Marrocco-Trischitta Massimiliano M, Melissano Germano, Kahlberg Andrea, Calori Giliola, Setacci Francesco, Chiesa Roberto
Department of Vascular Surgery, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy.
J Vasc Surg. 2009 Feb;49(2):296-301. doi: 10.1016/j.jvs.2008.09.041. Epub 2008 Nov 22.
Risk factors for perioperative and late mortality after thoracic endovascular aortic repair (TEVAR) remain ill-defined. In this study, we examined the prognostic significance of chronic kidney disease (CKD), a well-known predictor of death after thoracic aorta open repair, employing a stratification based on CKD stages derived from glomerular filtration rate (GFR) values.
A prospective database was evaluated for 179 consecutive patients electively submitted to TEVAR between 1999 and 2007. Preoperative GFR was estimated by using the Cockcroft-Gault equation. Patient groups were stratified into four quartiles by baseline serum creatinine (SC) and GFR values, with quartile I being the lowest, and quartile IV the highest, and into the five CKD stages in reverse order (I GFR >or= 90 ml/min/1.73 m(2); II 60-89; III 30-59; IV 15-29; V < 15). Prognostic significance of preoperative GFR values and CKD stages were investigated by means of univariate and multivariate analyses, and the Kaplan-Meier log-rank method.
A primary technical success was achieved in 166 of 179 patients (92.7%), and an initial clinical success in 158 (88.3%). Thirty-day mortality was 5% (nine cases). Paraplegia or paraparesis were observed in 11 (6.1%) patients, and completely resolved in six cases after cerebrospinal fluid drainage. Preoperative GFR quartiles and CKD stages were significant predictors of 30-day mortality (P = .004 and P < .0001 respectively), whereas SC quartiles did not affect the outcome (P = .12). In particular, GFR quartile I (<60 ml/min/1.73 m(2)) was associated with a ten-fold greater risk of perioperative death compared with the other three quartiles (Odds Ratio 11.4, 95% Confidence Interval 2.3-57.0, P = .003). Midterm survival was 88.8% (159 of 179) at a mean follow-up of 35.6 +/- 23.7 months. Actuarial survival at 60 months was 57.8%, 81.1%, 92.3%, and 100% for GFR quartiles I to IV respectively (P < .0001), and 0.0%, 66.7%, 59.2%, 88.6%, and 100% (P < .0001) for CKD stage V to I respectively. At univariate analyses, age (P = .019), preoperative SC quartiles (P = .001), GFR quartiles (P = .0002), and CKD stages (P < .0001) were all predictive of mid-term mortality. At multivariate Cox proportional hazards regression analysis, only CKD stages remained independently associated with the outcome (P = .008).
GFR is an accurate prognostic predictor in patients submitted to TEVAR. Also, perioperative and midterm mortality directly correlate with the severity of CKD stages, allowing a risk stratification model to be employed both for risk-adjusted preoperative evaluation, and to establish accurate matching criteria for comparative studies.
胸主动脉腔内修复术（TEVAR）围手术期及晚期死亡率的危险因素仍不明确。在本研究中，我们采用基于肾小球滤过率（GFR）值得出的慢性肾脏病（CKD）分期进行分层，研究CKD（胸主动脉开放修复术后死亡的一个众所周知的预测因素）的预后意义。
对1999年至2007年间连续179例行选择性TEVAR的患者的前瞻性数据库进行评估。术前GFR采用Cockcroft - Gault方程估算。根据基线血清肌酐（SC）和GFR值将患者组分为四个四分位数，四分位数I最低，四分位数IV最高，并按相反顺序分为五个CKD分期（I期GFR≥90 ml/min/1.73 m²；II期60 - 89；III期30 - 59；IV期15 - 29；V期<15）。通过单因素和多因素分析以及Kaplan - Meier对数秩检验方法研究术前GFR值和CKD分期的预后意义。
179例患者中有166例（92.7%）取得了主要技术成功，158例（88.3%）取得了初始临床成功。30天死亡率为5%（9例）。11例（6.1%）患者出现截瘫或轻瘫，其中6例经脑脊液引流后完全恢复。术前GFR四分位数和CKD分期是30天死亡率的显著预测因素（分别为P = 0.004和P < 0.0001），而SC四分位数不影响结果（P = 0.12）。特别是，GFR四分位数I（<60 ml/min/1.73 m²）与围手术期死亡风险相比其他三个四分位数高10倍相关（比值比11.4，95%置信区间2.3 - 57.0，P = 0.003）。平均随访35.6±23.7个月时，中期生存率为88.8%（179例中的159例）。GFR四分位数I至IV在60个月时的精算生存率分别为57.8%、81.1%、92.3%和100%（P < 0.0001），CKD分期V至I分别为0.0%、66.7%、59.2%、88.6%和100%（P < 0.0001）。在单因素分析中，年龄（P = 0.019）、术前SC四分位数（P = 0.001）、GFR四分位数（P = 0.0002）和CKD分期（P < 0.0001）均为中期死亡率的预测因素。在多因素Cox比例风险回归分析中，只有CKD分期仍与结果独立相关（P = 0.008）。
GFR是接受TEVAR患者的准确预后预测指标。此外，围手术期和中期死亡率与CKD分期的严重程度直接相关，这使得可以采用风险分层模型进行风险调整的术前评估，并为比较研究建立准确的匹配标准。
