*The Vascular Group, The Institute for Vascular Health and Disease, Department of Surgery and Division of Vascular Surgery, Albany, NY †Albany Medical College/Albany Medical Center Hospital, Albany, NY.
Ann Surg. 2016 Sep;264(3):538-43. doi: 10.1097/SLA.0000000000001864.
Safe and efficient endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (r-AAA) requires advanced infrastructure and surgical expertise not available at all US hospitals. The objective was to assess the impact of regionalizing r-AAA care to centers equipped for both open surgical repair (r-OSR) and EVAR (r-EVAR) by vascular surgeons.
A retrospective review of all patients with r-AAA undergoing open or endovascular repair in a 12-hospital region. Patient demographics, transfer status, type of repair, and intraoperative variables were recorded. Outcomes included perioperative morbidity and mortality.
Four hundred fifty-one patients with r-AAA were treated from 2002 to 2015. Three hundred twenty-one patients (71%) presented initially to community hospitals (CHs) and 130 (29%) presented to the tertiary medical center (MC). Of the 321 patients presenting to CH, 133 (41%) were treated locally (131 OSR; 2 EVAR) and 188 (59%) were transferred to the MC. In total, 318 patients were treated at the MC (122 OSR; 196 EVAR). At the MC, r-EVAR was associated with a lower mortality rate than r-OSR (20% vs 37%, P = 0.001). Transfer did not influence r-EVAR mortality (20% in r-EVAR presenting to MC vs 20% in r-EVAR transferred, P > 0.2). Overall, r-AAA mortality at the MC was 20% lower than CH (27% vs 46%, P < 0.001).
Regionalization of r-AAA repair to centers equipped for both r-EVAR and r-OSR decreased mortality by approximately 20%. Transfer did not impact the mortality of r-EVAR at the tertiary center. Care of r-AAA in the US should be centralized to centers equipped with available technology and vascular surgeons.
安全有效的血管内腹主动脉瘤破裂修复术（EVAR）需要先进的基础设施和外科专业知识，而这些并非所有美国医院都具备。本研究旨在评估将腹主动脉瘤破裂（r-AAA）的治疗区域化，以集中到具备开放手术修复（r-OSR）和血管内修复（r-EVAR）技术的中心。
对一个 12 家医院区域内所有接受开放或血管内修复治疗的 r-AAA 患者进行回顾性分析。记录患者的人口统计学、转院情况、修复类型和术中变量。主要观察指标包括围手术期发病率和死亡率。
2002 年至 2015 年间，共有 451 例 r-AAA 患者接受治疗。321 例（71%）患者最初就诊于社区医院（CH），130 例（29%）就诊于三级医疗中心（MC）。在 321 例就诊于 CH 的患者中，133 例（41%）在当地治疗（131 例接受 OSR 治疗；2 例接受 EVAR 治疗），188 例（59%）转至 MC 治疗。共有 318 例患者在 MC 治疗（122 例接受 OSR 治疗；196 例接受 EVAR 治疗）。在 MC 治疗的患者中，r-EVAR 的死亡率低于 r-OSR（20% vs. 37%，P=0.001）。转院并未影响 r-EVAR 的死亡率（在 MC 就诊的 r-EVAR 中，20%的患者死亡 vs. 转院的 r-EVAR 中，20%的患者死亡，P>0.2）。总体而言，MC 的 r-AAA 死亡率比 CH 低 20%（27% vs. 46%，P<0.001）。
将 r-AAA 修复区域化到同时具备 r-EVAR 和 r-OSR 治疗能力的中心，可使死亡率降低约 20%。转院并未影响三级医疗中心 r-EVAR 的死亡率。美国 r-AAA 的治疗应集中在具备可用技术和血管外科医生的中心。
