De Martino Randall R, Brooke Benjamin S, Robinson William, Schanzer Andres, Indes Jeffrey E, Wallaert Jessica B, Nolan Brian W, Cronenwett Jack L, Goodney Philip P
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Circ Cardiovasc Qual Outcomes. 2013 Sep 1;6(5):575-81. doi: 10.1161/CIRCOUTCOMES.113.000095.
Endovascular aortic aneurysm repair (EVAR) is often offered to patients with abdominal aortic aneurysms (AAAs) considered preoperatively to be unfit for open AAA repair (oAAA). This study describes the short- and long-term outcomes of patients undergoing EVAR with AAAs <6.5 cm who are considered unfit for oAAA.
We analyzed elective EVARs for AAAs <6.5 cm diameter in the Vascular Study Group of New England (2003-2011). Patients were designated as fit or unfit for oAAA by the treating surgeon. End points included in-hospital major adverse events and long-term mortality. We identified patient characteristics associated with being unfit for open repair and predictors of survival using multivariable analyses. Of 1653 EVARs, 309 (18.7%) patients were deemed unfit for oAAA. These patients were more likely to have advanced age, cardiac disease, chronic obstructive pulmonary disease, and larger aneurysms at the time of repair (54 versus 56 mm, P=0.001). Patients unfit for oAAA had higher rates of cardiac (7.8% versus 3.1%, P<0.01) and pulmonary (3.6 versus 1.6, P<0.01) complications and worse survival rates at 5 years (61% versus 80%; log rank P<0.01) compared with those deemed fit for oAAA. Finally, patients designated as unfit for oAAA had worse survival, even adjusting for patient characteristics and aneurysm size (hazard ratio, 1.6; 95% confidence interval, 1.2-2.2; P<0.01).
In patients with AAAs <6.5 cm, designation by the operating surgeon as unfit for oAAA provides insight into both short- and long-term efficacy of EVAR. Patients unable to tolerate oAAA may not benefit from EVAR unless their risk of AAA rupture is very high.
血管内主动脉瘤修复术（EVAR）通常用于术前被认为不适合开放性主动脉瘤修复术（oAAA）的腹主动脉瘤（AAA）患者。本研究描述了接受EVAR治疗的直径<6.5 cm且被认为不适合oAAA的AAA患者的短期和长期结局。
我们分析了新英格兰血管研究组（2003 - 2011年）中直径<6.5 cm的AAA的择期EVAR病例。治疗外科医生将患者指定为适合或不适合oAAA。终点包括住院期间的主要不良事件和长期死亡率。我们使用多变量分析确定了与不适合开放性修复相关的患者特征以及生存预测因素。在1653例EVAR病例中，309例（18.7%）患者被认为不适合oAAA。这些患者在修复时更可能年龄较大、患有心脏病、慢性阻塞性肺疾病且动脉瘤较大（54对56 mm，P = 0.001）。与被认为适合oAAA的患者相比，不适合oAAA的患者心脏（7.8%对3.1%，P<0.01）和肺部（3.6对1.6，P<0.01）并发症发生率更高，5年生存率更差（61%对80%；对数秩检验P<0.01）。最后，即使对患者特征和动脉瘤大小进行调整，被指定为不适合oAAA的患者生存率仍较差（风险比，1.6；95%置信区间，1.2 - 2.2；P<0.01）。
在直径<6.5 cm的AAA患者中，手术医生指定为不适合oAAA有助于了解EVAR的短期和长期疗效。无法耐受oAAA的患者可能无法从EVAR中获益，除非其AAA破裂风险非常高。
