Division of Vascular and Endovascular Surgery, Boston University, School of Medicine, Boston, Mass.
Division of Vascular and Endovascular Interventions, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY.
J Vasc Surg. 2019 Feb;69(2):405-413. doi: 10.1016/j.jvs.2018.04.031. Epub 2018 Jun 23.
Although endovascular repair of abdominal aortic aneurysms (AAAs) has been demonstrated to have favorable outcomes, not all cohorts of patients with AAA fare equally well. Our goal was to investigate perioperative and 1-year outcomes in patients with end-stage renal disease (ESRD) on dialysis, who have traditionally fared worse after vascular interventions, to assess how ESRD affects outcomes in a large modern cohort of endovascular aneurysm repair (EVAR) patients.
The Vascular Quality Initiative database was queried for all patients undergoing EVAR from 2010 to 2017. ESRD patients were compared with patients not on dialysis. Propensity-matched scoring and multivariable analysis were used to isolate the effects of ESRD.
Of 28,683 EVARs identified, there were 321 (1.12%) patients with ESRD on dialysis. Patients with ESRD had no difference in presenting AAA size (57.5 ± 12.7 mm vs 56.7 ± 17.2 mm; P = .44); however, they had more urgent/emergent repairs (20.6% vs 13.6%; P = .002) than those without ESRD. ESRD patients were more often younger, nonwhite, and nonobese and less likely to have commercial insurance (P < .05). ESRD patients more often had hypertension, coronary artery disease, congestive heart failure, previous lower extremity bypass, aneurysm repair, and carotid interventions (P < .05). There was no difference in the rate of concomitant procedures. Matching based on demographics, comorbidities, and operative details showed that ESRD patients had longer hospital length of stay (4.8 ± 9.4 days vs 4.1 ± 12.6 days; P = .026) and higher 30-day mortality (7% vs 2.4%; P < .001). There was no difference in cardiac, pulmonary, lower extremity, bowel, and stroke complications or return to the operating room. On multivariable analysis, ESRD was associated with 30-day mortality (odds ratio, 4.1; 95% confidence interval, 2.6-6.7; P < .001). Of the 24,750 elective EVARs, 1.04% had ESRD on dialysis. Matched data for elective EVAR show increased postoperative length of stay, hospital mortality, and 30-day mortality for ESRD patients on dialysis compared with those who are not. There was no association with postoperative myocardial infarction or pulmonary complications. At 1 year, patients with ESRD on dialysis had worse survival (78% vs 94%; P < .001), and ESRD was associated with higher mortality (hazard ratio, 3.3; 95% confidence interval, 2.5-4.2; P < .001).
Among patients undergoing EVAR, ESRD is independently associated with higher perioperative and 1-year mortality despite not being associated with higher postoperative complications. This should be taken into account during informed consent for EVAR and risk-benefit considerations in this high-risk population, particularly for elective repair.
尽管血管内修复腹主动脉瘤（AAA）已被证明具有良好的效果，但并非所有 AAA 患者的治疗效果都一样。我们的目标是研究终末期肾病（ESRD）透析患者的围手术期和 1 年结局，这些患者在血管介入治疗后通常预后较差，以评估 ESRD 如何影响大量现代血管内动脉瘤修复（EVAR）患者的结局。
查询 2010 年至 2017 年期间接受 EVAR 的所有患者的血管质量倡议数据库。将 ESRD 患者与未透析患者进行比较。采用倾向评分匹配评分和多变量分析来分离 ESRD 的影响。
在确定的 28683 例 EVAR 中，有 321 例（1.12%）患者患有 ESRD 并接受透析。ESRD 患者的 AAA 大小无差异（57.5±12.7mm vs 56.7±17.2mm；P=0.44）；然而，他们更常进行紧急/紧急修复（20.6% vs 13.6%；P=0.002）。ESRD 患者更年轻、非白人和非肥胖，并且不太可能拥有商业保险（P<0.05）。ESRD 患者更常患有高血压、冠状动脉疾病、充血性心力衰竭、下肢旁路、动脉瘤修复和颈动脉介入治疗（P<0.05）。同时进行的手术无差异。基于人口统计学、合并症和手术细节进行匹配后，ESRD 患者的住院时间更长（4.8±9.4 天 vs 4.1±12.6 天；P=0.026），30 天死亡率更高（7% vs 2.4%；P<0.001）。两组在心脏、肺部、下肢、肠道和中风并发症或返回手术室方面无差异。多变量分析显示，ESRD 与 30 天死亡率相关（比值比，4.1；95%置信区间，2.6-6.7；P<0.001）。在 24750 例择期 EVAR 中，有 1.04%的患者患有 ESRD 并接受透析。与未透析患者相比，ESRD 患者的术后住院时间、医院死亡率和 30 天死亡率均增加。与术后心肌梗死或肺部并发症无关联。1 年后，透析 ESRD 患者的生存率更差（78% vs 94%；P<0.001），ESRD 与更高的死亡率相关（风险比，3.3；95%置信区间，2.5-4.2；P<0.001）。
在接受 EVAR 的患者中，尽管 ESRD 与术后并发症无关联，但与围手术期和 1 年死亡率升高独立相关。在进行 EVAR 知情同意和高危人群的风险获益考虑时，应考虑到这一点，特别是对于择期修复。
