Quintana M Jesús, Gich Ignasi, Librero Julián, Bellmunt-Montoya Sergi, Escudero José R, Bonfill Xavier
Department of Clinical Epidemiology and Public Health, University Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain,
CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain,
Vasc Health Risk Manag. 2019 Apr 8;15:69-79. doi: 10.2147/VHRM.S191451. eCollection 2019.
The two main surgical treatments for abdominal aortic aneurysm (AAA) are open surgical repair (OSR) and endovascular aneurysm repair (EVAR). The aim of this study was to analyze variation among Spanish hospitals in the use of OSR or EVAR for AAA. A secondary aim was to assess changes in preferences for these two procedures over time.
This was a retrospective longitudinal study based on discharge data from public hospitals in Spain during 2002-2012. Patient inclusion criteria were: age >18 years, elective admission, primary diagnosis of unruptured AAA, and surgical treatment with OSR or EVAR. The characteristics of the treating center, patients, and in-hospital mortality were recorded.
We included 16,737 patients from 114 hospitals; 6,809 (40.7%) underwent EVAR and 9,928 (59.3%) underwent OSR. The total volume of surgeries increased throughout the period, and the probability that any given procedure was EVAR increased by 20% per year (OR 1.20, <0.001). The volume and distribution of the two procedures varied highly across the participating hospitals. Overall, in-hospital mortality rate was 3.6% and it decreased during the study period (5.3% in 2002 and 3.2% in 2012), mainly due to a decrease in OSR-related mortality, despite a slight increase in EVAR-related mortality. Hospitals with higher surgical volumes were more likely to use EVAR and have lower in-hospital mortality rates.
This study reveals high variability in the surgical treatment of unruptured AAA across Spanish hospitals. The number of interventions has increased in recent years, with EVAR accounting for a growing percentage of these surgical procedures. Overall in-hospital mortality rates decreased significantly during this period, mainly due to lower mortality among patients undergoing OSR. In-hospital mortality rates were lower in higher-volume centers, regardless of the surgical approach used. Further research on variability and appropriateness of surgical management of AAA is required to assess the suitability of concentrating elective AAA repair in more experienced centers to potentially achieve better outcomes.
腹主动脉瘤（AAA）的两种主要外科治疗方法是开放手术修复（OSR）和血管内动脉瘤修复（EVAR）。本研究的目的是分析西班牙各医院在使用OSR或EVAR治疗AAA方面的差异。次要目的是评估随着时间的推移，对这两种手术方法的偏好变化。
这是一项基于2002年至2012年西班牙公立医院出院数据的回顾性纵向研究。患者纳入标准为：年龄>18岁、择期入院、未破裂AAA的初步诊断以及采用OSR或EVAR进行手术治疗。记录治疗中心、患者的特征以及院内死亡率。
我们纳入了来自114家医院的16737例患者；6809例（40.7%）接受了EVAR，9928例（59.3%）接受了OSR。在此期间，手术总量有所增加，任何给定手术为EVAR的概率每年增加20%（比值比1.20，<0.001）。这两种手术的数量和分布在参与研究的医院之间差异很大。总体而言，院内死亡率为3.6%，且在研究期间有所下降（2002年为5.3%，2012年为3.2%），主要原因是与OSR相关的死亡率下降，尽管与EVAR相关的死亡率略有上升。手术量较高的医院更有可能使用EVAR且院内死亡率较低。
本研究揭示了西班牙各医院在未破裂AAA手术治疗方面存在高度差异。近年来手术干预数量有所增加，EVAR在这些手术中所占比例不断上升。在此期间，总体院内死亡率显著下降，主要原因是接受OSR的患者死亡率较低。无论采用何种手术方式，手术量较高的中心院内死亡率较低。需要对AAA手术管理的差异和适当性进行进一步研究，以评估将择期AAA修复集中在经验更丰富的中心是否合适，从而有可能取得更好的结果。
