We read with great interest the scientific letter by Ferrera et al.1 It was a valiant, pioneering initiative in Spain, with promising preliminary results. We would like to make some observations in relation to their study.

During the Aorta Code period, 40% of deaths occurred in patients who did not undergo surgery, that is, those who received medical or endovascular treatment. In contrast, during the standard care period, there were no deaths in nonsurgical patients. This means that nonsurgical mortality was higher during the Aorta Code period. Although it is unlikely that the difference would reach significance, it could be interesting to analyze why the nonsurgical patients died.

The study by Ferrer et al.1 demonstrated that during the Aorta Code period, there was a reduction in transfer time, preoperative complications, and surgical mortality from type A acute aortic syndrome (this mortality did not reach statistical significance). These are important advances that unfortunately have not resulted in an improvement in overall survival of patients with acute aortic syndrome. It would be useful to assess to what extent the higher mortality of nonsurgical patients during the Aorta Code period could have affected this overall result.

In addition, the higher rate of complicated aortic syndromes before surgery in the standard care period could have led to a higher preoperative risk and explain the higher surgical mortality observed in this period without leaving the focus on the surgical technique alone. It could be interesting to analyze to what extent the higher surgical mortality of the standard care period could have been due to the patients who underwent surgery being at higher risk.

We share the statement on page 97, first column, lines 10-12: “management of acute aortic disease by a small team of dedicated surgeons at a limited number of specialized centers has been found to improve survival outcomes”. However, the publication by Anderson et al.,2 on which this statement is based, refers exclusively to patients with type A aortic syndrome. It is possible that in the study by Ferran et al.1 that, in addition to sample size, the joint presentation of the outcomes of type A and type B aortic syndrome could explain the lack of parallelism between surgical mortality and overall mortality. In our opinion, this study could be strengthened by qualifying the third conclusion.