腹主动脉瘤治疗的范式转变：1996 年至 2008 年间 721 例患者的趋势。
Paradigm shifts in the treatment of abdominal aortic aneurysm: trends in 721 patients between 1996 and 2008.
机构信息
Vascular and Endovascular Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, USA.
出版信息
J Vasc Surg. 2010 Jun;51(6):1348-52; discussion 1352-3. doi: 10.1016/j.jvs.2010.01.078.
OBJECTIVE
This study evaluated longitudinal trends in abdominal aortic aneurysm (AAA) management after later-generation endografts became available.
METHODS
We retrospectively analyzed non-suprarenal AAA repairs between January 1, 1996, and December 31, 2008, performed at a single institution. Patients were stratified by endovascular AAA repair (EVAR) or open repair and the presence or absence of rupture. Thirty-day mortality rates were compared with the Fisher exact test.
RESULTS
During a 13-year period, 721 patients underwent AAA repair, comprising 410 (56.9%) with EVAR and 311 (43.1%) with open repair. A bimodal distribution of EVAR usage was observed, with initial escalation in the 1990s to 70%. A nadir of EVAR occurred in the early 2000s (40%), correlating with more conservative EVAR use after the limitations of first-generation endografts were understood. Between 2005 and 2008, average EVAR use increased to 84%. The overall 30-day mortality rate for the entire cohort, including ruptured AAA, was 3.8%: 2.0% (8 of 410) for EVAR and 6.1% (19 of 311) for open repair (P < .05). Ruptured AAA had a mortality rate of 0% (0 of 8) for EVAR vs 31% (9 of 29) for open (P = .16). Non-ruptured AAA mortality was 2.0% (8 of 402) for EVAR vs 3.6% (10 of 282) for open (P = .23). EVAR and open repair both had reductions in mortality in the latter half of the series, combining to provide a significant decrease in overall mortality to 1.8% for patients treated from 2003 to 2008 compared with 4.9% for 1996 to 2002 (P < .05). Open AAA repair became more complex during the study period. The average rate for juxtarenal open AAA repair was 17.7% (range, 6.5%-34.6%) between 1996 and 2002 compared with 55.6% (range, 29.6%-100%) between 2003 and 2008 (P < .05).
CONCLUSIONS
AAA treatment has undergone a profound and sustained paradigm shift, now averaging 84% of repairs performed with EVAR between 2005 and 2008. Overall mortality from AAA repair, including ruptures, was reduced 64% (from 4.9% to 1.8%) during the 13-year study period. Although EVAR and open repair both had improved mortality in the latter half of the series, the primary driver in reduced mortality for AAA repair has been the shift to EVAR.
目的
本研究评估了新一代覆膜支架问世后腹主动脉瘤（AAA）管理的纵向趋势。
方法
我们回顾性分析了 1996 年 1 月 1 日至 2008 年 12 月 31 日在一家机构进行的非肾上AAA 修复术。根据血管内 AAA 修复术（EVAR）或开放修复术以及是否破裂对患者进行分层。采用 Fisher 确切检验比较 30 天死亡率。
结果
在 13 年期间，721 名患者接受了 AAA 修复术，其中 410 例（56.9%）采用 EVAR，311 例（43.1%）采用开放修复术。EVAR 的使用呈双峰分布，最初在 20 世纪 90 年代上升至 70%。21 世纪初 EVAR 的使用率出现低谷，这与第一代覆膜支架的局限性得到理解后更保守的 EVAR 使用有关。2005 年至 2008 年期间，平均 EVAR 使用量增加至 84%。包括破裂性 AAA 在内的整个队列的 30 天死亡率为 3.8%：EVAR 为 2.0%（410 例中的 8 例），开放修复术为 6.1%（311 例中的 19 例）（P<.05）。破裂性 AAA 的 EVAR 死亡率为 0%（8 例中的 0 例），而开放修复术为 31%（29 例中的 9 例）（P=.16）。非破裂性 AAA 的 EVAR 死亡率为 2.0%（402 例中的 8 例），开放修复术为 3.6%（282 例中的 10 例）（P=.23）。在后半段系列中，EVAR 和开放修复术的死亡率均有所下降，合并后 2003 年至 2008 年期间治疗的患者总体死亡率降至 1.8%，而 1996 年至 2002 年期间为 4.9%（P<.05）。开放 AAA 修复术在研究期间变得更加复杂。1996 年至 2002 年期间，肾周 AAA 开放修复术的平均比例为 17.7%（范围 6.5%至 34.6%），而 2003 年至 2008 年期间为 55.6%（范围 29.6%至 100%）（P<.05）。
结论
AAA 治疗发生了深刻而持续的范式转变，现在 2005 年至 2008 年间进行的修复术平均有 84%采用 EVAR。在 13 年的研究期间，AAA 修复术的总体死亡率（包括破裂）下降了 64%（从 4.9%降至 1.8%）。尽管 EVAR 和开放修复术在后半段系列中死亡率均有所改善，但 AAA 修复术死亡率下降的主要原因是转向 EVAR。
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