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基于人群的降胸主动脉瘤开放修复术的结局

Population-based outcomes of open descending thoracic aortic aneurysm repair.

作者信息

Schermerhorn Marc L, Giles Kristina A, Hamdan Allen D, Dalhberg Suzanne E, Hagberg Robert, Pomposelli Frank

机构信息

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass, USA.

出版信息

J Vasc Surg. 2008 Oct;48(4):821-7. doi: 10.1016/j.jvs.2008.05.022. Epub 2008 Jun 30.

Abstract

OBJECTIVE

To evaluate national outcomes after open repair of descending thoracic aortic aneurysm (DTA).

METHODS

The DTA repairs were identified from the NIS database from 1988-2003 by ICD9 codes for thoracic vascular resection and replacement (38.45) and a diagnosis of intact (441.1) or ruptured (441.2) thoracic aortic aneurysm; excluding thoraco-abdominal aneurysm, abdominal aortic aneurysm repair, cardioplegia, hypothermia, cardiac surgery, or aorta to carotid or subclavian bypass. Demographics and comorbidities were noted. Outcomes included in-hospital mortality, length of stay, and complications. Annual hospital surgical volume terciles (high, medium, and low) were quantified for the series and patients assigned accordingly. Outcomes were compared between intact and ruptured aneurysm characteristics as well as annual hospital volume. Predictors of peri-operative mortality were analyzed by multivariate logistic regression.

RESULTS

A total of 2549 DTA repairs were identified (1976 intact, 573 ruptured). Mortality was 18% overall; 10% for intact (age <65 6.2%, 65-74 11.3%, >/=75 17.6%, P < .001), 45% for ruptured (age <65 33.3%, 65-74 47.1%, >/=75 52.4%, P < .001). Mortality decreased over the 15-year time-period (P < .0001). Mortality after intact repair was lower at a high volume hospital (HVH) (8%) than a low volume hospital (LVH) (13%) or medium volume hospital (MVH) (12%). Hospital volume tercile did not predict rupture mortality. Complications after intact DTA repair were coded in 42%; including respiratory (13%), cardiac (11%), acute renal failure (8%), stroke (3%), and neurologic (non-stroke) (2%). Complications were coded in 49% after ruptured DTA repair including respiratory (13%), cardiac (13%), acute renal failure (20%), stroke (3%), and neuro (non-stroke) (2%). Predictors of mortality (for all DTA repairs) were (odd ratio [OR], 95% confidence interval [CI]): age 65-74 vs age <65 (1.8, 1.4-2.4), age >/=75 vs age <65 (2.7, 2.0-3.6), rupture (6.3, 5.1-7.9), and LVH or MVH vs HVH (1.3, 1.1-1.7).

CONCLUSION

Mortality after open repair of DTA is high and complications are common. Mortality is dependent upon age, rupture status, and hospital surgical volume. Results of endovascular DTA repair should be compared using similar population-based data.

摘要

目的

评估降主动脉瘤(DTA)开放修复术后的全国性治疗结果。

方法

通过ICD9编码(胸血管切除和置换,38.45)以及完整(441.1)或破裂(441.2)胸主动脉瘤的诊断,从1988 - 2003年的国家住院患者样本(NIS)数据库中识别出DTA修复病例;排除胸腹主动脉瘤、腹主动脉瘤修复、心脏停搏、低温、心脏手术或主动脉至颈动脉或锁骨下动脉搭桥手术。记录人口统计学和合并症情况。结果包括住院死亡率、住院时间和并发症。对该系列病例按年度医院手术量三分位数(高、中、低)进行量化,并相应地对患者进行分组。比较完整和破裂动脉瘤特征以及年度医院手术量之间的结果。通过多因素逻辑回归分析围手术期死亡率的预测因素。

结果

共识别出2549例DTA修复病例(1976例完整,573例破裂)。总体死亡率为18%;完整动脉瘤患者死亡率为10%(年龄<65岁为6.2%,65 - 74岁为11.3%,≥75岁为17.6%,P <.001),破裂动脉瘤患者死亡率为45%(年龄<65岁为33.3%,65 - 74岁为47.1%,≥75岁为52.4%,P <.001)。死亡率在15年期间有所下降(P <.0001)。高手术量医院(HVH)完整修复后的死亡率(8%)低于低手术量医院(LVH)(13%)或中等手术量医院(MVH)(12%)。医院手术量三分位数不能预测破裂动脉瘤的死亡率。完整DTA修复术后并发症发生率为42%;包括呼吸系统(13%)、心脏(11%)、急性肾衰竭(8%)、中风(3%)和神经系统(非中风)(2%)。破裂DTA修复术后并发症发生率为49%,包括呼吸系统(13%)、心脏(13%)、急性肾衰竭(20%)、中风(3%)和神经系统(非中风)(2%)。死亡率的预测因素(针对所有DTA修复病例)为(比值比[OR],95%置信区间[CI]):年龄65 - 74岁与年龄<65岁相比(1.8,1.4 - 2.4),年龄≥75岁与年龄<65岁相比(2.7,2.0 - 3.6),破裂(6.3,5.1 - 7.9),以及LVH或MVH与HVH相比(1.3,1.1 - 1.7)。

结论

DTA开放修复术后死亡率高且并发症常见。死亡率取决于年龄、破裂状态和医院手术量。应使用类似的基于人群的数据来比较血管内DTA修复的结果。

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