Division of Vascular Surgery, University of Wisconsin, Madison, Wisc.
Department of Anesthesia, University of Wisconsin, Madison, Wisc.
J Vasc Surg. 2021 Sep;74(3):843-850. doi: 10.1016/j.jvs.2021.02.048. Epub 2021 Mar 26.
Patients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time.
This was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients.
A total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival.
TAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.
降主动脉瘤（dTAA）或胸腹主动脉瘤（TAAA）患者常伴有多种合并症。那些被认为可以接受介入治疗的患者会接受复杂的修复手术，早期结果良好。本研究的目的是确定与随时间变化相关的死亡率的变量。
这是对我们机构从 1983 年到 2015 年的前瞻性维护数据库的回顾性研究。如果患者接受开放或血管内修复 dTAA 或 TAAA，则将其纳入研究。如果患者因外伤性横断而接受介入治疗，则将其排除在外。本研究的主要结果是长期生存。次要结果包括与主动脉相关的死亡率。我们对所有患者都有死亡率和生存数据。
共有 946 名患者符合我们的研究标准，中位随访时间为 102.8 个月（四分位距[IQR]，58.9-148.2 个月）。队列的中位年龄为 71 岁（IQR，63-77 岁），大多数患者为男性（58.1%）。TAAA 病变的范围如下：I 型（14.2%），II 型（21.2%），III 型（17.1%），IV 型（26.2%）和 dTAA（21.2%）。共有 147 名患者（15.5%）有既往夹层。动脉瘤的中位直径为 6.4cm（IQR，6.0-7.0cm）。在研究期间，共有 158 名患者（16.7%）接受了血管内修复。与随时间变化相关的死亡率的变量包括年龄、手术时代、急性病、夹层、术前肌酐和 IV 型 TAAA。此外，在术后期间经历以下并发症与随时间变化的死亡率相关：神经、心脏和肺部。研究期间，主动脉相关死亡率为 2.1%（n=20）。与开放修复相比，急性情况下接受血管内修复的患者具有更好的长期生存率。然而，非急性情况下，开放修复与血管内修复之间的长期生存率无差异。此外，现代时代的修复与生存的改善有关。
TAAA 可以通过合理的围手术期死亡率进行修复。一旦患者接受动脉瘤修复，主动脉相关死亡率仍然很低。血管内治疗方法的增加极大地改变了 dTAA 和 TAAA 患者的治疗方法。此外，血管内修复与急性患者的围手术期死亡率降低和长期生存率显著提高相关。接受 TAAA 修复的患者通常被认为是高危患者，因此需要进行广泛的长期随访，以管理他们的合并症和并发症，因为这些是随时间变化导致死亡率的主要因素。
