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There has been great interest in the setting of threshold operative volumes for safety to guide centralisation of vascular surgical services by healthcare commissioners. This editorial examines the evidence for designing services around a numeric safety threshold in the relationship between volume and outcome in vascular surgery. Thresholds should be aimed at the best outcomes and equity of care. Equity means access to the most up-to-date technology and all the relevant support services for elective and emergency cases. The relationship of volume and outcome with quality is complex, and demands a shift in focus to infrastructural and procedural improvements that drive high-quality services rather than the concentration of planning exclusively around an operative volume threshold.

Aortic dissection represents the most common aortic emergency, affecting 3 to 4 per 100,000 people per year and is still associated with a high mortality. Twenty percent of the patients with aortic dissection die before reaching hospital and 30% die during hospital admission. Aortic dissections may be classified in 3 ways: according to their anatomical extent (the Stanford or DeBakey systems), according to the time from onset (acute or chronic), and according to the underlying pathology (the European Society of Cardiologists' system). Advances in endovascular technology have provided new treatment options. Hybrid endovascular and conventional open surgical repair represent the mainstay of treatment for acute type A dissection. Medical management remains the gold standard for acute and uncomplicated chronic type B dissection, though endovascular surgery offers exciting potential in the management of complicated type B dissection through sealing of the intimal entry tear.