集中化治疗时代破裂腹主动脉瘤修复术后的结果。
Outcomes after ruptured abdominal aortic aneurysm repair in the era of centralized care.
机构信息
Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pa.
Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pa; Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pa; Department of Health Policy and Administration, Pennsylvania State University, University Park, Pa.
出版信息
J Vasc Surg. 2020 Apr;71(4):1148-1161. doi: 10.1016/j.jvs.2019.06.187. Epub 2019 Aug 30.
OBJECTIVE
Little is known about the relationship between case volume and patient outcomes of those treated for ruptured abdominal aortic aneurysm (rAAA) after either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR). This study evaluated the impact of hospital case volume on outcomes after rAAA.
METHODS
Patients with rAAA were identified in the Society for Vascular Surgery Vascular Quality Initiative database from 2003 to 2017, excluding patients from years in which a limited number of hospitals were included (2003-2009, 2017). Patients were stratified according to type of aneurysm repair and further stratified according to aortic surgical volume of the treating facility. Univariate and multivariable analyses were performed.
RESULTS
Between 2010 and 2016, of 2895 patients who presented emergently with rAAA, 1246 underwent ruptured OAR (rOAR) and 1649 underwent ruptured EVAR (rEVAR). Before adjustment for demographics, comorbidities, and clinical characteristics, there were no differences in 1-year patient survival based on hospital OAR or EVAR volumes among patients undergoing rOAR or rEVAR. After adjustment for confounding variables, patients treated with rOAR at the highest volume OAR hospitals had a 33% lower hazard of mortality at 1 year relative to patients treated with rOAR at the lowest volume OAR hospitals. Preoperative interfacility transfer was associated with a 27% lower hazard of mortality after rOAR. There was no significant difference in hazard of mortality among patients undergoing rEVAR when they were stratified according to hospital EVAR volumes after adjustment for all other covariates.
CONCLUSIONS
Outcomes after rAAA repair are associated with hospital volume among patients undergoing rOAR but not among patients undergoing rEVAR. Thus, centralization of care may have an important impact on outcomes when OAR is indicated, suggesting a benefit for preoperative interfacility transfer of care when it is feasible.
目的
对于接受腹主动脉瘤破裂（rAAA）腔内修复术（EVAR）或开放修复术（OAR）治疗的患者，医院手术量与患者结局之间的关系知之甚少。本研究评估了 rAAA 后医院手术量对结局的影响。
方法
从 2003 年至 2017 年，在美国血管外科学会血管质量倡议数据库中识别出 rAAA 患者，排除纳入医院数量有限的年份（2003-2009 年，2017 年）的患者。根据动脉瘤修复类型对患者进行分层，并根据治疗医院的主动脉手术量进一步分层。进行单变量和多变量分析。
结果
在 2010 年至 2016 年期间，2895 例 rAAA 患者中，1246 例行破裂 OAR（rOAR），1649 例行破裂 EVAR（rEVAR）。在未调整人口统计学、合并症和临床特征的情况下，rOAR 或 rEVAR 患者根据医院 OAR 或 EVAR 量，1 年患者生存率无差异。在调整混杂变量后，在 OAR 量最高的医院接受 rOAR 治疗的患者，其 1 年死亡率较在 OAR 量最低的医院接受 rOAR 治疗的患者降低 33%。rOAR 后，术前院内转科与死亡率降低 27%相关。在调整所有其他协变量后，根据医院 EVAR 量对 rEVAR 患者进行分层时，患者死亡率的危险比无显著差异。
结论
rOAR 患者的结局与医院手术量相关，而 rEVAR 患者的结局则不然。因此，当需要 OAR 时，集中治疗可能对结局有重要影响，提示当可行时，术前将患者转至其他医院接受治疗有获益。
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