Flohr Tanya R, Snow Rachael, Aziz Faisal
Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pa.
Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pa.
J Vasc Surg. 2021 Oct;74(4):1183-1192.e5. doi: 10.1016/j.jvs.2021.04.033. Epub 2021 May 1.
The impact of anticoagulation on late endoleaks after endovascular aneurysm repair (EVAR) is unclear despite multiple investigators studying the relationship. The purpose of this study was to determine if long-term anticoagulation impacted the development of late endoleaks and if specific anticoagulants were more likely to exacerbate the development of endoleaks.
Using the Society for Vascular Surgery Vascular Quality Initiative database, patients undergoing EVAR between 2003 and 2019 for abdominal aortic aneurysms were evaluated. Patients were divided into two groups: those without a late endoleak and those with a late endoleak. Bivariate analysis was performed to assess preoperative, intraoperative, postoperative, and long-term follow-up variables. A multivariable analysis was done to determine associations of independent variables with late endoleaks. Patients were further subcategorized based on anticoagulation status before and after EVAR, specific type of anticoagulation, and the presence of an index endoleaks (diagnosed at the time of EVAR) to determine the subsequent frequency of late endoleaks.
A total of 29,783 patients were analyzed with 2169 (7.3%) having a late endoleak identified. Several risk factors were related to late endoleaks, including anticoagulation before and after EVAR (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.57-6.96; P < .001), anticoagulation after EVAR (OR, 1.88; 95% CI, 1.43-2.49; P < .001), and index endoleak (OR, 1.45; 95% CI, 1.26-1.66; P < .001). The frequency of late endoleaks in patients anticoagulated before and after EVAR and after EVAR as compared with those never anticoagulated was 16.89% and 14.40% vs 6.95%, respectively (both P > .001). No difference in late endoleaks were noted for patients treated with warfarin and novel oral anticoagulants. The most common type of index and late endoleak identified was type II, but patients with type I, type II, and type IV index endoleaks were more commonly found to have type I, type II, and type IV late endoleaks, respectively. The frequency of late endoleaks in patients with both an index endoleak and anticoagulation after EVAR was 20.42% as compared with patients with only anticoagulation after EVAR (14.63%; P = .0015) and with patients with index endoleaks not anticoagulated (10.06%; P < .00001).
Late endoleaks were more common in patients treated with anticoagulation after EVAR. No difference in late endoleak frequency was detected between anticoagulation with warfarin and novel oral anticoagulants. Patients on anticoagulation and those with an index endoleak were at a higher risk of having a late endoleak.
尽管有多项研究探讨了血管内动脉瘤修复术（EVAR）后抗凝治疗对晚期内漏的影响，但目前仍不清楚。本研究的目的是确定长期抗凝治疗是否会影响晚期内漏的发生，以及特定的抗凝剂是否更有可能加剧内漏的发生。
利用血管外科学会血管质量改进数据库，对2003年至2019年间因腹主动脉瘤接受EVAR治疗的患者进行评估。患者分为两组：无晚期内漏组和有晚期内漏组。进行双变量分析以评估术前、术中和术后及长期随访变量。进行多变量分析以确定自变量与晚期内漏的相关性。根据EVAR前后的抗凝状态、特定的抗凝类型以及索引内漏（在EVAR时诊断）的存在情况对患者进行进一步分类，以确定晚期内漏的后续发生频率。
共分析了29783例患者，其中2169例（7.3%）被确定有晚期内漏。几个危险因素与晚期内漏有关，包括EVAR前后的抗凝治疗（比值比[OR]，4.23；95%置信区间[CI]，2.57-6.96；P <.001）、EVAR后的抗凝治疗（OR，1.88；95%CI，1.43-2.49；P <.001）和索引内漏（OR，1.45；95%CI，1.26-1.66；P <.001）。与从未接受抗凝治疗的患者相比，EVAR前后接受抗凝治疗以及EVAR后接受抗凝治疗的患者晚期内漏的发生率分别为16.89%和14.40%，而从未接受抗凝治疗的患者为6.95%（两者P>.001）。接受华法林和新型口服抗凝剂治疗的患者晚期内漏发生率无差异。最常见的索引内漏和晚期内漏类型为II型，但I型、II型和IV型索引内漏的患者分别更常出现I型、II型和IV型晚期内漏。与仅在EVAR后接受抗凝治疗的患者（14.63%；P =.0015）和索引内漏未接受抗凝治疗的患者（10.06%；P <.00001）相比，EVAR后既有索引内漏又接受抗凝治疗的患者晚期内漏的发生率为20.42%。
EVAR后接受抗凝治疗的患者晚期内漏更为常见。华法林和新型口服抗凝剂在晚期内漏发生率上无差异。接受抗凝治疗的患者和有索引内漏的患者发生晚期内漏的风险更高。
