Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich.
Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Mich.
J Vasc Surg. 2019 Oct;70(4):1089-1098. doi: 10.1016/j.jvs.2018.12.024. Epub 2019 Mar 2.
Recent vascular societal guidelines have recommended an abdominal aortic aneurysm (AAA) size threshold for elective intervention; however, limited data have documented how well these AAA diameter benchmarks are being met. The objective of this study was to analyze variation in management of AAAs based on diameter and to determine the physician's rationale for intervention on small AAAs in relation to recommended treatment guidelines.
A retrospective review of a statewide vascular surgery registry of all elective endovascular or open surgical AAA repairs from January 2012 to January 2016 was performed. Patients were dichotomized on the basis of aortic diameter at time of intervention into either guideline size AAAs or small AAAs, which were defined as <5.5 cm in men, <5.0 cm in women, or with growth <1.0 cm/y. An internal review was conducted of all small AAAs to determine the physician's rationale for intervention. The primary outcomes were variation in adherence to recommended treatment guidelines and the physician's rationale for treatment of small AAAs. Risk-adjusted major complication and mortality rates were calculated at 30 days and 1 year using a propensity score matching analysis.
Among the 3932 patients who underwent an elective AAA repair, 485 (12.3%) were repaired at diameters smaller than recommended by guidelines. The median AAA size in the small AAA cohort was 5.1 cm (interquartile range, 4.7-5.3 cm) vs 5.6 cm (interquartile range, 5.2-6.1 cm) in the guideline-based group. Percentage of small AAA repairs varied widely between hospitals from 1.4% to 44.4%. The physician's rationale for the majority of early interventions included the patient's anxiety (12.0%), combined aortoiliac occlusive disease (14.8%), aneurysm anatomy (28.2%), and does not adhere to guidelines (30%). The small AAA cohort had no significant difference in the 30-day or 1-year risk-adjusted mortality in comparison to guideline size AAAs.
Despite well-established aortic diameter threshold guidelines, marked variation exists both at the hospital level and in terms of the physician's rationale for the management of elective AAA repairs. These findings demonstrate the challenge of providing uniform care for patients with AAAs despite established guidelines.
最近的血管学会指南建议对腹主动脉瘤（AAA）进行择期干预，采用AAA 直径作为干预阈值；然而，仅有有限的数据记录了这些 AAA 直径标准的实施情况。本研究的目的是分析基于直径的 AAA 管理变化，并确定医生对小 AAA 进行干预的理由，以及该理由与推荐的治疗指南的关系。
对 2012 年 1 月至 2016 年 1 月期间全州范围内所有择期行腔内或开放手术修复的血管外科 AAA 修复患者的病历进行回顾性研究。根据干预时的主动脉直径，患者被分为两组：指南大小 AAA 组或小 AAA 组。小 AAA 定义为男性<5.5cm、女性<5.0cm 或直径每年增长<1.0cm。对所有小 AAA 进行内部审查，以确定医生干预的理由。主要结局是评估建议的治疗指南的实施情况变化和医生治疗小 AAA 的理由。使用倾向评分匹配分析，在 30 天和 1 年时计算主要并发症和死亡率的风险调整率。
在 3932 例行择期 AAA 修复的患者中，485 例（12.3%）的 AAA 直径小于指南推荐的直径。小 AAA 组的 AAA 中位数为 5.1cm（四分位间距，4.7-5.3cm），而指南组为 5.6cm（四分位间距，5.2-6.1cm）。不同医院之间小 AAA 修复的比例差异很大，从 1.4%到 44.4%。大多数早期干预的医生理由包括患者的焦虑（12.0%）、合并主髂动脉闭塞性疾病（14.8%）、AAA 解剖结构（28.2%）和不遵守指南（30%）。与指南大小 AAA 相比，小 AAA 组在 30 天或 1 年的风险调整死亡率方面无显著差异。
尽管有明确的主动脉直径阈值指南，但在医院层面和医生对择期 AAA 修复管理的理由方面仍存在明显差异。这些发现表明，尽管有既定的指南，但为 AAA 患者提供统一的护理仍然具有挑战性。
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