Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Division of Vascular Surgery, Steward Medical Group, St. Elizabeth's Medical Center, Brighton, Mass.
J Vasc Surg. 2018 Oct;68(4):941-947. doi: 10.1016/j.jvs.2017.12.072. Epub 2018 Mar 31.
There is no consensus on the use or benefit of extracorporeal circulation (EC) during aneurysm repair of the descending thoracic aorta (DTA) or thoracoabdominal aorta (TAA). We evaluated the role of EC during DTA or TAA aneurysm repair using U.S. Medicare data.
Medicare (2004-2007) patients undergoing open repair of nonruptured DTA or TAA aneurysm were identified by International Classification of Diseases, Ninth Revision code. Specific exclusions included ascending aortic or arch repairs, concomitant cardiac procedures, and procedures employing deep hypothermic circulatory arrest. The impact of EC (code 3961) on early and late outcomes was analyzed using univariate analysis and multivariable regression. Survival was assessed using Kaplan-Meier analysis and Cox proportional hazards regression models.
There were 4230 patients who had repair of intact DTA or TAA aneurysms, 2433 (57%) of which employed EC. Differences in baseline clinical features of EC and non-EC patients showed that patients undergoing aortic reconstruction with EC were older (73 ± 1 years vs 72 ± 1 years; P = .002), were more likely to be female (53% vs 47%; P < .001), and had more hypertension (56% vs 53%; P = .02); they had less chronic obstructive pulmonary disease (28% vs 34%; P < .0001), peripheral vascular disease (5.7% vs 11.3%; P < .001), and chronic kidney disease (7.7% vs 5.5%; P = .003). The 30-day mortality (9.7% for EC vs 12.2%; P = .02) and any major complication (49% for EC vs 58%; P < .001) were significantly reduced with EC use. EC use was associated with a shorter length of stay (13.5 ± 13 days vs 17.2 ± 18 days; P < .01) and lower total hospital charges ($151,000 ± 140,000 vs $180,000 ± 190,000; P < .01) compared with non-EC patients. EC patients were more likely to be discharged home instead of to an extended care facility (67% vs 56%; P < .01). Multivariable regression modeling to adjust for baseline clinical differences showed EC to independently reduce the risk of operative mortality (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.65-0.97; P = .02), any complication (OR, 0.67; 95% CI, 0.59-0.76; P < .01), pulmonary complications (OR, 0.68; 95% CI, 0.59-0.79; P < .01), and acute renal failure (OR, 0.52; 95% CI, 0.44-0.61; P < .01). Long-term survival was higher (log-rank, P < .01) in EC patients at 1 year (81% ± 0.8% vs 73% ± 1%) and 5 years (67% ± 1% vs 52% ± 1%). Risk-adjusted Cox proportional hazards regression also showed that EC was independently associated with improved long-term survival (hazard ratio, 0.69; 95% CI, 0.63-0.74; P < .01).
Although important clinical variables such as DTA or TAA aneurysm extent and spinal cord ischemic complications cannot be assessed with the Medicare database, EC use during open DTA and TAA aneurysm repair is associated with improved late survival and a significant reduction in operative mortality, morbidity, and procedural costs. These data indicate that EC should be a more widely applied adjunct in open DTA or TAA aneurysm repair.
对于降主动脉（DTA）或胸腹主动脉（TAA）动脉瘤修复术，体外循环（EC）的使用或益处尚无共识。我们使用美国医疗保险数据评估了在 DTA 或 TAA 动脉瘤修复术中使用 EC 的作用。
通过国际疾病分类第 9 版代码确定接受非破裂性 DTA 或 TAA 动脉瘤开放修复的医疗保险患者。具体排除包括升主动脉或弓部修复、同时进行的心脏手术以及采用深低温循环停止的手术。使用单变量分析和多变量回归分析 EC（代码 3961）对早期和晚期结果的影响。使用 Kaplan-Meier 分析和 Cox 比例风险回归模型评估生存情况。
共有 4230 例患者接受了完整的 DTA 或 TAA 动脉瘤修复，其中 2433 例（57%）使用了 EC。EC 和非 EC 患者的基线临床特征差异表明，接受主动脉重建的患者年龄更大（73±1 岁比 72±1 岁；P=0.002），更可能为女性（53%比 47%；P<0.001），并且高血压更多（56%比 53%；P=0.02）；他们的慢性阻塞性肺疾病（28%比 34%；P<0.0001）、外周血管疾病（5.7%比 11.3%；P<0.001）和慢性肾脏病（7.7%比 5.5%；P=0.003）较少。30 天死亡率（EC 为 9.7%，非 EC 为 12.2%；P=0.02）和任何主要并发症（EC 为 49%，非 EC 为 58%；P<0.001）均显著降低。与非 EC 患者相比，EC 患者的住院时间更短（13.5±13 天比 17.2±18 天；P<0.01），总住院费用更低（151000±140000 美元比 180000±190000 美元；P<0.01）。与非 EC 患者相比，EC 患者更有可能出院回家而非长期护理机构（67%比 56%；P<0.01）。多变量回归模型调整基线临床差异后显示，EC 可独立降低手术死亡率（比值比[OR]，0.80；95%置信区间[CI]，0.65-0.97；P=0.02）、任何并发症（OR，0.67；95%CI，0.59-0.76；P<0.01）、肺部并发症（OR，0.68；95%CI，0.59-0.79；P<0.01）和急性肾衰竭（OR，0.52；95%CI，0.44-0.61；P<0.01）的风险。1 年（81%±0.8%比 73%±1%）和 5 年（67%±1%比 52%±1%）时，EC 患者的长期生存率更高（对数秩检验，P<0.01）。风险调整的 Cox 比例风险回归也显示，EC 与长期生存的改善独立相关（风险比，0.69；95%CI，0.63-0.74；P<0.01）。
尽管不能使用医疗保险数据库评估 DTA 或 TAA 动脉瘤程度和脊髓缺血性并发症等重要临床变量，但在开放性 DTA 和 TAA 动脉瘤修复术中使用 EC 与改善晚期生存率以及显著降低手术死亡率、发病率和手术费用相关。这些数据表明，EC 应该更广泛地应用于开放性 DTA 或 TAA 动脉瘤修复。
