Hua Hong T, Cambria Richard P, Chuang Sung K, Stoner Michael C, Kwolek Christopher J, Rowell Katherine S, Khuri Shukri F, Henderson William G, Brewster David C, Abbott William M
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 458, Boston, MA 02114, USA.
J Vasc Surg. 2005 Mar;41(3):382-9. doi: 10.1016/j.jvs.2004.12.048.
There remains no consensus on the appropriate application of endovascular abdominal aortic aneurysm repair (EVAR). Information from administrative databases, industry-sponsored trials, and single institutions has inherent deficiencies. This study was designed to compare early outcomes of open (OPEN) versus EVAR in a contemporary (2000 to 2003) large, multicenter prospective cohort.
Fourteen academic medical centers contributed data to the National Surgical Quality Improvement Program-Private Sector (NSQIP-PS), which ensures uniform, comprehensive, prospective, and previously validated data entry by trained, independent nurse reviewers. A battery of clinical and demographic features was assessed with multivariate analysis for association with the principal study end points of 30-day operative mortality and morbidity.
One thousand forty-two patients underwent elective infrarenal abdominal aortic aneurysm (AAA) repairs: 460 EVAR and 582 OPEN. EVAR patients were older (74 vs 71 years, P < .0001), included more men (84.6% vs 79.6%, P < .05), and had a higher incidence of chronic obstructive pulmonary disease (25.4% vs 17.9%, P < .01). EVAR resulted in significantly reduced overall morbidity (24% vs 35%, P < .0001) and hospital stay (4 vs 9 days, P < .0001). Cardiopulmonary and renal function-related comorbidities had the expected significant impact on mortality for both procedures at univariate analysis ( P < .05). While crude mortality rates between EVAR and OPEN did not differ significantly (2.8% vs 4.0%) ( P = 0.32). After multivariate analysis, correlates of operative mortality included OPEN (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.03 to 5.78; P < .05), advanced age (OR, 1.11; P < .001), history of angina (OR, 5.54; P < .01), poor functional status (OR, 5.78; P < .001), history of weight loss (OR, 7.42; P < .01), and preoperative dialysis (OR, 51.4; P < .0001). EVAR also compared favorably to OPEN (OR, 2.14; 95% CI, 1.58 to 2.89; P < .0001) for overall morbidity.
Significant morbidity accompanies AAA repair, even at major academic medical centers. These data strongly endorse EVAR as the preferred approach in the presence of significant cardiopulmonary or renal comorbidities, or poor preoperative functional status.
对于血管内腹主动脉瘤修复术（EVAR）的适当应用，目前尚无共识。来自行政数据库、行业赞助试验和单一机构的信息存在固有缺陷。本研究旨在比较当代（2000年至2003年）大型多中心前瞻性队列中开放手术（OPEN）与EVAR的早期结果。
14个学术医疗中心向国家外科质量改进计划-私营部门（NSQIP-PS）提供数据，该计划确保由训练有素的独立护士评审员进行统一、全面、前瞻性且先前已验证的数据录入。通过多变量分析评估一系列临床和人口统计学特征与30天手术死亡率和发病率等主要研究终点的相关性。
1042例患者接受了择期肾下腹主动脉瘤（AAA）修复术：460例行EVAR，582例行OPEN。接受EVAR的患者年龄更大（74岁对71岁，P <.0001），男性更多（84.6%对79.6%，P <.05），慢性阻塞性肺疾病发病率更高（25.4%对17.9%，P <.01）。EVAR导致总体发病率显著降低（24%对35%，P <.0001），住院时间缩短（4天对9天，P <.0001）。在单变量分析中，心肺和肾功能相关合并症对两种手术的死亡率均有预期的显著影响（P <.05）。虽然EVAR和OPEN之间的粗死亡率无显著差异（2.8%对4.0%）（P = 0.32）。多变量分析后，手术死亡率的相关因素包括OPEN（比值比[OR]，2.44；95%置信区间[CI]，1.03至5.78；P <.05）、高龄（OR，1.11；P <.001）、心绞痛病史（OR，5.54；P <.01）、功能状态差（OR，5.78；P <.001）、体重减轻病史（OR，7.42；P <.01）和术前透析（OR，51.4；P <.0001）。在总体发病率方面，EVAR也优于OPEN（OR，2.14；95%CI，1.58至2.89；P <.0001）。
即使在主要的学术医疗中心，AAA修复术也伴随着显著的发病率。这些数据强烈支持在存在显著心肺或肾脏合并症或术前功能状态差的情况下，将EVAR作为首选方法。
