Greco Giampaolo, Egorova Natalia, Anderson Patrice L, Gelijns Annetine, Moskowitz Alan, Nowygrod Roman, Arons Ray, McKinsey James, Morrissey Nicholas J, Kent K Craig
International Center for Health Outcomes and Innovation Research (inCHOIR), Columbia University, New York, NY 10032, USA.
J Vasc Surg. 2006 Mar;43(3):453-459. doi: 10.1016/j.jvs.2005.11.024.
The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome.
We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test.
We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001).
We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.
血管内技术在腹主动脉瘤（AAA）择期修复中的成功应用激发了人们对其用于应对一项长期存在的外科挑战——破裂腹主动脉瘤（RAAA）的浓厚兴趣。采用传统开放手术修复破裂动脉瘤的手术死亡率高达45%至50%。在本研究中，我们评估了四个大州目前RAAA血管内修复的频率以及该技术对患者预后的影响。
我们检查了加利福尼亚州、佛罗里达州、新泽西州和纽约州2000年至2003年的出院数据集，这四个州的总人口几乎占美国人口的三分之一。采用卡方分析对比例和趋势进行分析，采用学生t检验对连续变量进行分析。
我们发现，自2000年以来，血管内修复已开始成为RAAA的一种可行治疗选择，在2003年占病例修复数的6.2%。同期，RAAA开放手术的使用有所下降。血管内修复与开放修复相比，4年期间的总体死亡率显著更低（39.3%对47.7%，P = 0.005）。此外，与开放修复相比，血管内修复导致肺部、肾脏和出血并发症的发生率显著更低。血管内修复后的生存率与医院经验相关，通过择期和非择期血管内手术的总体数量来评估。对于血管内修复，小容量医院的死亡率为45.9%，大容量医院为26%（P = 0.0011）。手术量也是开放修复死亡率的一个决定因素，尽管程度要小得多（小容量医院为51.5%，大容量医院为44.3%；P < 0.0001）。
我们观察到，在具有丰富血管内经验的机构中，对RAAA采用血管内手术有益；然而，行政数据分析不能排除选择偏倚作为更好预后的一种解释。这些数据强烈支持进行前瞻性研究，以明确RAAA患者生存率的提高在多大程度上应归因于血管内治疗方法而非低风险患者的选择。
