腘动脉瘤开放修复与血管内修复的结果：基于人群队列的匹配比较。
Results After Open and Endovascular Repair of Popliteal Aneurysm: A Matched Comparison Within a Population Based Cohort.
机构信息
Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Hybrid and Interventional Surgery, Unit of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
Department of Clinical Sciences Malmö, Lund University, Sweden.
出版信息
Eur J Vasc Endovasc Surg. 2021 Jun;61(6):988-997. doi: 10.1016/j.ejvs.2021.02.007. Epub 2021 Mar 21.
OBJECTIVE
To identify factors affecting the outcome after open surgical (OSR) and endovascular (ER) repair of popliteal artery aneurysm (PA) in comparable cohorts.
METHODS
A matched comparison in a national, population based cohort of 592 legs treated for PA (2008 - 2012), with long term follow up. Registry data from 899 PA patients treated in 2014 - 2018 were analysed for time trends. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records and imaging were collected. Analysed risk factors were anatomy, comorbidities, and medication. Elongation and angulations were examined in a core lab. The main outcome was occlusion.
RESULTS
Patients in the ER group were older (73 vs. 68 years, p = .001), had more lung disease (p = .012), and were treated with dual antiplatelet therapy or anticoagulants more often (p < .001). The hazard ratio (HR with 95% confidence intervals) for occlusion was 2.69 (1.60 - 4.55, p < .001) for ER, but 3.03 (1.26 - 7.27, p = .013) for poor outflow. For permanent occlusion, the HR after ER was 2.47 (1.35 - 4.50, p = .003), but 4.68 (1.89 - 11.62, p < .001) for poor outflow. In the ER subgroup, occlusion was more common after acute ischaemia (HR 2.94 [1.45 - 5.97], p = .003; and poor outflow HR 14.39 [3.46 - 59.92], p < .001). Larger stent graft diameter reduced the risk (HR 0.71 [0.54 - 0.93], p = .014). In Cox regression analysis adjusted for indication and stent graft diameter, elongation increased the risk (HR 1.020 per degree [1.002 - 1.033], p = .030). PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, with those for elective procedures being 8 mm (p < .001). Indications and outcomes were similar during both time periods (2008 - 2012 and 2014 - 2018).
CONCLUSION
In comparable groups, ER had a 2.7 fold increased risk of any occlusion, and 2.4 fold increased risk of permanent occlusion, despite more aggressive medical therapy. Risk factors associated with occlusion in ER were poor outflow, smaller stent graft diameter, acute ischaemia, and angulation/elongation. An association between indication, acute ischaemia, and small stent graft diameter was identified.
目的
在可比队列中，确定影响腘动脉瘤（PA）开放手术（OSR）和血管内修复（ER）后结果的因素。
方法
对 2008 年至 2012 年接受 PA 治疗的 592 例肢体进行了一项全国性、基于人群的匹配比较，进行了长期随访。对 2014 年至 2018 年接受治疗的 899 例 PA 患者的登记数据进行了时间趋势分析。通过适应证将 77 例接受 ER 治疗的肢体与 154 例接受 OSR 治疗的肢体相匹配。收集病历和影像学资料。分析了解剖学、合并症和药物治疗等危险因素。在核心实验室检查了伸长和角度。主要结局是闭塞。
结果
ER 组患者年龄更大（73 岁 vs. 68 岁，p=0.001），肺部疾病更多（p=0.012），更常接受双联抗血小板治疗或抗凝治疗（p<0.001）。ER 的闭塞风险比（95%置信区间）为 2.69（1.60-4.55，p<0.001），但流出道不良的闭塞风险比为 3.03（1.26-7.27，p=0.013）。对于永久性闭塞，ER 后的 HR 为 2.47（1.35-4.50，p=0.003），但流出道不良的 HR 为 4.68（1.89-11.62，p<0.001）。在 ER 亚组中，急性缺血后闭塞更为常见（HR 2.94[1.45-5.97]，p=0.003；和流出道不良 HR 14.39[3.46-59.92]，p<0.001）。较大的支架移植物直径降低了风险（HR 0.71[0.54-0.93]，p=0.014）。在调整适应证和支架移植物直径的 Cox 回归分析中，伸长增加了风险（每度 HR 为 1.020[1.002-1.033]，p=0.030）。急性缺血治疗的 PA 支架移植物直径中位数为 6.5mm，择期手术的支架移植物直径为 8mm（p<0.001）。在 2008 年至 2012 年和 2014 年至 2018 年两个时期，适应证和结局相似。
结论
在可比组中，ER 的任何闭塞风险增加 2.7 倍，永久性闭塞风险增加 2.4 倍，尽管采用了更积极的药物治疗。与 ER 闭塞相关的危险因素包括流出道不良、支架移植物直径较小、急性缺血和角度/伸长。确定了适应证、急性缺血和小支架移植物直径之间的关联。
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