Unit of Vascular and Endovascular Surgery, Hospital S. Maria Misericordia, Perugia, Italy.
Unit of Vascular and Endovascular Surgery, Hospital S. Maria Misericordia, Perugia, Italy.
Eur J Vasc Endovasc Surg. 2014 Mar;47(3):296-303. doi: 10.1016/j.ejvs.2013.12.009. Epub 2014 Jan 18.
Current data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR.
Records of 1409 consecutive patients having elective EVAR during 1997-2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes.
One-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p < 00001), but no other differences in demographic and major baseline comorbidities with respect to the others. At baseline, mean abdominal aortic aneurysm (AAA) diameter was 56.43 mm vs. 54.65 mm (p = .076) and aortic neck length 26.54 mm vs. 25.21 mm (p = .26) in patients with and without anticoagulants, respectively. At 5 years, freedom from endoleak rates were 55.5% vs. 69.9% (p < .0001), and freedom from reintervention/conversion rates were 69.4% vs. 82.4% (p < .0001) in patients with (including those with delayed drug use) and without chronic anticoagulants, respectively. Controlling for covariates with the Cox regression method, at a mean follow-up of 64.3 ± 45.2 months after EVAR, use of anticoagulation drugs was independently associated with an increased risk of endoleak (odds ratio, OR 1.6; 95% confidence interval, CI: 1.23-2.07; p < .0001) and reintervention or late conversion rates (OR 1.8; 95% CI: 1.31-2.48; p < .0001).
The safety of anticoagulation therapy after EVAR is debatable. Chronic anticoagulation drug use risks exposure to a poor long-term outcome. A critical and balanced decision-making approach should be applied to patients with AAA and cardiac disease who may require prolonged anticoagulation treatment.
目前支持抗凝药物使用对动脉瘤密封和血管内腹主动脉瘤修复（EVAR）耐久性影响的数据相互矛盾。本研究评估了 EVAR 后慢性抗凝治疗的安全性。
回顾了 1997 年至 2011 年期间接受择期 EVAR 的 1409 例连续患者的记录。分析了有和无慢性抗凝剂患者的生存率、再干预、转换和内漏率。使用 Cox 比例风险模型估计抗凝治疗对结局的影响。
103 例（7.3%）患者在 EVAR 时正在接受慢性抗凝药物治疗（80 例使用维生素 K 拮抗剂）。另外确定了 46 例在修复后开始使用抗凝剂的患者。在修复时接受慢性抗凝治疗的患者（平均年龄 73.6 岁；91 名男性）心脏病发作更频繁（74.8%比 44.2%；p <0.0001），但在其他人口统计学和主要基线合并症方面与其他患者没有差异。基线时，有抗凝剂组的腹主动脉瘤（AAA）直径平均值为 56.43mm 比无抗凝剂组的 54.65mm（p=0.076），主动脉颈长度平均值为 26.54mm 比无抗凝剂组的 25.21mm（p=0.26）。5 年后，有内漏组的无内漏率为 55.5%比无内漏组的 69.9%（p<0.0001），无再干预/转换率为 69.4%比无再干预/转换组的 82.4%（p<0.0001）。在 Cox 回归方法控制协变量后，在 EVAR 后平均 64.3±45.2 个月的随访中，抗凝药物的使用与内漏（优势比，OR 1.6；95%置信区间，CI：1.23-2.07；p<0.0001）和再干预或迟发性转换率（OR 1.8；95%CI：1.31-2.48；p<0.0001）的风险增加独立相关。
EVAR 后抗凝治疗的安全性存在争议。慢性抗凝药物的使用会增加长期预后不良的风险。对于需要长期抗凝治疗的 AAA 和心脏病患者，应采用关键和平衡的决策方法。
