de Guerre Livia E V M, Dansey Kirsten, Li Chun, Lu Jinny, Patel Priya B, van Herwaarden Joost A, Jones Douglas W, Goodney Philip P, Schermerhorn Marc L
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht.
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
J Vasc Surg. 2021 Oct;74(4):1152-1160. doi: 10.1016/j.jvs.2021.02.024. Epub 2021 Mar 6.
The risk of aortic abdominal aneurysm (AAA) rupture increases with an increasing aneurysm diameter. However, the effect of the AAA diameter on late outcomes after aneurysm repair is unclear. Therefore, we assessed the association of a large AAA diameter with late outcomes for patients undergoing open and endovascular AAA repair.
We identified all patients who had undergone elective open or endovascular infrarenal aneurysm repair from 2003 to 2016 in the Vascular Quality Initiative linked to Medicare claims for long-term outcomes. A large AAA diameter was defined as a diameter >65 mm. We assessed the 5-year reintervention, rupture, mortality, and follow-up rates. We constructed propensity scores and used inverse probability-weighted Kaplan-Meier estimations and Cox proportional hazard models to identify independent associations between large AAA repair and our outcomes.
Of the 21,119 aneurysm repairs identified, 15.2% were for large AAAs. Of the 21,119 repairs, 19,017 were endovascular and 2102 were open. The large AAA cohort was less likely to have undergone endovascular aneurysm repair (EVAR; 84.9% vs 91%; P < .001), more likely to be older (median age, 76 vs 75 years; P < .001), and were less likely to be women (16.2% vs 21.7%; P < .001). After EVAR, patients with large AAAs had had lower adjusted 5-year freedom from reintervention (73.9% vs 84.6%; P < .001), freedom from rupture (88.5% vs 93.6%; P < .001), survival (58.0% vs 66.4%; P < .001), and freedom from loss to follow-up (77.7% vs 83.3%; P < .001) compared with patients with smaller AAAs. However, after open repair, the adjusted 5-year freedom from reintervention (95.8% vs 93.3%; P = .11), freedom from rupture (97.4% vs 97.8%; P = .32), survival (70.4% vs 74.0%; P = .13), and loss to follow-up (60.5% vs 62.8%; P = .86) were similar to the results for patients with smaller AAAs. For patients with large AAAs, the adjusted 5-year survival was lower after EVAR than that after open repair (55.3% vs 63.7%) but not after smaller AAA repair (67.3% vs 70.6%).
The 5-year adjusted reintervention, ruptures, mortality, and loss to follow-up rates for patients who had undergone large AAA EVAR were higher than those for patients who had undergone small AAA EVAR and large AAA open repair. Therefore, for patients with large AAAs who are medically fit, open repair should be strongly considered. Furthermore, these findings highlight the necessity for rigorous long-term follow-up after EVAR.
腹主动脉瘤（AAA）破裂风险随动脉瘤直径增大而增加。然而，AAA直径对动脉瘤修复术后远期结局的影响尚不清楚。因此，我们评估了大直径AAA与接受开放性和血管腔内AAA修复患者远期结局之间的关联。
我们在与医疗保险索赔相关联的血管质量倡议中识别出2003年至2016年期间接受择期开放性或血管腔内肾下动脉瘤修复的所有患者，以获取长期结局。大直径AAA定义为直径>65毫米。我们评估了5年再次干预、破裂、死亡率和随访率。我们构建了倾向评分，并使用逆概率加权Kaplan-Meier估计和Cox比例风险模型来确定大直径AAA修复与我们所关注结局之间的独立关联。
在识别出的21119例动脉瘤修复病例中，15.2%为大直径AAA修复。在这21119例修复中，19017例为血管腔内修复，2102例为开放性修复。大直径AAA队列接受血管腔内动脉瘤修复（EVAR）的可能性较小（84.9%对91%；P<.001），年龄较大的可能性更大（中位年龄，76岁对75岁；P<.001），女性的可能性更小（16.2%对21.7%；P<.001）。EVAR术后，大直径AAA患者调整后的5年无再次干预率（73.9%对84.6%；P<.001）、无破裂率（88.5%对93.6%；P<.001）、生存率（58.0%对66.4%；P<.001）和无失访率（77.7%对83.3%；P<.001）均低于小直径AAA患者。然而，开放性修复术后，调整后的5年无再次干预率（95.8%对93.3%；P=.11）、无破裂率（97.4%对97.8%；P=.32）、生存率（70.4%对74.0%；P=.13）和失访率（60.5%对62.8%；P=.86）与小直径AAA患者的结果相似。对于大直径AAA患者，EVAR术后调整后的5年生存率低于开放性修复术后（55.3%对63.7%），但小直径AAA修复术后则无此差异（67.3%对70.6%）。
接受大直径AAA-EVAR患者的5年调整后再次干预、破裂、死亡率和失访率高于接受小直径AAA-EVAR和大直径AAA开放性修复的患者。因此，对于身体状况适合的大直径AAA患者，应强烈考虑开放性修复。此外，这些发现凸显了EVAR术后进行严格长期随访的必要性。
