Columbia University Aortic Surgery Center, New York, NY.
Columbia University Aortic Surgery Center, New York, NY.
J Vasc Surg. 2021 Feb;73(2):451-458. doi: 10.1016/j.jvs.2020.05.027. Epub 2020 May 27.
Contemporary data on outcomes in open thoracoabdominal aortic aneurysm (TAAA) repair are limited to reports from major aortic referral centers showing excellent outcomes. This study aimed to characterize the national experience of open TAAA repair using national outcomes data, with a primary focus on the association of hospital volume with mortality and morbidity.
The Nationwide Inpatient Sample was queried from 1998 to 2011, and all patients with a diagnosis of TAAA who underwent open operative repair were included. These patients were further stratified into tertiles based on the operative volume of the institution that performed the operation: low volume (LV), <3 cases/y; medium volume (MV), 3 to 11 cases/y; and high volume (HV), ≥12 cases/y. Baseline demographics as well as perioperative outcomes were compared between these groups. Multivariable logistic regression was performed to determine predictors of operative mortality and morbidity. Subgroup analyses were performed for patients presenting for elective surgery and for those presenting for urgent and emergent surgery.
Overall operative mortality was 21% for the entire cohort. Operative mortality was higher at LV (26%) and MV (21%) centers compared with HV centers (15%; P < .001). This difference was similar in both elective surgery (LV, 18%; MV, 14%; HV, 12%; P < .001) and urgent and emergent surgery (LV, 34%; MV, 30%; HV, 19%; P < .001). Furthermore, rates of blood transfusion and acute renal failure were significantly lower in the HV group. Multivariable analysis revealed that compared with the HV group, patients operated on at LV centers (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.7-2.1; P < .001) and MV centers (OR, 1.5; 95% CI, 1.4-1.7; P < .001) had at least 1.5 times the odds of in-hospital mortality. The HV group also had significantly lower odds of dying in the subgroup analyses of both elective surgery and urgent and emergent surgery. Increasing TAAA volume was associated with increased use of distal aortic perfusion (OR, 1.03; 95% CI, 1.02-1.03; P < .001).
Patients with TAAA in the United States operated on at HV centers have significantly lower mortality and morbidity compared with patients operated on at lower volume centers. Consideration of referral to HV centers may be warranted, but further research is required to justify this conclusion.
目前有关开放性胸腹主动脉瘤（TAAA）修复术结果的数据仅限于大型主动脉转诊中心的报告，这些报告显示出了极好的结果。本研究旨在利用全国性的研究结果来描述开放性 TAAA 修复术的全国性经验，主要侧重于医院手术量与死亡率和发病率之间的关系。
从 1998 年至 2011 年，对全国住院患者样本进行了查询，包括所有接受开放性手术治疗的 TAAA 患者。这些患者根据手术医院的手术量进一步分为三个三分位数组：低手术量（LV）组，<3 例/年；中手术量（MV）组，3 至 11 例/年；高手术量（HV）组，≥12 例/年。比较这些组之间的基线人口统计学特征和围手术期结果。采用多变量逻辑回归确定手术死亡率和发病率的预测因素。对择期手术和紧急手术的患者进行了亚组分析。
整个队列的总手术死亡率为 21%。LV（26%）和 MV（21%）中心的手术死亡率高于 HV（15%）中心（P<.001）。在择期手术（LV，18%；MV，14%；HV，12%；P<.001）和紧急手术（LV，34%；MV，30%；HV，19%；P<.001）中，这种差异相似。此外，HV 组输血和急性肾衰竭的发生率明显较低。多变量分析显示，与 HV 组相比，在 LV 中心（比值比[OR]，1.9，95%置信区间[CI]，1.7-2.1；P<.001）和 MV 中心（OR，1.5；95%CI，1.4-1.7；P<.001）接受手术的患者院内死亡率至少增加了 1.5 倍。HV 组在择期手术和紧急手术的亚组分析中，死亡的可能性也明显降低。TAAA 手术量的增加与远端主动脉灌注的使用增加相关（OR，1.03；95%CI，1.02-1.03；P<.001）。
与在低手术量中心接受治疗的患者相比，在美国接受 HV 中心治疗的 TAAA 患者的死亡率和发病率明显较低。考虑将患者转至 HV 中心可能是合理的，但需要进一步的研究来证实这一结论。
