Branco Bernardino C, DuBose Joseph J, Zhan Luke X, Hughes John D, Goshima Kay R, Rhee Peter, Mills Joseph L
Department of Surgery, University of Arizona, Tucson, Ariz.
Department of Cardiothoracic and Vascular Surgery, University of Texas Health Sciences Center at Houston, Houston, Tex.
J Vasc Surg. 2014 Nov;60(5):1297-1307.e1. doi: 10.1016/j.jvs.2014.05.028. Epub 2014 Jun 26.
The rapid evolution of endovascular surgery has greatly expanded management options for a wide variety of vascular diseases. Endovascular therapy provides a less invasive alternative to open surgery for critically ill patients who have sustained arterial injuries. The purpose of this study was to evaluate recent trends in the management of arterial injuries in the United States with specific reference to the use of endovascular strategies and to examine the outcomes of endovascular vs open therapy for the treatment of civilian arterial traumatic injuries.
A 9-year analysis of the National Trauma Data Bank was performed to identify all patients who sustained arterial injuries. Demographics, clinical data, interventions, and outcomes were extracted. Propensity scores were used to match endovascular patients to those undergoing open operation. Patient outcomes were compared according to treatment approach.
A total of 23,105 patients were available for analysis. Overall, there was a significant increase in the use of endovascular procedures during 9 years (from 0.3% in 2002 to 9.0% in 2010; P < .001), particularly among blunt trauma patients (from 0.4% in 2002 to 13.2% in 2010; P < .001). This increase was noteworthy and dramatic for injuries of the internal iliac artery (from 8.0% in 2002 to 40.3% in 2010; P < .001), thoracic aorta (from 0.5% in 2002 to 21.9% in 2010; P < .001), and common/external iliac arteries (from 0.4% in 2002 to 20.4% in 2010; P < .001). A significant decrease was noted for open procedures (49.1% in 2002 to 45.6%; P < .001), especially for blunt trauma (42.9% in 2002 to 35.8% in 2010; P < .001). There was a stepwise increase in the proportion of patients managed by endovascular therapy as the Injury Severity Score increased (highest in the spectrum Injury Severity Score 31-50). When outcomes were compared between matched patients who underwent endovascular and open procedures, patients who underwent endovascular procedures had significantly lower in-hospital mortality (12.9% vs 22.4%; odds ratio, 0.5; 95% confidence interval, 0.4-0.6; P < .001). Endovascular patients also had decreased rates of sepsis (7.5% vs 5.4%; odds ratio, 0.7; 95% confidence interval, 0.5-0.9; P = .025).
The use of endovascular therapy in the United States has increased dramatically during the last decade, in particular among severely injured blunt trauma patients. Endovascular therapy was associated with improved in-hospital mortality and lower rates of sepsis.
血管内手术的迅速发展极大地扩展了各种血管疾病的治疗选择。对于遭受动脉损伤的重症患者，血管内治疗为开放手术提供了一种侵入性较小的替代方案。本研究的目的是评估美国动脉损伤治疗的近期趋势，特别提及血管内策略的使用情况，并探讨血管内治疗与开放治疗在治疗平民动脉创伤性损伤方面的疗效。
对国家创伤数据库进行了为期9年的分析，以确定所有遭受动脉损伤的患者。提取了人口统计学、临床数据、干预措施和治疗结果。使用倾向评分将血管内治疗患者与接受开放手术的患者进行匹配。根据治疗方法比较患者的治疗结果。
共有23105例患者可供分析。总体而言，9年间血管内手术的使用显著增加（从2002年的0.3%增至2010年的9.0%；P <.001），尤其是在钝性创伤患者中（从2002年的0.4%增至2010年的13.2%；P <.001）。这种增加在髂内动脉损伤（从2002年的8.0%增至2010年的40.3%；P <.001）、胸主动脉损伤（从2002年的0.5%增至2010年的21.9%；P <.001）以及髂总/外动脉损伤（从2002年的0.4%增至2010年的20.4%；P <.001）方面尤为显著且引人注目。开放手术的使用显著减少（从2002年的49.1%降至45.6%；P <.001），尤其是钝性创伤患者（从2002年的42.9%降至2010年的35.8%；P <.001）。随着损伤严重程度评分的增加，接受血管内治疗的患者比例逐步上升（在损伤严重程度评分为31 - 50的范围内最高）。当比较接受血管内手术和开放手术的匹配患者的治疗结果时，接受血管内手术的患者住院死亡率显著更低（12.9%对22.4%；优势比，0.5；95%置信区间，0.4 - 0.6；P <.001）。血管内治疗的患者败血症发生率也较低（7.5%对5.4%；优势比，0.7；95%置信区间，0.5 - 0.9；P =.025）。
在过去十年中，美国血管内治疗的使用显著增加，特别是在严重受伤的钝性创伤患者中。血管内治疗与改善住院死亡率和降低败血症发生率相关。
