Schermerhorn Marc L, O'Malley A James, Jhaveri Ami, Cotterill Philip, Pomposelli Frank, Landon Bruce E
Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
N Engl J Med. 2008 Jan 31;358(5):464-74. doi: 10.1056/NEJMoa0707348.
Randomized trials have shown reductions in perioperative mortality and morbidity with endovascular repair of abdominal aortic aneurysm, as compared with open surgical repair. Longer-term survival rates, however, were similar for the two procedures. There are currently no long-term, population-based data from the comparison of these strategies.
We studied perioperative rates of death and complications, long-term survival, rupture, and reinterventions after open as compared with endovascular repair of abdominal aortic aneurysm in propensity-score-matched cohorts of Medicare beneficiaries undergoing repair during the 2001-2004 period, with follow-up until 2005.
There were 22,830 matched patients undergoing open repair of abdominal aortic aneurysm in each cohort. The average age of the patients was 76 years, and approximately 20% were women. Perioperative mortality was lower after endovascular repair than after open repair (1.2% vs. 4.8%, P<0.001), and the reduction in mortality increased with age (2.1% difference for those 67 to 69 years old vs. 8.5% for those 85 years or older, P<0.001). Late survival was similar in the two cohorts, although the survival curves did not converge until after 3 years. By 4 years, rupture was more likely in the endovascular-repair cohort than in the open-repair cohort (1.8% vs. 0.5%, P<0.001), as was reintervention related to abdominal aortic aneurysm (9.0% vs. 1.7%, P<0.001), although most reinterventions were minor. In contrast, by 4 years, surgery for laparotomy-related complications was more likely among patients who had undergone open repair (9.7%, vs. 4.1% among those who had undergone endovascular repair; P<0.001), as was hospitalization without surgery for bowel obstruction or abdominal-wall hernia (14.2% vs. 8.1%, P<0.001).
As compared with open repair, endovascular repair of abdominal aortic aneurysm is associated with lower short-term rates of death and complications. The survival advantage is more durable among older patients. Late reinterventions related to abdominal aortic aneurysm are more common after endovascular repair but are balanced by an increase in laparotomy-related reinterventions and hospitalizations after open surgery.
随机试验表明，与开放性手术修复相比，腹主动脉瘤的血管内修复可降低围手术期死亡率和发病率。然而，两种手术的长期生存率相似。目前尚无基于人群的长期数据来比较这些策略。
我们研究了2001 - 2004年期间接受修复的医疗保险受益人的倾向得分匹配队列中，腹主动脉瘤开放性修复与血管内修复后的围手术期死亡率和并发症、长期生存率、破裂及再次干预情况，并随访至2005年。
每个队列中有22,830例匹配患者接受腹主动脉瘤开放性修复。患者的平均年龄为76岁，约20%为女性。血管内修复后的围手术期死亡率低于开放性修复（1.2%对4.8%，P<0.001），且死亡率的降低随年龄增加而增加（67至69岁者相差2.1%，85岁及以上者相差8.5%，P<0.001）。两个队列的晚期生存率相似，尽管生存曲线直到3年后才趋同。到4年时，血管内修复队列中腹主动脉瘤破裂的可能性高于开放性修复队列（1.8%对0.5%，P<0.001），与腹主动脉瘤相关的再次干预也是如此（9.0%对1.7%，P<0.001），尽管大多数再次干预是小手术。相比之下，到4年时，接受开放性修复的患者因剖腹手术相关并发症而进行手术的可能性更大（9.7%，血管内修复患者为4.1%；P<0.001），因肠梗阻或腹壁疝未进行手术而住院的情况也是如此（14.2%对8.1%，P<0.001）。
与开放性修复相比，腹主动脉瘤的血管内修复与较低的短期死亡率和并发症发生率相关。老年患者的生存优势更持久。血管内修复后与腹主动脉瘤相关的晚期再次干预更常见，但开放性手术后剖腹手术相关的再次干预和住院增加可与之相平衡。
