Chandra Venita, Trang Karen, Virgin-Downey Whitt, Dalman Ronald L, Mell Matthew W
Division of Vascular Surgery, Stanford University Medical Center, Stanford, Calif.
School of Medicine, Stanford University Medical Center, Stanford, Calif.
J Vasc Surg. 2018 Nov;68(5):1360-1366. doi: 10.1016/j.jvs.2018.02.036. Epub 2018 Apr 25.
Previous studies have reported increased perioperative mortality of nonruptured symptomatic abdominal aortic aneurysms (Sx-AAA) compared with asymptomatic elective AAA (E-AAA) repairs, but no long-term-outcomes have been reported. We sought to compare long-term outcomes of Sx-AAA and E-AAA after repair at a single academic institution.
Patients receiving AAA repair for Sx-AAA and E-AAA from 1995 through 2015 were included. Ruptured AAA and suprarenal or thoracoabdominal AAA were excluded. Demographics, comorbidities, and operative approach were collected. Long-term mortality was the primary outcome, determined by chart review or link to Social Security Death Index. Additionally, long-term mortality and reinterventions were compared after groups were matched with nearest neighbor propensity to reduce bias.
AAA repair was performed for 1054 E-AAA (383 open repair [36%], 671 endovascular aneurysm repair [EVAR] [64%]), and 139 symptomatic aneurysms (60 open repair [43%], 79 EVAR [57%]). Age (73 years vs 74 years; P = .13) and aneurysm diameter were similar between Sx-AAA and E-AAA (6.0 cm vs 5.8 cm; P = .5). The proportion of women was higher for Sx-AAA (26% vs 16%; P = .003), as was the proportion of non-Caucasians (40% vs 29%; P = .009). After propensity matching, there were no differences between groups for patient characteristics, AAA diameter, treatment modality, or comorbidities, including hypertension, coronary artery disease, congestive heart failure, diabetes, hyperlipidemia, lung disease, diabetes, renal disease, and smoking history. Women were treated for Sx-AAA at significantly smaller aortic diameters; however, compared with men (5.1 cm vs 6.3 cm; P < .001). Perioperative mortality was 5.0% for Sx-AAA and 2.3% for E-AAA (P = .055). By life-table analysis, Sx-AAA had lower 5-year (62% vs 71%) and 10-year (39% vs 51%) survivals (P = .01) compared with E-AAA for the entire cohort. Similar trends were observed for 5-year and 10-year mortality after propensity matching (63% and 40% vs 71% and 52%; P = .05). When stratified by repair type 5-year and 10-year survivals trended lower after open surgery (68% and 42% Sx-AAA vs 84% and 59% E-AAA; P = .08) but not EVAR (59% and 40% Sx-AAA vs 61% and 49% E-AAA; P = .4). Aneurysm-related reinterventions were similar for Sx-AAA and E-AAA (15% vs 14%; P = .8). Reinterventions were more common after EVAR compared with open repair (22% vs 7%, Sx-AAA P = .015; 20% vs 4% E-AAA; P = .007).
Patients with Sx-AAA had lower long-term survival and similar aneurysm-related reinterventions compared with patients with E-AAA undergoing repair. Women also underwent repair for Sx-AAA at a significantly smaller size when compared with men, which emphasizes the role of gender in AAA symptomatology. Differences in long-term survival may be only partially explained by measured patient, aneurysm, and operative factors, and may reflect unmeasured social factors or suggest inherent differences in pathophysiology of Sx-AAAs.
既往研究报道，与无症状择期腹主动脉瘤（E-AAA）修复术相比，非破裂性有症状腹主动脉瘤（Sx-AAA）围手术期死亡率增加，但尚无长期预后的报道。我们试图比较在单一学术机构中Sx-AAA和E-AAA修复术后的长期预后。
纳入1995年至2015年接受Sx-AAA和E-AAA修复术的患者。排除破裂性腹主动脉瘤和肾上腹主动脉瘤或胸腹主动脉瘤。收集人口统计学资料、合并症和手术方式。长期死亡率是主要结局，通过病历审查或与社会保障死亡指数的链接来确定。此外，在将两组与最近邻倾向匹配以减少偏倚后，比较长期死亡率和再次干预情况。
对1054例E-AAA进行了腹主动脉瘤修复术（383例开放修复[36%]，671例血管内动脉瘤修复术[EVAR][64%]），以及139例有症状动脉瘤（60例开放修复[43%]，79例EVAR[57%]）。Sx-AAA和E-AAA的年龄（73岁对74岁；P = 0.13）和动脉瘤直径相似（6.0 cm对5.8 cm；P = 0.5）。Sx-AAA的女性比例较高（26%对16%；P = 0.003），非白种人的比例也较高（40%对29%；P = 0.009）。倾向匹配后，两组在患者特征、腹主动脉瘤直径、治疗方式或合并症方面无差异，包括高血压、冠状动脉疾病、充血性心力衰竭、糖尿病、高脂血症、肺部疾病、糖尿病、肾脏疾病和吸烟史。女性接受Sx-AAA治疗时的主动脉直径明显较小；然而，与男性相比（5.1 cm对6.3 cm；P < 0.001）。Sx-AAA的围手术期死亡率为5.0%，E-AAA为2.3%（P = 0.055）。通过生命表分析，与整个队列中的E-AAA相比，Sx-AAA的5年（62%对71%）和10年（39%对51%）生存率较低（P = 0.01）。倾向匹配后，5年和10年死亡率也观察到类似趋势（63%和40%对71%和52%；P = 0.05）。按修复类型分层时，开放手术后5年和10年生存率呈下降趋势（Sx-AAA为68%和42%，E-AAA为84%和59%；P = 0.08），但EVAR并非如此（Sx-AAA为59%和40%，E-AAA为61%和49%；P = 0.4）。Sx-AAA和E-AAA的动脉瘤相关再次干预相似（15%对14%；P = 0.8）。与开放修复相比，EVAR后再次干预更常见（Sx-AAA为22%对7%，P = 0.015；E-AAA为20%对4%；P = 0.007）。
与接受修复术的E-AAA患者相比，Sx-AAA患者的长期生存率较低，且动脉瘤相关再次干预相似。与男性相比，女性接受Sx-AAA修复时的尺寸也明显较小，这强调了性别在腹主动脉瘤症状学中的作用。长期生存率的差异可能仅部分由测量的患者、动脉瘤和手术因素解释，可能反映未测量的社会因素，或提示Sx-AAA病理生理学的内在差异。
