is warranted, this study of a national sample suggests that endovascular TAA repair
is safe in the short-term, associated with fewer cardiac, respiratory, and hemorrhagic complications, and requires a shorter
hospital stay. ( J Vasc Surg 2009;49:1112-6.)

An open surgical approach to thoracic aortic aneurysm
(TAA) repair has been the method of treatment for 50
years. Open aneurysm repair (OAR) is associated with
significant complications, however, including intraopera-
tive and postoperative myocardial infarction, renal insuffi-
ciency, hemorrhage, postoperative pneumonia, lower ex-
tremity ischemia, stroke, and paralysis. These risks are
compounded because aneurysm patients frequently have
multiple cardiovascular comorbidities, protracted hospital
stays, and poor long-term survival.1 Despite this, these risks
are frequently outweighed by the threat of aneurysm rup-
ture, estimated to be 50% to 75% for large, untreated
aneurysms, and its incumbent high mortality rate.2-4
The last 20 years has witnessed the rapid development
of a number of catheter-based approaches for the treatment
of vascular pathologies since Parodi first established the
feasibility of endovascular stent grafting.5 In the mid-
1990s, the endovascular paradigm was first applied to an-
eurysms of the thoracic aorta.6,7 Short-term results appear
promising, but there remains a dearth of evidence on the
success of this approach, in no small part due to the
relatively rare occurrence of TAA compared with abdomi-
nal aortic aneurysm (AAA). TAA is estimated to occur in
From the Department of Surgery,a Sections of General Surgery,b Cardiac
Surgery,c and Vascular Surgery,d University of Michigan Medical School.
Competition of interest: none.
Presented at the Society for Clinical Vascular Surgery Annual Meeting, Las
Vegas, Nev, Mar 7, 2008.
Reprint requests: Gilbert R. Upchurch Jr, MD, Section of Vascular Surgery,
CVC 5463, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5867
(e-mail: riversu@umich.edu).
0741-5214/$36.00
Copyright © 2009 by the Society for Vascular Surgery.
doi:10.1016/j.jvs.2008.12.024
1112
6/100,000 person-years, compared with 36.5/100,000
person-years for AAA.4,8 To date, no prospective, random-
ized trial has compared the two approaches, and the current
published reports are plagued with significant limitations.9
Single-institution studies often display sampling bias and
the effects of institutional learning curves. Case series are
frequently weakened by small patient sample sizes and
heterogeneous patient populations.
In late 2005, an International Classification and Diag-
nosis, Ninth Revision (ICD-9), procedure code unique to
endovascular thoracic aortic aneurysm repair (TEVAR) was
introduced.10 This allows for an analysis of data comparing
OAR and TEVAR that provides a “snapshot” of the current
state of practice in the United States (US). A literature
search reveals that this is the first study comparing OAR and
TEVAR patient outcomes from a large, unselected sam-
pling that represents nearly the entire scope of unruptured
TAA repairs in the country.
METHODS
All data were abstracted from the Nationwide Inpatient
Sample (NIS)11 from October 1, 2005, through December
31, 2005. The NIS, the largest all-payer inpatient care
database, is sponsored by the Agency for Healthcare Re-
search and Quality12 and contains data from ⬎8 million
hospital discharges annually from 1054 hospitals in 37
states, representing 90% of all US hospital discharges. The
database contains patient and hospital demographic data,
ICD-9 diagnosis and procedure codes, mortality informa-
tion, and hospital charges.
Patients with an ICD-9 primary diagnosis code for
TAA without mention of rupture (441.2) and with a pri-
JOURNAL OF VASCULAR SURGERY
Volume 49, Number 5 Orandi et al 1113

Table I. Demographic and cardiovascular comorbidity data for open versus endovascular thoracic aortic aneurysm
repair

Variable Total OAR TEVAR P

Patients, No. (%) 1030 (100) 763 (74.0) 267 (26.0)

Age, mean ⫾ SD, y 67.1 ⫾ 21.4 66.1 ⫾ 21.3 69.9 ⫾ 20.9 .01
Sex, No. (%)
Male 689 (66.9) 504 (66.1) 185 (69.2)
Female 341 (33.1) 259 (33.9) 82 (30.8) .35
Race, No. (%)
White 661 (85.1) 533 (89.0) 128 (71.8)
Nonwhite 116 (14.9) 66 (11.0) 50 (28.2) ⬍.0001
Pre-op comorbidities
Number, No. (%)
0-1 490 (47.6) 407 (53.3) 83 (31.2)
2-3 483 (46.9) 330 (43.3) 153 (57.3)
⬍4 57 (5.5) 26 (3.4) 31 (11.6) ⬍.0001
Cardiovascular
Diabetesa 104 (10.1) 84 (11.0) 20 (7.6) .12
Hypertensionb 694 (67.4) 490 (64.3) 204 (76.2) .0004
Renal insufficiencyc 150 (14.6) 97 (12.7) 53 (20.0) .0036
COPDd 204 (19.8) 138 (18.1) 66 (24.8) .02
Ischemic heart diseasee 397 (38.5) 282 (36.9) 115 (43.1) .07
CVODf 91 (8.8) 41 (5.3) 50 (18.8) ⬍.0001
PADg 75 (7.3) 25 (3.3) 50 (18.7) ⬍.0001
COPD, Chronic obstructive pulmonary disease; CVOD, cerebrovascular occlusive disease; OAR, open aneurysm repair; PAD, peripheral arterial disease;
TEVAR, thoracic endovascular aneurysm repair.
a
Based on ICD-9 codes 250.0-250.9.
b
Based on ICD-9 codes 401.0-405.9.
c
Based on ICD-9 codes 584.0-586.0.
d
Based on ICD-9 codes 490.0-496.0.
e
Based on ICD-9 codes 410.0-414.9.
f
Based on ICD-9 codes 430.0-438.0.
g
Based on ICD-9 codes 440.0-440.9, 443.0-443.9.

mary procedure code for endovascular implantation of a
graft in the thoracic aorta or resection of a vessel with
replacement, specifically any thoracic vessel involvement
(39.73 and 38.45, respectively) were selected for analysis.
Exclusion criteria included age ⬍50 years, concurrent
ICD-9 procedure codes for both OAR and TEVAR, and
ICD-9 diagnosis codes for congenital anomalies such as
gonadal dysgenesis, Marfan syndrome, and Turner syn-
drome, as well as the diagnosis of polyarteritis nodosa
(758.6, 759.82, 446). Patients with abdominal or thoraco-
abdominal aneurysm diagnosis codes (441.1, 441.5,
441.4, 441.0, 441.6, 441.7) were excluded, as were those
with procedure codes for the repair of these pathologies
(39.71, 38.44).
Outcomes assessed included in-hospital mortality,
postoperative complications, length of stay, hospital
charges, hospital costs, patient disposition after discharge,
and patient demographics such as age, gender, race, and
number of cardiovascular comorbidities. The ICD-9 cod-
ing system has specific codes for complications resulting
from a procedure, and these were used to determine the
complication rates. The number of comorbidities was de-
termined by the presence of ICD-9 diagnosis codes for
diabetes mellitus, hypertension, preoperative renal insuffi-
ciency, chronic obstructive pulmonary disease, ischemic
heart disease, cerebrovascular occlusive disease, and periph-
eral arterial disease.
Statistical analysis was performed using SAS 9.1 soft-
ware (SAS Institute, Cary, NC). Descriptive statistics for
baseline patient characteristics and in-hospital mortality
were obtained. Where appropriate, univariate tests of asso-
ciation used the ␹2 test, and multiple logistic regression
analyses were used to determine predictors of in-hospital
mortality, complications, and discharge status. Odds ratios
(OR) and 95% confidence intervals (CI) were calculated.
Values of P ⬍ .05 were considered statistically significant.
RESULTS
During the last quarter of 2005, 1030 intact, unrup-
tured TAAs were repaired (Table 1). Of those, 267 (26%)
were repaired by TEVAR, and the remaining 763 (74%)
were repaired by OAR.
The average ages were 66 years for OAR patients and
nearly 70 years for TEVAR (P ⫽ .01). Data on race were
unavailable for 253 patients (24.6%). Of the remaining
patients, almost 15% were nonwhite, and 43% of these
underwent TEVAR compared with 19% of white patients
(P ⬍ .0001). Women comprised one-third of the sample
size (n ⫽ 341) and were as likely as men to undergo
TEVAR (24% vs 27%; P ⫽ .35).
TEVAR patients tended to have a higher burden of
cardiovascular comorbidities (P ⬍ .0001). Although
TEVAR and OAR patients were similar in their rates of
diabetes mellitus (P ⫽ .12) and ischemic heart disease (P ⫽
 JOURNAL OF VASCULAR SURGERY
1114 Orandi et al May 2009

Table II. Clinical outcomes after open vs endovascular OAR (95% CI, 4.9%-8.4%), TEVAR was associated with a
thoracic aortic aneurysm repair significantly shorter hospital stay, fewer cardiac, respiratory,
and hemorrhagic complications, and a higher likelihood of
Variable OAR TEVAR P discharge to home rather than an extended-care facility.
Multivariate analysis revealed that women are less likely
Total patients, No. (%) 763 (74.0) 267 (26.0)
Death, No. (%) 49 (6.4) 21 (7.7) .49 to be discharged to home than men. Overall, women
Complication, No. (%) undergoing TAA repair were older than their male coun-
Any 253 (33.1) 55 (20.4) ⬍.0001 terparts (P ⫽ .0270), and this was generally true when
Cardiac 144 (18.9) 15 (5.7) ⬍.0001 broken down by repair type and the number of comorbidi-
Length of stay, d
Median ⫾ SD 9.9 ⫾ 20.3 5.7 ⫾ 10.2 .0015
ties present. No women with four or more comorbidities
Median 7 5 .0011 underwent TEVAR. Women undergoing TAA repair
Disposition, No. (%) tended to be older and sicker, which may explain why
Home 601 (78.8) 242 (90.3) female gender predicts discharge to an extended-care facil-
Institution 112 (14.7) 5 (2.0) ⬍.0001 ity rather than to home.
OAR, Open aneurysm repair; SD, standard deviation; TEVAR, thoracic Based on our data, OAR is currently performed approx-
endovascular aneurysm repair. imately three times as often as TEVAR. If the experience
with AAA is mirrored, it is entirely likely that the propor-
.07), the TEVAR patients were significantly more likely to tion of TAA repairs performed with an endovascular ap-
have hypertension, renal insufficiency, chronic obstructive proach will increase. Stent grafts are designed and simulation-
pulmonary disease, cerebrovascular occlusive disease, and tested to be durable for 10 years, and in the coming years,
peripheral artery disease (Table 1). more evidence will become available about the in vivo
In-hospital mortality did not differ between the two longevity of these grafts.9 If the data are favorable, many
repair approaches (Table II): OAR patients had a 6.4% more patients, particularly younger patients, will become
mortality rate compared with 7.7% for TEVAR patients candidates for TEVAR. As the technology proliferates and
(P ⫽ .49). OAR patients had a higher overall complication the collective clinical experience with TEVAR increases on
rate (33% vs 20%; P ⬍ .0001). The two approaches were an individual practitioner and an institutional level, the
equivalent in their rates of iatrogenic cerebrovascular acci- mortality rate associated with endovascular repair for TAAs
dent; however, hematoma development, postoperative in- may decrease just as it has for endovascular AAA repair.13,14
fections, and cardiac, respiratory, and hemorrhagic compli- Our study demonstrated equivalent in-hospital costs
cations were more likely to develop in OAR patients (Table and charges for the two types of repair. Although this
III). information is useful in informing health care economists,
On average, TEVAR patients had hospital stays that policy decisions must be based on in-hospital as well as
were approximately half as long as OAR patients (P ⫽ long-term financial data. That TEVAR patients are more
.0015) and were more likely to be discharged to home often discharged to home rather than to an extended-care
rather than to an extended-care facility (P ⬍ .0001; Fig). facility may favor this approach in the short-term, although
Most TEVAR patients are discharged from the hospital this information must be tempered by the fact that many
within the first few days of their procedure, and a signifi- well-recognized complications of EVAR—namely en-
cantly higher number of OAR patients had prolonged doleak, stent migration, and stent fracture—are known to
hospitalizations (⬎10 days) than did TEVAR patients. occur more frequently after hospital discharge. In addition,
TAA repair had an average hospital charge to the pa- TEVAR patients currently require life-long computed to-
tient or insurer of $119,932 and an average cost to the mography surveillance, a cost that is not captured by the
hospital of $50,285, with no significant difference between NIS. Further study comparing the late costs of both ap-
the two approaches (data not shown). A subgroup analysis proaches using different data sources is needed.
of patients who were free of complications found that the Analysis of data for those patients who were free of
TEVAR approach was associated with a $10,000 reduction complications revealed that the length of stay was short-
in cost (P ⫽ .0331), but no difference in hospital charges. ened by approximately 1 day for both types of repair and
Multivariate analysis used the type of repair, age, gen- costs and charges were decreased. The decrease in costs
der, and the number of comorbidities to predict death, the favored TEVAR.
development of a complication, and discharge to home Analysis of patient demographics reveals that this is one
(Table IV). OAR and an increased comorbidity burden of the few examples in medicine of patients who belong to
were significant predictors of death. The type of repair and a minority racial group being more likely to receive the
age predicted the development of a complication, and the cutting edge care (ie, TEVAR). Prima facie, it may suggest
repair type, age, gender, and comorbidity burden all pre- that nonwhite patients are recipients of better, more tech-
dicted discharge to home. nologically advanced care. A more likely explanation, how-
ever, is that minority patients tend to come to medical
DISCUSSION attention much later than white patients and with more
Although our study demonstrated no difference in cardiovascular comorbidities, making them poorer candi-
mortality rates between TEVAR (95% CI, 5.2%-11.7%) and dates for OAR. Certainly, this explanation would be more
JOURNAL OF VASCULAR SURGERY
Volume 49, Number 5 Orandi et al 1115

Table III. Postoperative complications after open versus endovascular thoracic aortic aneurysm repair

Variable OAR TEVAR OR 95% CI

a
Iatrogenic CVA 0.034 0.019 1.84 0.70-4.84
Complication from a procedure
Cardiacb 0.189 0.057 3.85 2.23-6.66
Respiratoryc 0.072 0 41.81 2.57-679.21
Urinaryd 0.014 0.076 0.17 0.08-0.36
Complication during a procedure
Hemorrhagee 0.064 0.018 3.70 1.43-9.50
Hematomaf 0.077 0.089 0.85 0.52-1.40
Other postoperative infectiong 0.014 0 7.73 0.45-132.16
CI, confidence interval; CVA, cerebrovascular accident; OAR, open aneurysm repair; OR, odds ratio; TEVAR, thoracic endovascular aneurysm repair.
a
Based on ICD-9 code 997.02.
b
Based on ICD-9 code 997.1.
c
Based on ICD-9 code 997.3.
d
Based on ICD-9 code 997.5.
e
Based on ICD-9 code 998.11.
f
Based on ICD-9 code 998.1.
g
Based on ICD-9 code 998.5, 998.59.

Table IV. Multivariate analysis of independent

predictors of adverse outcomes

Outcome OR 95% CI P

Death
Repair type (OAR vs TEVAR) 3.5 1.2-10.4 .03
Age (vs 50-64 years)
65-79 2.4 0.4-14.1 .53
ⱖ80 1.6 0.2-12.3
Sex (male vs female) 0.8 0.4-1.9 .68
Comorbidities (vs 0-1)
2-3 1.4 0.6-3.3 ⬍.0001
Fig 1. Inpatient length of stay for open (dark bars) and endovas- 4-5 14.1 4.9-40.7
cular (gray bars) thoracic aortic aneurysm repair. Complication
Repair type (OAR vs TEVAR) 1.5 1.0-2.3 .04
Age (vs 50-64 years)
65-79 2.7 1.6-4.7 .001
consistent with the previously published reports on dispar- ⱖ80 2.9 1.4-6.0
ities in cardiovascular health care.15-17 Sex (male vs female) 1.0 0.7-1.4 .92
Comorbidities (vs 0-1)
This investigation does present limitations associated 2-3 1.0 0.7-1.4 .18
with studies that use large administrative databases. Owing 4-5 0.4 0.2-1.1
to the nature of the NIS, only in-hospital events, including Discharge to home
mortality, can be captured. Because hospital admissions are Repair type (OAR vs TEVAR) 0.1 0.1-0.3 ⬍.0001
Age (vs 50-64 years)
not linked, readmissions are counted as separate events and
⬎65-79 0.4 0.1-1.1 .04
cannot be linked to the original hospitalization. Accord- ⱖ80 0.2 0.1-0.7
ingly, the NIS is not an appropriate data source for assessing Sex (male vs female) 3.4 2.1-5.5 ⬍.0001
late complications associated with TEVAR. Comorbidities (vs 0-1)
2-3 0.4 0.3-0.7 ⬍.0001
Furthermore, limited clinical information is available,
4-5 0.0 0.0-0.1
making it impossible to garner more specific details such as
aneurysm size or morphology. It is also not possible to CI, Confidence interval; EVAR, endovascular aneurysm repair; OAR, open
aneurysm repair; OR, odds ratio; TEVAR, thoracic endovascular aneurysm
evaluate all of the clinically important outcomes of TAA
repair.
repair with the NIS, including postoperative paraplegia,
which is a well-known and feared complication of TAA
repair. The complication code for iatrogenic cerebrovascu- The limited granularity of the database precludes its use
lar accident refers specifically to ischemic or hemorrhagic in ascertaining more detailed information about the exact
stroke complicating a procedure. Although the code may surgical methods used. Certain techniques for open surgi-
include postprocedural paralysis, it is secondary to cerebral cal repair have become outmoded, but the database does
damage as the mechanism of injury, rather than spinal cord not distinguish those cases in which they are used from the
injury, which is a major concern in the repair of TAA but, ones in which the most up-to-date, preferred surgical
regrettably, cannot be assessed using the NIS database. methods are used. This analysis includes all of those cases.

1116 Orandi et al
In addition, it is important to be cognizant that all TAA
repairs fitting the inclusion criteria were included in this
study, irrespective of surgeon and hospital volume. The
literature does suggest that increased hospital volume—and
especially surgeon volume—are important determinants of
patient outcomes, particularly in major procedures such as
TAA repair.18,19
Only in-hospital events were captured, so it is possible
that the TEVAR mortality rate is underestimated because
these patients are released from the hospital more quickly
than OAR patients; however, the equivalent mortality rates
are consistent with single-institution series comparing the
two approaches.20,21 On the other hand, OAR patients are
more likely to be discharged to an extended-care facility.
Deaths that occur at these secondary facilities are not
captured in the NIS database, which may cause the OAR
mortality rate to be underestimated as well. Studies of
midterm follow-up for TEVAR show that the real concern
for death lies in the immediate perioperative period before
hospital discharge,22-24 suggesting that our mortality rate
accurately captures the bulk of repair-related deaths.
CONCLUSIONS
This study demonstrates that endovascular repair is
equivalent to open surgical repair for TAA repair in terms of
in-hospital mortality, and is favorable in the development
of cardiac, respiratory, and hemorrhagic complications,
hospital length of stay, and discharge to home. Additional
long-term study of the clinical and economic outcomes, as
well as select immediate postoperative outcomes, such as
paraplegia, between the two approaches is warranted.
We thank Zhaohui Fan and Vivek Sharma for their
assistance in analysis of the NIS database.
AUTHOR CONTRIBUTIONS
Conception and design: BO, GD, HP, GU
Analysis and interpretation: BO, JD, GD, HP, GU
Data collection: BO, GU
Writing the article: BO, JD, GU
Critical revision of the article: BO, JD, GD, HP, GU
Final approval of the article: BO, GU
Statistical analysis: BO
Obtained funding: N/A
Overall responsibility: GU
REFERENCES
1. Leurs LJ, Bell R, Degrieck Y, Thomas S, Hobo R, Lundbom J, et al.
Endovascular treatment of thoracic aortic diseases: Combined experi-
ence from the EUROSTAR and United Kingdom Thoracic Endograft
registries. J Vasc Surg 2004;40:670-9.
2. Johansson G, Markstrom U, Sweedenborg J. Ruptured thoracic aortic
aneurysms: a study of incidence and mortality rates. J Vasc Surg 1995;
21:985-8.
3. McNamara JJ, Pressler V. Natural history of arteriosclerotic thoracic
aneurysms. Ann Thorac Surg 1978;26:468-73.
JOURNAL OF VASCULAR SURGERY
May 2009
4. Bickerstaff LK, Pairolero PC, Hollier LH, Melton LJ, Van Peenen HJ,
Cherry KJ, et al. Thoracic aortic aneurysm: a population based ap-
proach. Surgery 1982;92:1103-7.
5. Parodi J, Palmaz J, Barone H. Transfemoral intraluminal graft implan-
tation for abdominal aortic aneurysms. Ann Vasc Surg 1991;5:494-9.
6. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP.
Transluminal placement of endovascular stent-grafts for the treatment
of descending thoracic aortic aneurysms. N Engl J Med 1994;331:
1729-34.
7. Mitchell RS, Dake MD, Semba CP, Fogarty TJ, Zarins CK, Liddel RP,
et al. Endovascular stent-graft repair of thoracic aortic aneurysms.
J Thorac Cardiovasc Surg 1996;111:1054-62.
8. Melton LJ 3rd, Bickerstaff LK, Hollier LH, Van Peenen HJ, Lie JT,
Pairolero PC, et al. Changing incidence of abdominal aortic aneurysms:
a population-based study. Am J Epidemiol 1984;120:379-86.
9. Svensson LG, Kouchoukos NT, Miller DC. Expert consensus docu-
ment on the treatment of descending thoracic aortic disease using
endovascular stent-grafts. Ann Thorac Surg 2008;85:S1-41.
10. International Classification of Diseases; Rev 9. Washington, DC: De-
partment of Health and Human Services; 1991.
11. HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and
Utilization Project (HCUP). 2005. Rockville, MD: Agency for Health-
care Research and Quality. www.hcup-us.ahrq.gov/nisoverview.jsp.
12. HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and
Utilization Project (HCUP). What is the NIS? 2005. Rockville, MD:
Agency for Healthcare Research and Quality. http://www.hcup-us.
ahrq.gov/nisoverview.jsp#Whatis.
13. Cowan JA Jr, Dimick JB, Henke PK, Rectenwald J, Stanley JC, Up-
church GR Jr. Epidemiology of aortic aneurysm repair in the United
States from 1993 to 2003. Ann N Y Acad Sci 2006;1085:1-10.
14. Dimick JB, Stanley JC, Axelrod DA, Kazmers A, Henke PK, Jacobs LA,
et al. Variation in death rate after abdominal aortic aneurysmectomy in
the United States: impact of hospital volume, gender, and age. Ann
Surg 2002;235:579-85.
15. Kressin NR, Petersen LA. Racial differences in the use of invasive
cardiovascular procedures: review of the literature and prescription for
future research. Ann Intern Med 2001;135:352-66.
16. Huber TS, Wang JG, Wheeler KG, Cuddeback JK, Dame DA, Ozaki
CK, et al. Impact of race on the treatment for peripheral arterial
occlusive disease. J Vasc Surg 1999;30:417-25.
17. Feinglass J, Rucker-Whitaker C, Lindquist L, McCarthy WJ, Pearce
WH. Racial differences in primary and repeat lower extremity amputa-
tion: results from a multihospital study. J Vasc Surg 2005;41:823-9.
18. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista
I, et al. Hospital volume and surgical mortality in the United States.
N Engl J Med 2002;346:1128-37.
19. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE,
Lucas FL. Surgeon volume and operative mortality in the United States.
N Engl J Med 2003;349:2117-27.
20. Ellozy SH, Carroccio A, Minor M, Jacobs T, Chae K, Cha A, et al.
Challenges of endovascular tube graft repair of thoracic aortic aneu-
rysm: midterm follow-up and lessons learned. J Vasc Surg 2003;38:
676-83.
21. Najibi S, Terramani TT, Weiss VJ, Mac Donald MJ, Lin PH, Redd DC,
et al. Endoluminal versus open treatment of descending thoracic aortic
aneurysms. J Vasc Surg 2002;36:732-7.
22. Tespili M, Banfi C, Valsecchi O, Aiazzi L, Ricucci C, Guagliumi G, et al.
Endovascular treatment of thoracic aortic disease: mid-term follow-up.
Catheter Cardiovasc Interv 2007;70:595-601.
23. Fattori R, Napoli G, Lovato L, Grazia C, Piva T, Rocchi G, et al.
Descending thoracic aortic diseases: stent-graft repair. Radiology 2003;
229:176-83.
24. Sandroussi C, Waltham M, Hughes CF, May J, Harris JP, Stephen MS,
et al. Endovascular grafting of the thoracic aorta, an evolving therapy:
ten-year experience in a single centre. ANZ J Surg 2007;77:974-80.
Submitted Sep 17, 2008; accepted Dec 9, 2008.