Division of Cardiothoracic Surgery, Hugh E. Stephenson Department of Surgery, University of Missouri-Columbia School of Medicine, Columbia, MO 65212, USA.
J Thorac Cardiovasc Surg. 2011 Nov;142(5):1010-8. doi: 10.1016/j.jtcvs.2011.08.014. Epub 2011 Sep 9.
Recent studies support the use of endovascular treatment for ruptured abdominal aortic aneurysms, but few studies have examined the use of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm. We evaluated nationwide data regarding short-term outcomes of TEVAR and open aortic repair (OAR) for ruptured descending thoracic aortic aneurysm.
From US Nationwide Inpatient Sample data, we identified 923 patients who underwent ruptured descending thoracic aortic aneurysm repair in 2006-2008 and who had no concomitant aortic disorders. Of these patients, 364 (39.4%) underwent TEVAR and 559 (60.6%) underwent OAR. Multivariable regression was used to assess the effect of TEVAR versus OAR after adjusting for potential confounding factors. Outcomes assessed were in-hospital mortality, complications, failure to rescue (defined as the mortality among patients in whom a complication develops), and disposition. Backward stepwise logistic regression was used to identify independent predictors of outcomes for each approach.
Patients undergoing TEVAR were older (72 ± 12 years vs 65 ± 15 years; P < .001) and had a higher Deyo comorbidity index (4.19 ± 1.79 vs 3.14 ± 2.05; P < .001) than patients undergoing OAR. Unadjusted mortality was 23.4% (85/364) for TEVAR and 28.6% (160/559) for OAR. After risk adjustment, the odds of mortality, complications, and failure to rescue were similar for TEVAR and OAR (P > .1 for all), but patients undergoing TEVAR had a greater chance of routine discharge (odds ratio [OR] = 3.3; P < .001). An interaction was identified that linked hospital size and operative approach with risk of complications (P < .001). In smaller hospitals, TEVAR was associated with lower complication rates than OAR (OR = 0.21; P < .05). Regression analysis revealed that smaller hospital size predicted significantly higher rates of mortality (OR = 2.4; P < .05), complications (OR = 4.0; P < .005), and failure to rescue (OR = 51.12; P < .001) in those undergoing OAR but not in those undergoing TEVAR. Preexisting renal disorders substantially increased mortality risk (OR = 10.81; P < .001) and failure to rescue (OR = 309.54; P < .001) in patients undergoing TEVAR.
Nationwide data for ruptured descending thoracic aortic aneurysm reveal equivalent mortality, complication rates, and failure to rescue for TEVAR and OAR but more frequent routine discharge with TEVAR. Unlike OAR outcomes, TEVAR outcomes were not poorer in smaller hospitals, where TEVAR produced fewer complications than OAR. Therefore, TEVAR may be an ideal alternative to OAR for ruptured descending thoracic aortic aneurysm, particularly in small hospitals where expertise in OAR may be lacking and immediate transfer to a higher echelon of care may not be feasible.
最近的研究支持使用血管内治疗破裂的腹主动脉瘤，但很少有研究探讨胸主动脉腔内修复术（TEVAR）在破裂的降主动脉瘤中的应用。我们评估了全国范围内关于 TEVAR 和开放主动脉修复术（OAR）治疗破裂的降主动脉瘤的短期结果的数据。
我们从美国全国住院患者样本数据中确定了 923 名 2006-2008 年接受破裂的降主动脉瘤修复的患者，且没有合并其他主动脉疾病。这些患者中，364 例（39.4%）接受了 TEVAR，559 例（60.6%）接受了 OAR。采用多变量回归在调整潜在混杂因素后评估 TEVAR 与 OAR 的效果。评估的结果包括院内死亡率、并发症、救援失败（定义为发生并发症的患者的死亡率）和处置。采用向后逐步逻辑回归确定每种方法的独立预后预测因素。
与接受 OAR 的患者相比，接受 TEVAR 的患者年龄更大（72 ± 12 岁 vs 65 ± 15 岁；P <.001），Deyo 合并症指数更高（4.19 ± 1.79 vs 3.14 ± 2.05；P <.001）。TEVAR 的未调整死亡率为 23.4%（85/364），OAR 的死亡率为 28.6%（160/559）。在风险调整后，TEVAR 和 OAR 的死亡率、并发症和救援失败的几率相似（所有 P >.1），但接受 TEVAR 的患者更有可能常规出院（优势比[OR] = 3.3；P <.001）。发现了一个交互作用，该作用将医院规模和手术方法与并发症风险联系起来（P <.001）。在较小的医院中，TEVAR 与 OAR 相比，并发症发生率较低（OR = 0.21；P <.05）。回归分析显示，较小的医院规模显著预测了接受 OAR 的患者死亡率（OR = 2.4；P <.05）、并发症（OR = 4.0；P <.005）和救援失败（OR = 51.12；P <.001）的发生率较高，但接受 TEVAR 的患者则不然。预先存在的肾脏疾病显著增加了接受 TEVAR 的患者的死亡率风险（OR = 10.81；P <.001）和救援失败的风险（OR = 309.54；P <.001）。
全国范围内破裂的降主动脉瘤数据显示，TEVAR 和 OAR 的死亡率、并发症发生率和救援失败率相当，但 TEVAR 更常常规出院。与 OAR 结果不同，TEVAR 结果在较小的医院中并不差，在这些医院中，TEVAR 的并发症发生率低于 OAR。因此，TEVAR 可能是破裂的降主动脉瘤的理想替代 OAR 的方法，特别是在 OAR 专业知识可能不足且立即转至更高层次的治疗可能不可行的小医院。
