Chandra Venita, Trang Karen, Virgin-Downey Whitt, Tran Ken, Harris E John, Dalman Ronald L, Lee Jason T, Mell Matthew W
Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
School of Medicine, Stanford University, Stanford, Calif.
J Vasc Surg. 2017 Dec;66(6):1679-1685. doi: 10.1016/j.jvs.2017.04.033. Epub 2017 Jun 12.
We compared the management of patients with symptomatic, unruptured abdominal aortic aneurysms (AAAs) treated at a tertiary care center between two decades. This 20-year period encapsulated a shift in surgical approach to aortic aneurysms from primarily open to primarily endovascular, and we sought to determine the effect of this shift in the evaluation, treatment, and clinical outcomes of patients with symptomatic AAA.
We reviewed 1429 consecutive patients with unruptured AAAs treated at a tertiary care hospital by six staff surgeons between 1995 and 2004 (era 1) and between 2005 and 2014 (era 2). Of those patients, 160 (11%) were symptomatic from their aneurysm and were included in our study. Patient demographics, operative approach, and outcomes were analyzed and compared for each period.
Era 1 included 75 patients (71% men; average age, 73.1 ± 10.0 years) treated for symptomatic AAA (91.9% infrarenal, 4.0% juxtarenal, and 4.0% pararenal); of these, 68% were treated with open repair and 32.0% were treated with an endovascular repair. Perioperative mortality during this period was 5.3% (7.8% for the open cohort and 0% for the endovascular cohort). Era 2 included 85 patients (72.9% men; average age 72.0 ± 9.5 years) treated for symptomatic AAA (90.1% infrarenal, 7.5% juxtarenal, and 2.4% pararenal); of these, 29% were treated open and 71% underwent endovascular repair. Perioperative mortality was 5.9% (8.0% for the open cohort and 5.0% for the endovascular cohort). Era 2 had a significantly higher rate of endovascular repair compared with era 1 (71% vs 32%; P < .0001) and a trend toward decreased long-term mortality. The length of stay for era 2 was significantly reduced compared with era 1 (4 days vs 6 days; P = .005).
To our knowledge, this is the largest single-institution cohort of symptomatic AAAs, which comprise 10% to 11% of overall aneurysms. As expected, we found a significant shift over time in the approach to these patients from a primarily open to a primarily endovascular technique. The modern era was also associated with decreased lengths of stay and fewer gastrointestinal and wound complications but no significant differences in overall perioperative mortality.
我们比较了二十年间在一家三级医疗中心接受治疗的有症状、未破裂腹主动脉瘤（AAA）患者的管理情况。这20年期间涵盖了主动脉瘤手术方式从主要的开放手术向主要的血管内修复的转变，我们试图确定这种转变对有症状AAA患者的评估、治疗及临床结局的影响。
我们回顾了1995年至2004年（第1阶段）以及2005年至2014年（第2阶段）期间，由六位外科医生在一家三级医疗医院连续治疗的1429例未破裂AAA患者。在这些患者中，160例（11%）因动脉瘤出现症状并被纳入我们的研究。对每个阶段的患者人口统计学资料、手术方式及结局进行分析和比较。
第1阶段包括75例接受有症状AAA治疗的患者（71%为男性；平均年龄73.1±10.0岁）（91.9%为肾下型，4.0%为近肾型，4.0%为肾旁型）；其中，68%接受开放修复，32.0%接受血管内修复。该阶段围手术期死亡率为5.3%（开放手术组为7.8%，血管内修复组为0%）。第2阶段包括85例接受有症状AAA治疗的患者（72.9%为男性；平均年龄72.0±9.5岁）（90.1%为肾下型，7.5%为近肾型，2.4%为肾旁型）；其中，29%接受开放手术，71%接受血管内修复。围手术期死亡率为5.9%（开放手术组为8.0%，血管内修复组为5.0%）。与第1阶段相比，第2阶段血管内修复率显著更高（71%对32%；P<0.0001），且有长期死亡率降低的趋势。与第1阶段相比，第2阶段的住院时间显著缩短（4天对6天；P=0.005）。
据我们所知，这是有症状AAA最大的单机构队列，占所有动脉瘤的10%至11%。正如预期的那样，我们发现随着时间推移，这些患者的治疗方式从主要的开放手术显著转变为主要的血管内技术。现代阶段还与住院时间缩短、胃肠道及伤口并发症减少相关，但围手术期总体死亡率无显著差异。
