1 Unit of Vascular Surgery, Ospedale S. Maria della Misericordia, University of Perugia, Italy.
2 Department of Vascular Medicine, German Aortic Center, Hamburg, Germany.
J Endovasc Ther. 2019 Feb;26(1):105-112. doi: 10.1177/1526602818820090. Epub 2018 Dec 28.
To compare outcomes of patients treated for pararenal aortic aneurysms using fenestrated endovascular aneurysm repair (fEVAR) vs open surgical repair (OSR) in 3 high-volume centers.
A multicenter retrospective analysis was conducted of 200 pararenal abdominal aortic aneurysm patients electively treated with OSR (n=108) or fEVAR (n=92) from 1998 to 2015 at 3 tertiary institutions. Endpoints were 30-day morbidity and mortality, late reinterventions, visceral artery occlusion, and mortality. Analysis was conducted on the entire population and on a propensity score-matched population constructed on age, gender, coronary artery disease (CAD), and chronic renal failure.
In the total cohort, fEVAR patients were significantly (p<0.001) older and had higher frequencies of CAD (p<0.001) and previous stroke (p=0.003). OSR patients had higher risk of perioperative morbidity (OR 2.5, 95% CI 1.09 to 5.71, p=0.033), specifically respiratory failure (OR 4.06, 95% CI 1.12 to 4.72, p=0.034). These findings were confirmed in the propensity-adjusted analysis, where cardiac complications were also higher after OSR (OR 12.8, 95% CI 0.07 to 0.21, p=0.02). No difference in perioperative mortality (2.2% in fEVAR vs 1.9% in OSR) was identified. Mean follow-up was 50 months (range 0-119). Four-year results showed higher survival (91.2% vs 69.3%, p=0.02) and freedom from reintervention (95.6% vs 77.8%, p=0.01) after OSR in the unmatched population, with a small but significant (p=0.021) difference in the risk of late visceral artery occlusion/stenosis after fEVAR. On propensity analysis, no differences in late survival were found between groups.
fEVAR and OSR may afford similar early and midterm survival rates. Higher risks of perioperative systemic complications after OSR are counterbalanced by higher risks of late visceral vessel patency issues and need for reintervention after fEVAR. Both procedures are safe and effective in the long term in experienced centers, where patient evaluation should drive the treatment strategy.
比较在 3 家高容量中心接受腔内修复治疗(fenestrated endovascular aneurysm repair,fEVAR)和开放手术修复(open surgical repair,OSR)治疗的肾周腹主动脉瘤患者的结局。
对 1998 年至 2015 年期间,3 家三级医院对 200 例肾周腹主动脉瘤患者(OSR 组 108 例,fEVAR 组 92 例)进行了多中心回顾性分析。主要终点为 30 天发病率和死亡率、晚期再干预、内脏动脉闭塞和死亡率。在整个队列和基于年龄、性别、冠状动脉疾病(coronary artery disease,CAD)和慢性肾功能衰竭的倾向评分匹配队列中进行了分析。
在总队列中,fEVAR 患者明显(p<0.001)更年长,CAD(p<0.001)和既往卒中(p=0.003)的发生率更高。OSR 患者围手术期发病率较高(OR 2.5,95%CI 1.09 至 5.71,p=0.033),特别是呼吸衰竭(OR 4.06,95%CI 1.12 至 4.72,p=0.034)。在倾向评分调整分析中也证实了这一点,OSR 术后心脏并发症也更高(OR 12.8,95%CI 0.07 至 0.21,p=0.02)。两组围手术期死亡率无差异(fEVAR 组为 2.2%,OSR 组为 1.9%)。中位随访时间为 50 个月(0 至 119 个月)。在未匹配的人群中,OSR 组的 4 年生存率(91.2%比 69.3%,p=0.02)和免于再干预的生存率(95.6%比 77.8%,p=0.01)更高,而 fEVAR 组的晚期内脏动脉闭塞/狭窄风险有微小但显著的差异(p=0.021)。在倾向评分分析中,两组之间的晚期生存率无差异。
fEVAR 和 OSR 可能提供相似的早期和中期生存率。OSR 术后全身并发症风险较高,但与 fEVAR 后晚期内脏血管通畅问题和再干预风险较高相平衡。在经验丰富的中心,两种方法在长期治疗中均安全有效,患者评估应决定治疗策略。