Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY.
J Vasc Surg. 2021 May;73(5):1583-1592.e2. doi: 10.1016/j.jvs.2020.08.147. Epub 2020 Oct 6.
Endovascular abdominal aortic aneurysm repair (EVAR) has been preferred to open surgical repair (OSR) for the treatment of abdominal aortic aneurysms (AAAs) in high-risk patients. We compared the perioperative and long-term outcomes of EVAR for patients designated as unfit for OSR using a large national dataset.
The Vascular Quality Initiative database was queried for patients who had undergone elective EVAR for AAAs >5 cm from 2013 to 2019. The patients were stratified into two cohorts according to their suitability for OSR (fit vs unfit). The primary outcomes included perioperative (in-hospital) major adverse events, perioperative mortality, and mortality at 1 and 5 years. Patient demographics and postoperative outcomes were analyzed to identify the predictors of perioperative and long-term mortality.
Of 16,183 EVARs, 1782 patients had been deemed unfit for OSR. The unfit cohort was more likely to be older and female, with a greater proportion of hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and larger aneurysm diameters. Postoperatively, the unfit cohort was more likely to have experienced cardiopulmonary complications (6.5% vs 3%; P < .001), with greater perioperative mortality (1.7% vs 0.6%; P < .001) and 1- and 5-year mortality (13% and 29% for the unfit vs 5% and 14% for the fit cohorts, respectively; P < .001). A subgroup analysis of the unfit cohort revealed that those deemed unfit because of a hostile abdomen had significantly lower 1- and 5-year mortality (6% and 20%, respectively) compared with those considered unfit because of cardiopulmonary compromise and frailty (14% and 30%, respectively; P = .451). Reintervention-free survival at 1 and 5 years was significantly greater in the fit cohort (93% and 82%, respectively) compared with that for the unfit cohort (85% and 68%, respectively; P < .001). The designation as unfit for OSR was an independent predictor of both perioperative (odds ratio, 1.59; 95% confidence interval [CI], 1.03-2.46; P = .038) and long-term mortality (hazard ratio [HR], 1.92; 95% CI, 1.69-2.17; P < .001). Advanced age (odds ratio, 2.91; 95% CI, 1.28-6.66; P = .011) was the strongest determinant of perioperative mortality, and end-stage renal disease (HR, 2.51; 95% CI, 1.78-3.55; P < .001) was the strongest predictor of long-term mortality. Statin use (HR, 0.77; 95% CI, 0.69-0.87; P < .001) and angiotensin-converting enzyme inhibitor use (HR, 0.83; 95% CI, 0.75-0.93; P < .001) were protective of long-term mortality.
Despite low perioperative mortality, the long-term mortality of those designated by operating surgeons as unfit for OSR was rather high for patients undergoing elective EVAR, likely owing to the competing risk of death from medical frailty. An unfit designation because of a hostile abdomen did not confer any additional risks after EVAR. Judicious estimation of the patient's life expectancy is essential when considering the treatment options for this subset of patients deemed unfit for OSR.
对于高危患者的腹主动脉瘤（AAA），血管内腹主动脉瘤修复术（EVAR）已优于开放手术修复术（OSR）。我们使用大型国家数据库比较了为不适合 OSR 的患者进行 EVAR 的围手术期和长期结果。
从 2013 年至 2019 年，对接受择期 EVAR 治疗>5cm 的 AAA 患者的血管质量倡议数据库进行了查询。根据他们是否适合 OSR（适合与不适合）将患者分为两组。主要结果包括围手术期（住院期间）主要不良事件、围手术期死亡率以及 1 年和 5 年的死亡率。分析患者的人口统计学和术后结果，以确定围手术期和长期死亡率的预测因素。
在 16183 例 EVAR 中，有 1782 例患者被认为不适合 OSR。不适合组更可能是老年人和女性，高血压、冠心病、充血性心力衰竭、慢性阻塞性肺疾病和更大的动脉瘤直径比例更高。术后，不适合组更可能经历心肺并发症（6.5%对 3%；P<0.001），围手术期死亡率更高（1.7%对 0.6%；P<0.001），1 年和 5 年死亡率更高（不适合组分别为 13%和 29%，适合组分别为 5%和 14%；P<0.001）。不适合组的亚组分析显示，由于腹部情况恶劣而被认为不适合的患者的 1 年和 5 年死亡率明显较低（分别为 6%和 20%），而由于心肺功能受损和体弱而被认为不适合的患者分别为 14%和 30%（P=0.451）。1 年和 5 年的无再干预生存率在适合组中明显更高（分别为 93%和 82%），而在不适合组中分别为 85%和 68%（P<0.001）。不适合 OSR 的手术医生指定是围手术期（比值比，1.59；95%置信区间 [CI]，1.03-2.46；P=0.038）和长期死亡率（风险比 [HR]，1.92；95%CI，1.69-2.17；P<0.001）的独立预测因素。高龄（比值比，2.91；95%CI，1.28-6.66；P=0.011）是围手术期死亡率的最强决定因素，终末期肾病（HR，2.51；95%CI，1.78-3.55；P<0.001）是长期死亡率的最强预测因素。他汀类药物使用（HR，0.77；95%CI，0.69-0.87；P<0.001）和血管紧张素转换酶抑制剂使用（HR，0.83；95%CI，0.75-0.93；P<0.001）是长期死亡率的保护因素。
尽管围手术期死亡率较低，但对于接受择期 EVAR 的被手术医生指定为不适合 OSR 的患者，其长期死亡率相当高，这可能是由于体弱多病导致的死亡竞争风险所致。由于腹部情况恶劣而被认为不适合进行 EVAR 并不会带来任何额外的风险。在考虑将这些被认为不适合 OSR 的患者作为治疗选择时，明智地估计患者的预期寿命至关重要。
