Department of Vascular and Endovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
J Vasc Surg. 2012 Oct;56(4):911-9.e2. doi: 10.1016/j.jvs.2012.02.055.
This study determined the effect of pulmonary disease on outcomes after endovascular abdominal (EVAR) and endovascular thoracoabdominal aortic aneurysm (eTAAA) repair.
A prospective study of high-risk patients undergoing EVAR and eTAAA repair between 1998 and 2009 was used to contrast clinical and endovascular outcomes between patients with (group 1) and without (group 2) chronic obstructive pulmonary disease (COPD). COPD patients were classified in accordance with the severity of their pulmonary disease using the Global Initiative for Chronic Obstructive Lung Disease criteria. Survival, morphologic changes, and complications were assessed using Cox models and life-table analyses. The cause and timing of deaths between the groups was compared.
Of 905 patients analyzed, 289 (32%) had COPD (group 1) and the remaining patients (group 2) did not have COPD. EVAR was performed in 334 patients (37%), and fenestrated or branched devices were used in the remaining 571 (63%). Group 1 patients were younger (73.5 ± 6.7 vs 75.6 ± 8.2 years), had a better glomerular filtration rate (67.8 ± 25.8 vs 61.0 ± 23.3 mL/min/1.73 m(2)), had higher hematocrits (41.6 ± 5.0 vs 40.5 ± 4.6), and had more extensive aneurysms. Mean follow-up was 39.5 ± 30.9 months. Early (3% vs 3%) and late (2% vs 1%) aneurysm-related deaths were similar between the two groups. Survival in group 1 depended on the severity of disease. Survival in patients with Global Initiative for Chronic Obstructive Lung Disease classification I and II was similar to group 2. Those with classifications III and IV demonstrated lower survival rates. Relevant pulmonary function test variables included a lower forced expiratory volume in 1 second and forced expiratory flow in the middle 50%, which were associated with decreased survival. Surrogate endovascular outcome analyses demonstrated that group 1 patients had fewer endoleaks (20% vs 25%; P = .05) and more rapid sac shrinkage rate (1.66 mm/y difference; P < .001).
The perioperative risk of death between COPD patients and non-COPD patients is eliminated when endovascular techniques are used. Long-term survival in COPD patients is most strongly related to the severity of their disease, and forced expiratory volume in 1 second and forced expiratory flow in the middle 50% are reasonable indicators of poor long-term outcomes. Morphologic changes after EVAR and eTAAA repair are more favorable in COPD patients, with a lower endoleak rate and faster sac shrinkage.
本研究旨在探讨肺部疾病对腹主动脉瘤腔内修复术（EVAR）和胸腹主动脉瘤腔内修复术（eTAAA）后结局的影响。
采用前瞻性研究，对 1998 年至 2009 年间接受 EVAR 和 eTAAA 修复的高危患者进行对比，分析患有（第 1 组）和不患有（第 2 组）慢性阻塞性肺疾病（COPD）患者的临床和腔内治疗结局。根据全球慢性阻塞性肺病倡议（GOLD）标准，根据肺部疾病的严重程度对 COPD 患者进行分类。采用 Cox 模型和寿命表分析评估生存率、形态变化和并发症。比较两组之间的死亡原因和时间。
在 905 例分析患者中，289 例（32%）患有 COPD（第 1 组），其余患者（第 2 组）无 COPD。334 例患者行 EVAR（37%），其余 571 例患者行开窗或分支装置治疗（63%）。第 1 组患者更年轻（73.5±6.7 岁 vs 75.6±8.2 岁），肾小球滤过率（GFR）更高（67.8±25.8 vs 61.0±23.3 mL/min/1.73 m²），血细胞比容更高（41.6±5.0 vs 40.5±4.6），动脉瘤更大。平均随访时间为 39.5±30.9 个月。两组早期（3% vs 3%）和晚期（2% vs 1%）与动脉瘤相关的死亡率相似。第 1 组患者的生存率取决于疾病的严重程度。GOLD 分类 I 和 II 患者的生存率与第 2 组相似。III 类和 IV 类患者的生存率较低。与生存相关的肺功能检测变量包括较低的 1 秒用力呼气量（FEV1）和用力呼出 50%中间肺活量（FEF50%），与生存率降低相关。替代腔内治疗结局分析表明，第 1 组患者的内漏发生率较低（20% vs 25%；P=.05），瘤腔缩小率较快（1.66mm/y 差异；P<.001）。
当采用腔内技术时，COPD 患者与非 COPD 患者的围手术期死亡风险可以消除。COPD 患者的长期生存率与疾病的严重程度密切相关，FEV1 和 FEF50%是预后不良的合理指标。EVAR 和 eTAAA 修复后的形态变化在 COPD 患者中更为有利，内漏发生率较低，瘤腔缩小较快。
