Division of Vascular Surgery, University of Minnesota, Minneapolis, Minn.
Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minn.
J Vasc Surg. 2019 Jul;70(1):92-101.e1. doi: 10.1016/j.jvs.2018.10.090. Epub 2019 Jan 2.
Endovascular aneurysm repair (EVAR) is an accepted approach for patients presenting with ruptured abdominal aortic aneurysm (rAAA) and suitable anatomy. The effect of anesthesia modality on mortality outcomes in rAAA has not been well described. Using the Vascular Quality Initiative database, this study compares local anesthesia (LA) vs general anesthesia (GA) in EVAR for rAAA.
The Vascular Quality Initiative database was queried for patients presenting with rAAA managed with open surgical repair, EVAR under LA (rEVAR-LA), and EVAR under GA (rEVAR-GA) between 2003 and 2017. Patients were observed until the earlier end point of either death or 1-year follow-up. Kaplan-Meier event rates are presented at 30 days and 1 year. Cox proportional hazards regression was used to model risk of death, with adjustment for demographic and clinical factors. Additional multivariate Cox hazards analyses were used to assess effect modifiers for 1-year mortality for the different repair methods.
A total of 3330 patients (77.4% male) met the inclusion criteria (1594 [47.9%] open surgical repair, 226 [6.8%] rEVAR-LA, and 1510 [45.3%] rEVAR-GA). Patients treated with rEVAR-LA compared with rEVAR-GA had decreased intraoperative time, number of intraoperative blood transfusions, intraoperative crystalloid administration, intensive care unit length of stay, and postoperative pulmonary complications. Mortality rates with rEVAR-LA were lower compared with rEVAR-GA at 30 days (15.5% vs 23.3%; adjusted hazard ratio [AHR], 0.70; 95% confidence interval [CI], 0.49-0.99; P = .04) and at 1 year (22.5% vs 32.3%; AHR, 0.71; 95% CI, 0.53-0.96; P = .02). Patients undergoing EVAR who were <75 years old and those without preoperative hypotension had the greatest survival benefit from LA compared with GA (both factors: AHR, 0.14 [95% CI, 0.03-0.57]; single factor: AHR, 0.57 [95% CI, 0.36-0.91]).
This study demonstrates that rEVAR-LA for rAAA may be a safe alternative to rEVAR-GA for certain patients, with lower morbidity and improved mortality. Further prospective study is warranted to confirm mortality benefit in rEVAR-LA for rAAA.
血管内动脉瘤修复术（EVAR）是一种治疗破裂性腹主动脉瘤（rAAA）和合适解剖结构的方法。麻醉方式对 rAAA 死亡率的影响尚未得到很好的描述。本研究使用血管质量倡议数据库，比较局部麻醉（LA）与全身麻醉（GA）在 rAAA 的 EVAR 中的应用。
2003 年至 2017 年，血管质量倡议数据库检索了接受开放手术修复、LA 下 EVAR（rEVAR-LA）和 GA 下 EVAR（rEVAR-GA）治疗的 rAAA 患者。患者观察至死亡或 1 年随访的较早终点。30 天和 1 年时，采用 Kaplan-Meier 事件率进行评估。采用 Cox 比例风险回归模型，对人口统计学和临床因素进行调整，以评估死亡率。采用多变量 Cox 风险分析评估不同修复方法 1 年死亡率的调节因素。
共有 3330 名（77.4%为男性）符合纳入标准（1594 名[47.9%]接受开放手术修复，226 名[6.8%]接受 rEVAR-LA，1510 名[45.3%]接受 rEVAR-GA）。与 rEVAR-GA 相比，rEVAR-LA 组术中时间、术中输血次数、术中晶体液用量、重症监护病房住院时间和术后肺部并发症减少。rEVAR-LA 组 30 天死亡率（15.5%比 23.3%；调整后的危险比 [AHR]，0.70；95%置信区间 [CI]，0.49-0.99；P=0.04）和 1 年死亡率（22.5%比 32.3%；AHR，0.71；95% CI，0.53-0.96；P=0.02）均较低。年龄<75 岁和术前无低血压的 EVAR 患者，LA 组的生存率明显高于 GA 组（两者：AHR，0.14[95%CI，0.03-0.57]；单一因素：AHR，0.57[95%CI，0.36-0.91]）。
本研究表明，对于某些患者，rAAA 的 rEVAR-LA 可能是 rEVAR-GA 的安全替代方法，可降低发病率，提高生存率。需要进一步的前瞻性研究来证实 rEVAR-LA 在 rAAA 中的死亡率获益。
