Department of Vascular Surgery, Danbury Hospital, Danbury, Conn.
Department of Vascular Surgery, Danbury Hospital, Danbury, Conn.
J Vasc Surg. 2021 Apr;73(4):1227-1233.e1. doi: 10.1016/j.jvs.2020.08.116. Epub 2020 Sep 1.
The current Society for Vascular Surgery (SVS) guidelines, based on randomized controlled trials published more than a decade ago, recommend a minimum threshold diameter of 5.5 cm for infrarenal abdominal aortic aneurysm (iAAA) repair. It is unknown whether practice patterns with respect to size of repair have changed since the publication of these guidelines. We aimed to evaluate the real-world practice of vascular surgeons in our region with respect to iAAA size at the time of repair, whether this has changed over the past 12 years and if any changes were associated with the repair type, open vs endovascular.
The Vascular Study Group of New England (VSGNE) database was used to identify all patients who received iAAA repair between 2003 and 2015. The primary end point was to quantify the annual percentage of iAAAs repaired in different size categories (≥5.5 cm; <5.5 cm but ≥5.0 cm; <5.0 cm) over the study time period and by type of repair. The secondary end points were morbidity and mortality in these groups. We excluded nonelective cases (ruptured or symptomatic), patients with coexisting iliac artery aneurysms, and those missing critical data.
A total of 5314 patients with iAAA repairs (1538 open, 3776 endovascular) were identified in the VSGNE database during the study period. In 40% (2110 of 5314) of patients, repair was performed for aneurysms <5.5 cm, with endovascular aneurysm repair (EVAR) comprising 75% (1581 of 2110) and open 25% (529 of 2110). More EVARs were performed for <5.5 cm in 2015 (46%) compared with 2003 (33%) (P < .05, n - 1 χ) with an average increase of 1.1%/y. There was also a non-statistically significant increase in open repair of small aneurysms (0.7%/y; P = .759). Overall, 30-day mortality was 1.11% in the EVAR group (0.54% in <5.0 cm, 0.91% in ≥5.0 but <5.5 cm, and 1.55% in ≥5.5 cm), compared with 3% in the open group (2.88%, 1.79%, and 3.77%, respectively) with no significant change in mortality in either group over time.
Despite the SVS guidelines suggesting surveillance rather than repair of iAAA <5.5 cm, an increasing proportion of repairs in the VSGNE database were performed below that threshold. The reasons for this are likely multifactorial and might include a lesser complexity and lower operative mortality for smaller aneurysms and markedly improved third- and fourth-generation stent graft technology with possibly better long-term survival. As such, it may be time to re-examine the current guidelines for iAAA repair.
目前，基于发表于十多年前的随机对照试验，美国血管外科学会（SVS）指南建议对肾下型腹主动脉瘤（iAAA）进行修复的最小直径阈值为 5.5cm。目前尚不清楚自这些指南发表以来，血管外科医生在修复 iAAA 时的大小的实践模式是否发生了变化。我们旨在评估我们所在地区血管外科医生在 iAAA 修复时的实际情况，即大小是否在过去 12 年中发生了变化，以及任何变化是否与修复类型（开放手术与血管内修复术）有关。
使用血管研究组新英格兰（VSGNE）数据库来确定 2003 年至 2015 年间接受 iAAA 修复的所有患者。主要终点是量化研究期间不同大小类别（≥5.5cm；＜5.5cm 但≥5.0cm；＜5.0cm）中每年接受 iAAA 修复的比例，以及按修复类型进行的分类。次要终点是这些组的发病率和死亡率。我们排除了非择期病例（破裂或有症状）、同时存在髂动脉瘤的患者以及缺少关键数据的患者。
在研究期间，VSGNE 数据库中共有 5314 例 iAAA 修复患者（1538 例开放手术，3776 例血管内修复术）。在 40%（2110 例中有 5314 例）的患者中，进行了＜5.5cm 的动脉瘤修复，其中血管内修复术占 75%（1581 例中有 2110 例），开放手术占 25%（2110 例中有 529 例）。2015 年接受＜5.5cm 修复的血管内修复术比例（46%）高于 2003 年（33%）（P＜0.05，n-1 χ），平均每年增加 1.1%。小型动脉瘤开放修复也呈非统计学意义的增长（0.7%/年；P=0.759）。总体而言，血管内修复术组的 30 天死亡率为 1.11%（＜0.0 时为 0.54%，≥0.5 但＜0.5 时为 0.91%，≥0.55 时为 1.55%），而开放手术组为 3%（分别为 2.88%、1.79%和 3.77%），两组的死亡率在研究期间均无明显变化。
尽管 SVS 指南建议对 iAAA＜5.5cm 进行监测而不是修复，但 VSGNE 数据库中进行修复的比例却在不断增加。其原因可能是多方面的，可能包括较小的动脉瘤的复杂性和手术死亡率较低，以及第三代和第四代支架移植物技术的显著改进，可能带来更好的长期生存。因此，现在可能需要重新审查 iAAA 修复的现行指南。
