Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
Circulation. 2011 Dec 13;124(24):2661-9. doi: 10.1161/CIRCULATIONAHA.111.033944. Epub 2011 Nov 21.
The goal of this study was to describe short- and long-term survival of patients with descending thoracic aortic aneurysms (TAAs) after open and endovascular repair (TEVAR).
Using Medicare claims from 1998 to 2007, we analyzed patients who underwent repair of intact and ruptured TAA, identified from a combination of procedural and diagnostic International Classification of Disease, ninth revision, codes. Our main outcome measure was mortality, defined as perioperative mortality (death occurring before hospital discharge or within 30 days), and 5-year survival, from life-table analysis. We examined outcomes across repair type (open repair or TEVAR) in crude, adjusted (for age, sex, race, procedure year, and Charlson comorbidity score), and propensity-matched cohorts. Overall, we studied 12 573 Medicare patients who underwent open repair and 2732 patients who underwent TEVAR. Perioperative mortality was lower in patients undergoing TEVAR compared with open repair for both intact (6.1% versus 7.1%; P=0.07) and ruptured (28% versus 46%; P<0.0001) TAA. However, patients with intact TAA selected for TEVAR had significantly worse survival than open patients at 1 year (87% for open, 82% for TEVAR; P=0.001) and 5 years (72% for open; 62% for TEVAR; P=0.001). Furthermore, in adjusted and propensity-matched cohorts, patients selected for TEVAR had worse 5-year survival than patients selected for open repair.
Although perioperative mortality is lower with TEVAR, Medicare patients selected for TEVAR have worse long-term survival than patients selected for open repair. The results of this observational study suggest that higher-risk patients are being offered TEVAR and that some do not benefit on the basis of long-term survival. Future work is needed to identify TEVAR candidates unlikely to benefit from repair.
本研究旨在描述胸降主动脉瘤（TAA）患者行开放手术和血管内修复术（TEVAR）后的短期和长期生存情况。
利用 1998 年至 2007 年的医疗保险索赔数据，我们分析了接受完整 TAA 和破裂 TAA 修复的患者，通过手术和诊断国际疾病分类，第九版代码的组合进行识别。我们的主要观察指标是死亡率，定义为围手术期死亡率（死亡发生在出院前或 30 天内）和 5 年生存率，通过生命表分析。我们在未调整（按年龄、性别、种族、手术年份和 Charlson 合并症评分）、调整和倾向匹配队列中检查了不同修复类型（开放修复或 TEVAR）的结果。总体而言，我们研究了 12573 名接受开放修复的 Medicare 患者和 2732 名接受 TEVAR 的患者。对于完整 TAA（6.1%比 7.1%；P=0.07）和破裂 TAA（28%比 46%；P<0.0001），TEVAR 组的围手术期死亡率低于开放修复组。然而，选择 TEVAR 的完整 TAA 患者在 1 年（开放组为 87%，TEVAR 组为 82%；P=0.001）和 5 年（开放组为 72%；TEVAR 组为 62%；P=0.001）时的生存情况明显差于开放组患者。此外，在调整和倾向匹配队列中，选择 TEVAR 的患者的 5 年生存率比选择开放修复的患者差。
尽管 TEVAR 的围手术期死亡率较低，但接受 TEVAR 的 Medicare 患者的长期生存情况比接受开放修复的患者差。这项观察性研究的结果表明，高风险患者被推荐行 TEVAR，而有些患者并未从长期生存中获益。需要进一步研究以确定不太可能从修复中获益的 TEVAR 患者。
