血管质量倡议中的血管内腹主动脉瘤修复后 5 年再干预。
Five-year reintervention after endovascular abdominal aortic aneurysm repair in the Vascular Quality Initiative.
机构信息
Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
出版信息
J Vasc Surg. 2020 Mar;71(3):799-805.e1. doi: 10.1016/j.jvs.2019.05.057. Epub 2019 Aug 27.
OBJECTIVE
Patients who undergo endovascular abdominal aortic aneurysm repair (EVR) remain at risk for reintervention and rupture. We sought to define the 5-year rate of reintervention and rupture after EVR in the Vascular Quality Initiative (VQI).
METHODS
We identified all patients in the VQI who underwent EVR from 2003 to 2015. We linked patients in the VQI to Medicare claims for long-term outcomes. We stratified patients on baseline clinical and procedural characteristics to identify those at risk for reintervention. Our primary outcomes were 5-year rates of reintervention and late aneurysm rupture after EVR. We assessed these with Kaplan-Meier survival estimation.
RESULTS
We studied 12,911 patients who underwent EVR. The mean age was 75.5 years, 79.9% were male, 3.9% were black, and 89.1% of operations were performed electively. The 5-year rate of reintervention for the entire cohort was 21%, and the 5-year rate of late aneurysm rupture was 3%. Reintervention rates varied across categories of EVR urgency. Patients who underwent EVR electively had the lowest 5-year rate of reintervention at 20%. Those who underwent surgery for symptomatic aneurysms had higher rates of reintervention at 25%. Patients undergoing EVR emergently for rupture had the highest rate of reintervention, 27% at 4 years (log-rank across the three groups, P < .001). Black race and aneurysm size of 6.0 cm or greater were associated with significantly elevated reintervention rates (black, 31% vs white, 20% [log-rank, P < .001]; aneurysm size 6.0 cm or greater, 27% vs all others, <20% [log-rank, P < .001]). There were no significant associations between age or gender and the 5-year rate of reintervention.
CONCLUSIONS
More than one in five Medicare patients undergo reintervention within 5 years after EVR in the VQI; late rupture remains low at 3%. Black patients, those with large aneurysms, and those who undergo EVR urgently and emergently have a higher likelihood of adverse outcomes and should be the focus of diligent long-term surveillance.
目的
接受血管内腹主动脉瘤修复术（EVR）的患者仍有再次干预和破裂的风险。我们旨在确定血管质量倡议（VQI）中 EVR 后 5 年的再干预和破裂率。
方法
我们在 VQI 中确定了 2003 年至 2015 年期间接受 EVR 的所有患者。我们将 VQI 中的患者与 Medicare 索赔进行了链接，以了解长期结果。我们根据基线临床和程序特征对患者进行分层，以确定有再干预风险的患者。我们的主要结果是 EVR 后 5 年的再干预率和晚期动脉瘤破裂率。我们使用 Kaplan-Meier 生存估计来评估这些结果。
结果
我们研究了 12911 名接受 EVR 的患者。平均年龄为 75.5 岁，79.9%为男性，3.9%为黑人，89.1%的手术为择期进行。整个队列的 5 年再干预率为 21%，5 年晚期动脉瘤破裂率为 3%。再干预率在 EVR 紧急程度的各个类别中有所不同。择期接受 EVR 的患者 5 年再干预率最低，为 20%。因症状性动脉瘤而接受手术的患者再干预率较高，为 25%。因破裂而紧急接受 EVR 的患者再干预率最高，4 年内为 27%（三组间的对数秩检验，P<0.001）。黑人种族和动脉瘤大小为 6.0cm 或更大与显著升高的再干预率相关（黑人，31%比白人，20%[对数秩检验，P<0.001]；动脉瘤大小为 6.0cm 或更大，27%比其他所有人，<20%[对数秩检验，P<0.001]）。年龄或性别与 5 年再干预率之间无显著相关性。
结论
VQI 中超过五分之一的 Medicare 患者在 EVR 后 5 年内再次接受干预；晚期破裂率仍保持在 3%的低水平。黑人患者、动脉瘤较大的患者以及紧急和紧急接受 EVR 的患者发生不良结局的可能性更高，应作为密切长期监测的重点。
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