血管内主动脉瘤修复术中急性手术转换的结果。
Outcomes of acute intraoperative surgical conversion during endovascular aortic aneurysm repair.
机构信息
Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
出版信息
J Vasc Surg. 2011 Nov;54(5):1244-50; discussion 1250. doi: 10.1016/j.jvs.2011.04.046. Epub 2011 Aug 6.
PURPOSE
Outcomes and predictors of acute surgical conversion during endovascular aortic aneurysm repair (EVAR) were examined using the American College of Surgeons-National Safety and Quality Improvement Project (ACS-NSQIP) Database (2005 to 2008).
METHODS
Acute intraoperative surgical conversions occurring during elective EVAR were identified using Current Procedural Terminology codes. Nonemergent EVAR and primary open surgical repairs of infrarenal aneurysms were examined for comparison. Perioperative morbidity was categorized as wound, pulmonary, venous thromboembolic, genitourinary, cardiovascular, operative, and septic. Mortality, overall morbidity, and length of stay (LOS) were examined.
RESULTS
We identified 72 acute conversions, 2414 open repairs, and 6332 EVAR without acute conversion. Demographics and comorbidities were generally similar among operative groups. Mean operative time was 274 minutes for acute conversion vs 226 minutes for primary open repair and 162 minutes for EVAR (conversion vs EVAR and open repair vs EVAR P < .0001 for each; conversion vs open repair P = .0014; analysis on rank operative time). Blood transfusion was required in 69% of acute conversions (mean volume, 6.0 units) vs 73% of open repairs (mean volume, 3.3 units) and 12% of EVARs (mean volume, 2.6 units; P < .0001 for each pair-wise comparison; analysis on rank number of units among those transfused). Major morbidity was 28% for acute conversions, 28% for open repairs, and 12% for EVARs. Mortality was 4.2% for acute conversions, 3.2% for open repairs, and 1.3% for EVARs. Median (quartile 1, quartile 3) LOS was 7 (5, 9) days for acute conversion and open repair, and 2 (1, 3) days for EVAR. Morbidity and mortality were significantly higher for acute conversion and open repair vs EVAR. The OR (95% confidence interval) for morbidity was 2.9 (1.7-4.8) after conversion and 2.8 (2.5-3.2) after open repair (P < .0001 for both) and for mortality was 3.4 (1.0-10.9; P = .0437) for conversion and 2.5 (1.9-3.5; P < .0001) for open repair. Morbidity and mortality were similar between acute conversion and open repair. A similar pattern among repair groups was demonstrated for LOS, with similar LOS for acute conversions and open repair, which were significantly longer than those observed for EVAR. No significant demographic or medical risk factor predictors of acute conversion during EVAR were identified.
CONCLUSION
Acute surgical conversion was a rare complication affecting 1.1% of EVAR cases, with no broadly identifiable at-risk population. When conversion did occur, morbidity and mortality rates paralleled those observed for elective open repair.
目的
使用美国外科医师学会-国家手术质量改进计划（ACS-NSQIP）数据库（2005 年至 2008 年）研究血管内腹主动脉瘤修复（EVAR）过程中急性手术转换的结果和预测因素。
方法
使用当前手术术语代码识别择期 EVAR 过程中发生的急性术中手术转换。将非紧急 EVAR 和肾下动脉瘤的原发性开放手术修复作为对照进行检查。围手术期发病率分为伤口、肺部、静脉血栓栓塞、泌尿生殖、心血管、手术和脓毒症。检查死亡率、总发病率和住院时间（LOS）。
结果
我们确定了 72 例急性转换，2414 例开放修复和 6332 例无急性转换的 EVAR。手术组的一般人口统计学和合并症相似。手术时间平均为急性转换 274 分钟，原发性开放修复 226 分钟，EVAR 162 分钟（转换与 EVAR 和开放修复与 EVAR 相比，P<0.0001 ；转换与开放修复，P=0.0014；分析手术时间的等级）。69%的急性转换需要输血（平均量为 6.0 单位），73%的开放修复需要输血（平均量为 3.3 单位），12%的 EVAR 需要输血（平均量为 2.6 单位；每组间比较，P<0.0001；分析输注患者的单位数等级）。急性转换的主要发病率为 28%，开放修复为 28%，EVAR 为 12%。急性转换的死亡率为 4.2%，开放修复为 3.2%，EVAR 为 1.3%。急性转换和开放修复的中位数（四分位间距 1，四分位间距 3）为 7（5，9）天，EVAR 为 2（1，3）天。急性转换和开放修复的发病率和死亡率明显高于 EVAR。转换后的发病率的 OR（95%置信区间）为 2.9（1.7-4.8），开放修复后的发病率为 2.8（2.5-3.2）（两者均 P<0.0001），死亡率的 OR 为 3.4（1.0-10.9；P=0.0437），开放修复的死亡率为 2.5（1.9-3.5；P<0.0001）。急性转换和开放修复之间的发病率和死亡率相似。在修复组中，住院时间也表现出类似的模式，急性转换和开放修复的住院时间相似，明显长于 EVAR。在 EVAR 过程中未发现急性转换的明显人口统计学或医疗风险因素预测因素。
结论
急性手术转换是一种罕见的并发症，影响 1.1%的 EVAR 病例，没有广泛可识别的高危人群。当确实发生转换时，发病率和死亡率与择期开放修复相似。
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