Wessels Lyndsey E, Calvo Richard Y, Sise Michael J, Bowie Jason M, Butler William J, Bansal Vishal, Sise C Beth
Trauma Service, Scripps Mercy Hospital, San Diego, CA, USA.
Vasc Endovascular Surg. 2020 May;54(4):325-332. doi: 10.1177/1538574420907193. Epub 2020 Feb 21.
Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown.
Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality.
Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, < .001) and was the primary repair method at level I trauma centers ( < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72).
Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.
在创伤中心，开放性修复破裂腹主动脉瘤（rAAA）已显示出更好的治疗效果。创伤中心的优势是否能延伸至rAAA的血管内修复尚不清楚。
采用回顾性队列研究，利用加利福尼亚州全州卫生规划与发展办公室2007年至2014年出院数据库来识别rAAA患者。数据包括人口统计学和入院因素、出院处置、编码及医院特征。医院按创伤中心指定情况和教学医院状态进行分类。评估修复类型和创伤中心指定情况（一级、二级或其他——其他创伤中心和非指定医院）的影响，以确定9种术后并发症的发生率和风险、住院死亡率及出院后30天死亡率。
在1941例rAAA修复患者中，61.2%接受开放性修复，37.8%接受血管内修复；1.0%两种修复方式都采用了。在研究期间，血管内修复有所增加。医院中12.0%为一级创伤中心，25.0%为二级创伤中心，63.0%为其他。共有48.7%的医院为教学医院（一级创伤中心为100%；二级创伤中心为4,2.2%；其他为41.8%）。血管内修复在教学医院明显更为常见（41.5%对34.3%，P<0.001），且是一级创伤中心的主要修复方法（P<0.001）。与开放性修复相比，血管内修复对大多数并发症和住院死亡率具有保护作用。二级创伤中心的血管内修复患者住院死亡率风险最高（风险比1.67，95%置信区间[CI]：0.95 - 2.92），其他医院也是如此（风险比1.66，95%CI：1.01 - 2.72）。
总体而言，血管内修复与不良结局风险较低相关。一级创伤中心的血管内修复住院死亡率风险较低，这可能是其教学医院地位、组织结构及其他因素所致。这些因素贡献的权重值得进一步研究。
