Huang Ying, Gloviczki Peter, Duncan Audra A, Kalra Manju, Oderich Gustavo S, Fleming Mark D, Harmsen William S, Bower Thomas C
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
J Vasc Surg. 2017 May;65(5):1313-1322.e4. doi: 10.1016/j.jvs.2016.10.093. Epub 2016 Dec 27.
The purpose of this study was to evaluate whether maximal aortic diameter affects outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA).
Clinical data of patients undergoing EVAR between 1997 and 2011 for nonruptured asymptomatic AAAs in a tertiary center were reviewed. Patients were classified according to diameter of AAA: group 1, <5.0 cm; group 2, 5.0 to 5.4 cm; group 3, 5.5 to 5.9 cm; and group 4, ≥6.0 cm. The primary end point was all-cause mortality; secondary end points were complications, reinterventions, and ruptures.
There were 874 patients studied (female, 108 [12%]; group 1, 119; group 2, 246; group 3, 243; group 4, 266); mean age was 76 ± 7.2 years. The 30-day mortality rate was 1.0%, not significantly different between groups (P = .22); complication and reintervention rates were 13% and 4.1%, respectively, similar between groups (P < .05). Five-year survival was 68%; freedom from complications and reinterventions was 65% and 74%, respectively; rupture rate was 0.5%. Multivariate analysis revealed that factors associated with all-cause mortality included maximal aortic diameter, age, gender, surgical risk, cancer history, and endograft type (P < .05). Group 4 had increased risks of mortality (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.38-2.85; P = .002) and complications (HR, 1.6; 95% CI, 1.2-2.7; P = .009) relative to group 1. Reinterventions were more frequent for aneurysms ≥6.0 cm (HR, 2.0; 95% CI, 1.2-3.3; P = .01). Late rupture rate after EVAR was not different between groups.
Maximal aortic diameter is associated with long-term outcomes after elective EVAR. Patients with large AAAs (≥6.0 cm) have higher all-cause mortality, complication, and reintervention rates after EVAR than those with smaller aneurysms. We continue to recommend that AAAs be repaired when they reach 5.5 cm as recommended by the guidelines of the Society for Vascular Surgery. On the basis of our data, EVAR should be considered even in high-risk patients with a maximal aortic diameter between 5.5 and 6.0 cm because surgical risk with aneurysm size above 6.0 cm will increase significantly.
本研究旨在评估腹主动脉瘤（AAA）血管内修复术（EVAR）后最大主动脉直径是否会影响预后。
回顾了1997年至2011年在一家三级中心接受非破裂无症状AAA的EVAR患者的临床资料。根据AAA直径对患者进行分类：第1组，<5.0 cm；第2组，5.0至5.4 cm；第3组，5.5至5.9 cm；第4组，≥6.0 cm。主要终点是全因死亡率；次要终点是并发症、再次干预和破裂。
共研究了874例患者（女性108例[12%]；第1组119例；第2组246例；第3组243例；第4组266例）；平均年龄为76±7.2岁。30天死亡率为1.0%，各组间无显著差异（P = 0.22）；并发症和再次干预率分别为13%和4.1%，各组间相似（P < 0.05）。五年生存率为68%；无并发症和再次干预的比例分别为65%和74%；破裂率为0.5%。多变量分析显示，与全因死亡率相关的因素包括最大主动脉直径、年龄、性别、手术风险、癌症病史和血管内移植物类型（P < 0.05）。与第1组相比，第4组的死亡风险（风险比[HR]，2.0；95%置信区间[CI]，1.38 - 2.85；P = 0.002）和并发症风险（HR，1.6；95% CI，1.2 - 2.7；P = 0.009）增加。≥6.0 cm的动脉瘤再次干预更为频繁（HR，2.0；95% CI，1.2 - 3.3；P = 0.01）。EVAR后的晚期破裂率在各组间无差异。
最大主动脉直径与择期EVAR后的长期预后相关。大AAA（≥6.0 cm）患者EVAR后的全因死亡率、并发症和再次干预率高于较小动脉瘤患者。我们继续建议按照血管外科学会指南的建议，AAA直径达到5.5 cm时进行修复。根据我们的数据，即使是最大主动脉直径在5.5至6.0 cm之间的高危患者也应考虑EVAR，因为动脉瘤直径大于6.0 cm时手术风险将显著增加。
