Sala-Almonacil Vicente A, Zaragozá-García José M, Ramírez-Montoya Mauricio, Molina-Nácher Vicente, Martínez-Perelló Inmaculada, Gómez-Palonés Francisco J
Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain -
Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain.
J Cardiovasc Surg (Torino). 2017 Dec;58(6):801-813. doi: 10.23736/S0021-9509.17.09727-0. Epub 2017 Jan 27.
Many patients with complex abdominal aortic aneurysms are unfit for open repair. New endovascular technologies and bailout techniques are being used for managing these complex anatomies. The purpose of this study is to compare the results obtained with advanced endovascular aneurysm repair (a-EVAR) techniques (fenestrated and chimney endografts) to those obtained with open repair for the treatment of complex abdominal aortic aneurysms not anatomically suitable for standard endovascular exclusion (infrarenal neck <10 mm, juxtarenal, suprarenal and Crawford's type IV thoracoabdominal aneurysms).
All patients that underwent open surgery (OS cohort; historical, January 1994-December 2015) or a-EVAR (a-EVAR cohort; prospective, January 2006-December 2015) at our institution for complex abdominal aortic aneurysms that meet the anatomical criteria described above on the preoperatory contrast-enhanced computed tomography scan were included. Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) was employed for risk-assessment.
A total of 108 patients were included, all of them male: 56 in the OS cohort and 52 in the a-EVAR cohort (mean age: 67.5±6.7 vs. 72.65±6.4 years, respectively; P=0.000). V-POSSUM predicted 4 deaths for the OS cohort and 3 deaths for the a-EVAR cohorts within the postoperative period and morbidity rates of 57% and a 44.4%, respectively. All-cause 30-day mortality rates were 9 patients (16%) for the OS cohort and 2 patients (3.8%) for the a-EVAR cohort (P=0.038). Thirty-day morbidity rates were 59% for the OS cohort and 44% for the a-EVAR cohort (P=0.09). Mean cost of treatment was € 15,707 per patient for the OS cohort (median: € 11,516; inter-quartilic range [IQR]: € 7901; min-max: € 5069-11,0052) and € 33,457 per patient for the a-EVAR cohort (median: € 29,663; IQR: € 5979; min-max: € 13,865-19,3536), P=0.000.
A-EVAR is a feasible alternative to open surgery for complex abdominal aortic aneurysms at our institution, with lower 30-day mortality rates, yet increasing double the amount the total cost of the therapy.
许多患有复杂腹主动脉瘤的患者不适合进行开放修复手术。新的血管内技术和补救技术正被用于处理这些复杂的解剖结构。本研究的目的是比较采用先进的血管内动脉瘤修复（a-EVAR）技术（开窗和烟囱式腔内移植物）与开放修复治疗解剖结构上不适合标准血管内排除术（肾下颈部<10mm、近肾、肾上和克劳福德IV型胸腹主动脉瘤）的复杂腹主动脉瘤所获得的结果。
纳入所有在我们机构接受开放手术（OS队列；回顾性研究，1994年1月至2015年12月）或a-EVAR（a-EVAR队列；前瞻性研究，2006年1月至2015年12月）治疗的符合上述术前增强CT扫描解剖标准的复杂腹主动脉瘤患者。采用血管生理和手术严重程度评分系统（V-POSSUM）进行风险评估。
共纳入108例患者，均为男性：OS队列56例，a-EVAR队列52例（平均年龄分别为67.5±6.7岁和72.65±6.4岁；P=0.000）。V-POSSUM预测OS队列术后死亡4例，a-EVAR队列术后死亡3例，发病率分别为57%和44.4%。OS队列全因30天死亡率为9例（16%），a-EVAR队列为2例（3.8%）（P=0.038）。OS队列30天发病率为59%，a-EVAR队列为44%（P=0.09）。OS队列每位患者的平均治疗费用为15,707欧元（中位数：11,516欧元；四分位间距[IQR]：7901欧元；最小值-最大值：5069-110,052欧元），a-EVAR队列每位患者为33,457欧元（中位数：29,663欧元；IQR：5979欧元；最小值-最大值：13,865-193,536欧元），P=0.000。
在我们机构，对于复杂腹主动脉瘤，a-EVAR是开放手术的一种可行替代方案，30天死亡率较低，但治疗总成本增加了一倍。
