Hicks Caitlin W, Black James H, Arhuidese Isibor, Asanova Luda, Qazi Umair, Perler Bruce A, Freischlag Julie A, Malas Mahmoud B
Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
Division of Vascular and Endovascular Therapy, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
J Vasc Surg. 2015 Feb;61(2):291-7. doi: 10.1016/j.jvs.2014.04.078. Epub 2014 Aug 22.
Previous reports have documented better outcomes after open abdominal aortic aneurysm (AAA) repair in tertiary centers compared with lower-volume hospitals, but outcome variability for endovascular AAA repair (EVAR) vs open AAA repairs in a large tertiary center using a Medicare-derived mortality risk prediction model has not been previously reported. In the current study, we compared the observed vs predicted mortality after EVAR and open AAA repair in a single large tertiary vascular center.
We retrospectively analyzed all patients who underwent repair of a nonruptured infrarenal AAA in our center from 2003 to 2012. Univariable and multivariable logistic regression were used to evaluate 30-day mortality. Patients were stratified into low-risk, medium-risk, and high-risk groups, and mortality was predicted for each patient based on demographics and comorbidities according to the Medicare risk prediction model.
We analyzed 297 patients (EVAR, 72%; open AAA repair, 28%; symptomatic, 25%). Most of our patients were of high and moderate risk (48% and 28%, respectively). The observed 30-day mortality was 1.9% after EVAR vs 2.4% after open repair (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.14-4.29; P = .67). There was no difference in mortality with EVAR vs open repair after adjusting for predefined patient characteristics (OR, 0.92; 95% CI, 0.16-7.43; P = .93); only preoperative renal disease was predictive of 30-day mortality after AAA repair in our cohort (OR, 8.39; 95% CI, 1.41-67.0). The observed mortality within our study was significantly lower than the Medicare-derived expected mortality for each treatment group within patients stratified as high risk or medium risk (P ≤ .0002 for all).
Despite treating patients with high preoperative risk status, we report a 10-fold decrease in operative mortality for EVAR and open AAA repair in a tertiary vascular center compared with national Medicare-derived predictions. High-risk patients should be considered for aneurysm management in dedicated aortic centers, regardless of approach.
既往报告显示，与规模较小的医院相比，三级中心行开放性腹主动脉瘤（AAA）修复术后的预后更好，但此前尚未有研究报告在大型三级中心使用医疗保险衍生的死亡率风险预测模型对血管内AAA修复术（EVAR）与开放性AAA修复术的预后差异。在本研究中，我们比较了在单一大型三级血管中心行EVAR和开放性AAA修复术后观察到的死亡率与预测死亡率。
我们回顾性分析了2003年至2012年在本中心接受非破裂性肾下腹主动脉瘤修复术的所有患者。采用单变量和多变量逻辑回归评估30天死亡率。患者被分为低风险、中风险和高风险组，并根据医疗保险风险预测模型，基于人口统计学和合并症对每位患者的死亡率进行预测。
我们分析了297例患者（EVAR占72%；开放性AAA修复占28%；有症状者占25%）。我们的大多数患者为高风险和中度风险（分别为48%和28%）。EVAR术后观察到的30天死亡率为1.9%，开放性修复术后为2.4%（优势比[OR]，0.77；95%置信区间[CI]，0.14 - 4.29；P = 0.67）。在根据预先定义的患者特征进行调整后，EVAR与开放性修复的死亡率无差异（OR，0.92；95% CI，0.16 - 7.43；P = 0.93）；在我们的队列中，仅术前肾病可预测AAA修复术后的30天死亡率（OR，8.39；95% CI，1.41 - 67.0）。在分层为高风险或中风险的患者中，我们研究中观察到的死亡率显著低于每个治疗组医疗保险衍生的预期死亡率（所有P≤0.0002）。
尽管我们治疗的患者术前风险状态较高，但与全国医疗保险衍生的预测相比，我们报告在三级血管中心行EVAR和开放性AAA修复术的手术死亡率降低了10倍。无论采用何种方法，对于高风险患者，均应考虑在专门的主动脉中心进行动脉瘤治疗。
