编辑精选 - 基于国际注册中心的集中化和血管内动脉瘤修复对破裂腹主动脉瘤治疗的影响。
Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries.
机构信息
Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.
Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden.
出版信息
Eur J Vasc Endovasc Surg. 2018 Aug;56(2):181-188. doi: 10.1016/j.ejvs.2018.01.014. Epub 2018 Feb 23.
OBJECTIVES
Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes.
MATERIALS AND METHODS
RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (≥50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR.
RESULTS
There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6 cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5 cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p < .001, and the adjusted OR was 0.38 (0.31-0.47), p < .001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p < .001; adjusted OR = 0.60 (0.46-0.78), p < .001. Peri-operative mortality was lower in the highest volume centres (QI > 22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p < .001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p < .001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume.
CONCLUSIONS
Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.
目的
腹主动脉瘤破裂（RAAA）的当前治疗方法在各中心和国家之间存在差异，尤其是在血管内修复术（EVAR）的实施程度和血管外科集中化程度方面。本研究评估了这些差异及其对结果的影响。
材料与方法
调查了 11 个国家的血管外科登记处 2010-2013 年的 RAAA 修复情况。总体上、按国家、按治疗方式（EVAR 或开放主动脉修复[OAR]）、中心容量（五分位数 IV）以及中心是否主要行 EVAR（≥50%的 RAAA 行 EVAR[EVAR(p)]）或主要行 OAR[OAR(p)]进行分析。主要结局是围手术期死亡率。数据以平均值或括号内的 95%CI 表示，并与卡方检验以及校正后的 OR 进行比较。
结果
共纳入 9273 例患者。平均年龄为 74.7（74.5-74.9）岁，82.7%的患者为男性（81.9-83.6）。破裂时的平均 AAA 直径为 7.6cm（7.5-7.6）。这些动脉瘤中，10.7%（10.0-11.4）小于 5.5cm。行 EVAR 的比例为 23.1%（22.3-24.0）。在 OAR(p)中心行 6817 例手术，在 EVAR(p)中心行 1217 例手术。总的围手术期死亡率为 28.8%（27.9-29.8）。OAR 的围手术期死亡率为 32.1%（31.0-33.2），EVAR 为 17.9%（16.3-19.6），p<0.001，校正后 OR 为 0.38（0.31-0.47），p<0.001。EVAR(p)中心的围手术期死亡率为 23.0%（20.6-25.4），OAR(p)中心为 29.7%（28.6-30.8），p<0.001；校正后 OR 为 0.60（0.46-0.78），p<0.001。高容量中心（每年>22 例修复）的围手术期死亡率为 23.3%（21.2-25.4），低于 QII-V 的 30.0%（28.9-31.1），p<0.001。与其他中心相比，OAR 后高容量中心的围手术期死亡率更低，分别为 25.3%（23.0-27.6）和 34.0%（32.7-35.4），p<0.001。根据容量，EVAR 后中心的围手术期死亡率在 EVAR 中心之间没有显著差异。
结论
以 EVAR 为主要治疗方法或具有高病例量的中心，围手术期死亡率较低。然而，大多数修复手术仍在低容量中心和以 OAR 为主要策略的中心进行。急性血管外科服务的重组可能会改善 RAAA 修复的结果。
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