Forbes Thomas L, Chu Michael W A, Lawlor D Kirk, DeRose Guy, Harris Kenneth A
Division of Vascular Surgery, London Health Sciences Centre and the University of Western Ontario, London, Ontario, Canada.
J Vasc Surg. 2007 Aug;46(2):218-22. doi: 10.1016/j.jvs.2007.03.047. Epub 2007 Jun 27.
Recently, practice guideline documents have recommended the completion of different levels of interventional experience and 5 or 10 thoracic endovascular aortic cases prior to surgeon credentialing. This study's purpose was to determine whether these requirements are valid by reviewing three surgeons' learning curves with thoracic aortic endovascular repairs.
Between 1998 and 2006, 67 patients underwent emergent or elective endovascular repair of thoracic aortic pathologies by one of three vascular surgeons with extensive experience with catheter manipulation and abdominal aortic endografts. Following standard retrospective review, each surgeon's learning curve was analyzed using the cumulative sum failure method with a target success rate of 95% derived from the literature. The main outcome variable was primary technical success.
These 67 patients presented with several pathologies including elective (n = 31) and ruptured (n = 11) thoracic aortic aneurysms, acute dissections or aortic ulcers (n = 10), and acute blunt thoracic aortic trauma (n = 15). The mean age was 65 (range: 20 to 90) and the early (30 day) mortality rate was 19.4% in urgent cases (n = 36) and 0% in elective cases (n = 31). Paraplegia occurred in two patients (3%). Primary technical success was achieved in 62 cases (92.5%) and did not differ between surgeons (92.6%, 91.3%, 94.1%, respectively; P = .9). Each surgeon's cases were plotted sequentially and the resulting learning curves were similar. Although acceptable outcomes were obtained throughout the study period, improved results, compared with the target success rate, were not achieved until each surgeon treated 5 to 10 patients.
This study supports the case volume requirements of the Society for Vascular Surgery credentialing guidelines, which also requires extensive catheter and guidewire experience. With this background in catheter manipulation and endovascular abdominal aortic repair, surgeons can achieve optimal outcomes with thoracic aortic lesions following 5 to 10 cases.
最近，实践指南文件建议在外科医生获得资质认证之前，需完成不同水平的介入经验以及5例或10例胸段血管腔内主动脉手术。本研究的目的是通过回顾三位外科医生胸段主动脉血管腔内修复术的学习曲线，来确定这些要求是否合理。
1998年至2006年间，67例患者接受了三位血管外科医生之一进行的胸段主动脉病变的急诊或择期血管腔内修复术，这三位医生在导管操作和腹主动脉内支架方面经验丰富。经过标准的回顾性分析，使用累积和失败法分析每位外科医生的学习曲线，目标成功率根据文献设定为95%。主要结局变量为初次技术成功。
这67例患者存在多种病变，包括择期（n = 31）和破裂性（n = 11）胸段主动脉瘤、急性夹层或主动脉溃疡（n = 10）以及急性钝性胸段主动脉损伤（n = 15）。平均年龄为65岁（范围：20至90岁），急诊病例（n = 36）的早期（30天）死亡率为19.4%，择期病例（n = 31）为0%。两名患者（3%）发生截瘫。62例（92.5%）获得了初次技术成功，不同外科医生之间无差异（分别为92.6%、91.3%、94.1%；P = 0.9）。依次绘制每位外科医生的病例，得到的学习曲线相似。虽然在整个研究期间都获得了可接受的结果，但直到每位外科医生治疗5至10例患者后，与目标成功率相比，结果才有所改善。
本研究支持血管外科学会资质认证指南中的病例数量要求，该指南还要求有丰富的导管和导丝经验。有了这种导管操作和腹主动脉血管腔内修复的背景，外科医生在处理5至10例胸段主动脉病变后可获得最佳结果。
