Wang Tiehao, Zhao Jichun, Yuan Ding, Ma Yukui, Huang Bin, Yang Yi, Zeng Guojun
Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China.
Medicine (Baltimore). 2018 Jul;97(27):e11313. doi: 10.1097/MD.0000000000011313.
Several observational studies and randomized trials have compared open surgery (OS) and endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). However, none of these studies addressed optimal management of hemodynamically (hd) unstable patients. Our objective was to compare perioperative outcomes in patients undergoing OS vs EVAR for hd-stable and hd-unstable rAAAs.This retrospective study was conducted in West China Hospital from January 2005 to December 2015. Unstable patients were defined as those who have at least 1 of the following: preoperative shock, preoperative transfusion >4 units, preoperative intubation, cardiac arrest, or unconsciousness. Univariable and multivariable logistic regression analyses were performed.Of the 102 patients, 70.6% underwent OS and 29.4% EVAR. About 46.1% were unstable, and for these patients, OS was performed in 70.2% and EVAR in 29.8%. The 30-day mortality was 23.6% (OS, 25.6%; EVAR, 18.8%; P = .585) for hd-stable patients and was 42.6% (OS, 45.5%; EVAR, 35.7%; P = .537) for hd-unstable patients. Patients with OS had longer operative time and more transfusion. Amongst hd-stable patients, OS subgroup had a higher rate of pneumonia (33.3% vs 6.3%, P = .045), longer intensive care unit (ICU) stay (43.2 vs 15.2 hours, P = .02), and length of stay (11.6 vs 8.6 days, P = .041). Among hd-unstable patients, OS subgroup had a longer ICU stay (134.3 vs 63.8 hours, P = .047). Hospitalization costs of OS group were significantly lower than those of EVAR group, regardless of hemodynamic stability.Approximately one-third of patients with rAAA were treated by EVAR at our institution. EVAR may be the preferred approach for anatomically suitable rAAAs. However, patients treated by EVAR had a similar mortality compared with those treated by OS. In addition, OS is not an independent factor for a higher 30-day mortality, and the costs of OS were much cheaper than those of EVAR. Therefore, OS is difficult to replace, especially in developing countries.
多项观察性研究和随机试验比较了开放手术（OS）和血管腔内主动脉修复术（EVAR）治疗破裂性腹主动脉瘤（rAAA）的效果。然而，这些研究均未涉及血流动力学（hd）不稳定患者的最佳治疗方案。我们的目的是比较接受OS与EVAR治疗血流动力学稳定和不稳定的rAAA患者的围手术期结局。
这项回顾性研究于2005年1月至2015年12月在华西医院进行。不稳定患者定义为至少具备以下一项情况的患者：术前休克、术前输血>4单位、术前插管、心脏骤停或昏迷。进行了单变量和多变量逻辑回归分析。
在102例患者中，70.6%接受了OS治疗，29.4%接受了EVAR治疗。约46.1%的患者血流动力学不稳定，其中70.2%的患者接受了OS治疗，29.8%的患者接受了EVAR治疗。血流动力学稳定患者的30天死亡率为23.6%（OS组为25.6%，EVAR组为18.8%；P = 0.585），血流动力学不稳定患者的30天死亡率为42.6%（OS组为45.5%，EVAR组为35.7%；P = 0.537）。接受OS治疗的患者手术时间更长，输血量更多。在血流动力学稳定的患者中，OS亚组的肺炎发生率更高（33.3%对6.3%，P = 0.045），重症监护病房（ICU）住院时间更长（43.2小时对15.2小时，P = 0.02），住院时间更长（11.6天对8.6天，P = 0.041）。在血流动力学不稳定的患者中，OS亚组的ICU住院时间更长（134.3小时对63.8小时，P = 0.047）。无论血流动力学稳定性如何，OS组的住院费用均显著低于EVAR组。
在我们机构，约三分之一的rAAA患者接受了EVAR治疗。EVAR可能是解剖结构合适的rAAA的首选治疗方法。然而，接受EVAR治疗的患者与接受OS治疗的患者死亡率相似。此外，OS不是30天死亡率升高的独立因素，且OS的费用比EVAR便宜得多。因此，OS难以被取代，尤其是在发展中国家。
