Ultee Klaas H J, Zettervall Sara L, Soden Peter A, Buck Dominique B, Deery Sarah E, Shean Katie E, Verhagen Hence J M, Schermerhorn Marc L
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
J Vasc Surg. 2017 Aug;66(2):343-352.e1. doi: 10.1016/j.jvs.2017.01.026. Epub 2017 Mar 30.
Thoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes.
Patients admitted with an rTAA between 1993 and 2012 were identified from the National Inpatient Sample. Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis.
A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly used from 2% of total admissions in 2003-2004 to 43% in 2011-2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993-1994 (P < .001 for all) but was most pronounced among those aged 80 years with a 7.5-fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003-2004 to 27% in 2011-2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable between 63% and 60% (P = .167). Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P < .001). In adjusted analysis, open repair was associated with a twofold higher mortality than TEVAR (odds ratio, 2.0; 95% confidence interval, 1.7-2.5).
TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened the eligibility of patients for surgical treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing surgical repair.
胸主动脉腔内修复术（TEVAR）已成为治疗破裂性胸主动脉瘤（rTAA）的开放修复术的替代方法。本研究的目的是评估全国范围内使用TEVAR治疗rTAA的趋势，并确定其对围手术期结局的影响。
从国家住院患者样本中识别出1993年至2012年间因rTAA入院的患者。根据治疗方式将患者分组：TEVAR、开放修复或非手术治疗。主要结局是随时间变化的治疗趋势和院内死亡。次要结局包括围手术期并发症和住院时间。使用 Cochr an-Armitage趋势检验进行趋势分析，并使用多变量逻辑回归分析确定调整后的死亡风险。
共纳入12399例患者，其中1622例（13%）接受TEVAR治疗，2808例（23%）接受开放修复，7969例（64%）未接受手术治疗。TEVAR的使用比例从2003 - 2004年占总入院人数的2%增加到2011 - 2012年的43%（P <.001）。同时，接受开放修复的患者比例下降（从29%降至12%；P <.001），非手术治疗的患者比例下降（从69%降至45%；P <.001）。自1993 - 1994年以来，所有年龄组接受手术修复的患者比例均有所增加（所有年龄组P <.001），但在80岁及以上患者中最为明显，增加了7.5倍。引入TEVAR后，手术死亡率从2003 - 2004年的36%降至2011 - 2012年的27%（P <.001）；接受非手术治疗的患者死亡率在63%至60%之间保持稳定（P =.167）。rTAA入院后的总体死亡率从55%降至42%（P <.001）。自2005年以来，开放修复的死亡率为33%，TEVAR为22%（P <.001）。在调整分析中，开放修复的死亡率比TEVAR高两倍（比值比，2.0；95%置信区间，1.7 - 2.5）。
TEVAR已取代开放修复成为rTAA的主要手术治疗方法。血管内治疗的引入似乎扩大了患者接受手术治疗的资格，特别是在老年人中。自引入TEVAR以来，rTAA入院后的死亡率有所下降，这是手术死亡率改善以及接受手术修复的患者比例增加的结果。
