Matsumura Jon S, Katzen Barry T, Sullivan Timothy M, Dake Michael D, Naftel David C
Department of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois 60611, USA.
Ann Vasc Surg. 2009 Mar;23(2):153-8. doi: 10.1016/j.avsg.2008.07.006. Epub 2008 Sep 6.
Clinical decision making for asymptomatic abdominal aortic aneurysms (AAAs) weighs risk of aneurysm rupture, treatment hazards, and overall survival expectations. AAA diameter is the primary parameter in assessing rupture risk. Perioperative risk assessment has been extensively studied, and in-hospital mortality has been reduced to less than 8% with higher-risk open repair and less than 3% with endovascular repair. The purpose of this report is to determine risk factors that predict 2-year survival following open and endovascular AAA repair. We studied 334 patients enrolled in a multicenter clinical trial evaluating an endovascular graft in comparison to standard open repair of infrarenal AAA. Demographic, medical history, physical examination, laboratory, anatomic, procedural, and standardized risk score system variables were analyzed in a multivariable Cox proportional hazard model. Overall survival was 89% at 2 years. Heart disease, cancer, and stroke were the most common causes of death, and no deaths were due to AAA rupture. Cox modeling demonstrated that there were several independent predictors for death after AAA repair: smaller body mass index (p=0.005), Society for Vascular Surgery pulmonary risk score >or=1 (p=0.005), history of erectile dysfunction (p=0.008), history of heart valve replacement (p=0.008), lower preoperative platelet count (p=0.012), larger ratio of AAA diameter/proximal neck diameter (p=0.020), and lower ankle-brachial index (p=0.031). Age, gender, and open or endovascular treatment group are not significant independent risk factors for 2-year mortality in this study. Clinical, laboratory, and anatomic factors predict survival after open and endovascular repair of AAAs. With progressive reduction of in-hospital mortality, assessment of patient longevity after AAA repair has become a more important factor in clinical decision making. Use of valid predictors of patient survival will optimize resource utilization and improve overall patient outcomes. Better selection of patients for any method of repair may improve overall utility more than choice of open or endovascular techniques.
无症状腹主动脉瘤（AAA）的临床决策需权衡动脉瘤破裂风险、治疗风险及总体生存预期。AAA直径是评估破裂风险的主要参数。围手术期风险评估已得到广泛研究，高危开放修复的院内死亡率已降至8%以下，血管内修复的死亡率则低于3%。本报告的目的是确定预测开放和血管内AAA修复术后2年生存率的危险因素。我们研究了334例参与多中心临床试验的患者，该试验对比了血管内移植物与肾下腹主动脉瘤标准开放修复术。在多变量Cox比例风险模型中分析了人口统计学、病史、体格检查、实验室检查、解剖学、手术及标准化风险评分系统变量。2年时的总体生存率为89%。心脏病、癌症和中风是最常见的死亡原因，无死亡因AAA破裂所致。Cox模型表明，AAA修复术后死亡有多个独立预测因素：较低的体重指数（p = 0.005）、血管外科学会肺部风险评分≥1（p = 0.005）、勃起功能障碍病史（p = 0.008）、心脏瓣膜置换病史（p = 0.008）、术前较低的血小板计数（p = 0.012）、较大的AAA直径/近端颈部直径比值（p = 0.020）及较低的踝肱指数（p = 0.031）。在本研究中，年龄、性别及开放或血管内治疗组并非2年死亡率的显著独立危险因素。临床、实验室及解剖学因素可预测AAA开放和血管内修复术后的生存情况。随着院内死亡率的逐步降低，AAA修复术后患者寿命的评估已成为临床决策中更重要的因素。使用有效的患者生存预测指标将优化资源利用并改善患者总体预后。相较于开放或血管内技术的选择，更好地筛选适合任何修复方法的患者可能会更大程度地提高总体效用。
