Ali Mujtaba M, Flahive Julie, Schanzer Andres, Simons Jessica P, Aiello Francesco A, Doucet Danielle R, Messina Louis M, Robinson William P
Division of Vascular & Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass.
Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.
J Vasc Surg. 2015 Jun;61(6):1399-407. doi: 10.1016/j.jvs.2015.01.042. Epub 2015 Mar 7.
Previous studies have reported that endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs) has lower postoperative mortality than open repair (OR). However, comparisons involved heterogeneous populations that lacked adjustment for preoperative risk. We hypothesize that for RAAA patients stratified by a validated measure of preoperative mortality risk, EVAR has a lower in-hospital mortality and morbidity than does OR.
In-hospital mortality and morbidity after EVAR and OR of RAAA were compared in patients from the Vascular Quality Initiative (2003-2013) stratified by the validated Vascular Study Group of New England RAAA risk score into low-risk (score 0-1), medium-risk (score 2-3), and high-risk (score 4-6) groups.
Among 514 patients who underwent EVAR and 651 patients who underwent OR of RAAA, EVAR had lower in-hospital mortality (25% vs 33%, P = .001). In risk-stratified patients, EVAR trended toward a lower mortality in the low-risk group (n = 626; EVAR, 10% vs OR, 15%; P = .07), had a significantly lower mortality in the medium-risk group (n = 457; EVAR, 37% vs OR, 48%; P = .02), and no advantage in the high-risk group (n = 82; EVAR, 95% vs OR, 79%; P = .17). Across all risk groups, cardiac complications (EVAR, 29% vs OR, 38%; P = .001), respiratory complications (EVAR, 28% vs OR, 46%; P < .0001), renal insufficiency (EVAR, 24% vs OR, 38%; P < .0001), lower extremity ischemia (EVAR, 2.7% vs OR, 8.1%; P < .0001), and bowel ischemia (EVAR, 3.9% vs OR, 10%; P < .0001) were significantly lower after EVAR than after OR. Across all risk groups, median (interquartile range) intensive care unit length of stay (EVAR, 2 [1-5] days vs OR, 6 [3-13] days; P < .0001) and hospital length of stay (EVAR, 6 [4-12] days vs OR, 13 [8-22] days; P < .0001) were lower after EVAR.
This novel risk-stratified comparison using a national clinical database showed that EVAR of RAAA has a lower mortality and morbidity compared with OR in low-risk and medium-risk patients and that EVAR should be used to treat these patients when anatomically feasible. For RAAA patients at the highest preoperative risk, there is no benefit to using EVAR compared with OR.
既往研究报道，破裂腹主动脉瘤（RAAA）的血管腔内修复术（EVAR）术后死亡率低于开放修复术（OR）。然而，这些比较涉及的人群异质性较大，且未对术前风险进行调整。我们假设，对于根据术前死亡风险的有效测量方法分层的RAAA患者，EVAR的住院死亡率和发病率低于OR。
在血管质量改进计划（2003 - 2013年）的患者中，将RAAA接受EVAR和OR治疗后的住院死亡率和发病率进行比较，这些患者根据新英格兰RAAA风险评分这一有效指标分层为低风险（评分0 - 1）、中风险（评分2 - 3）和高风险（评分4 - 6）组。
在514例行EVAR的患者和651例行OR的RAAA患者中，EVAR的住院死亡率较低（25%对33%，P = 0.001）。在风险分层患者中，低风险组（n = 626；EVAR为10%，OR为15%；P = 0.07）中EVAR的死亡率有降低趋势，中风险组（n = 457；EVAR为37%，OR为48%；P = 0.02）中EVAR的死亡率显著降低，高风险组（n = 82；EVAR为95%，OR为79%；P = 0.17）中EVAR无优势。在所有风险组中，心脏并发症（EVAR为29%，OR为38%；P = 0.001）、呼吸并发症（EVAR为28%，OR为46%；P < 0.0001）、肾功能不全（EVAR为24%，OR为38%；P < 0.0001）、下肢缺血（EVAR为2.7%，OR为8.1%；P < 0.0001）和肠缺血（EVAR为3.9%，OR为10%；P < 0.0001）在EVAR后均显著低于OR后。在所有风险组中，EVAR后的重症监护病房中位（四分位间距）住院时间（EVAR为2[1 - 5]天，OR为6[3 - 13]天；P < 0.0001）和住院时间（EVAR为6[4 - 12]天，OR为13[8 - 22]天；P < 0.0001）均较短。
这项使用国家临床数据库进行的新型风险分层比较显示，RAAA的EVAR在低风险和中风险患者中与OR相比死亡率和发病率更低，并且在解剖结构可行时应使用EVAR治疗这些患者。对于术前风险最高的RAAA患者，与OR相比使用EVAR没有益处。
