Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany.
Department of Vascular and Endovascular Surgery and Munich Aortic Center, University Hospital rechts der Isar, Technical University Munich, Munich, Germany; Department of Vascular Surgery, University Hospital Zürich, Zürich, Switzerland.
J Vasc Surg. 2021 Dec;74(6):1894-1903.e3. doi: 10.1016/j.jvs.2021.06.021. Epub 2021 Jun 26.
Acute abdominal aortic occlusion (AAO) is a rare vascular emergency associated with high morbidity and mortality. In the present study, we analyzed the clinical management and outcomes for a consecutive patient series during a 16-year period.
We included all patients with an acute AAO and bilateral acute limb ischemia who had been treated between 2004 and 2019. Patients with dissection, aneurysm rupture, or chronic occlusive disease were excluded. The patient characteristics, surgical procedures, and outcomes were extracted retrospectively from a prospective aortic database, electronic patient files, and outpatient examination records. The extent of ischemia was classified according to the TASC II (Inter-Society Consensus for the Management of Peripheral Arterial Disease) section on acute limb ischemia. The primary endpoints were 30-day mortality (safety endpoint) and the combined 6-month amputation and/or death rate (efficacy endpoint). The follow-up outcomes, amputation rates, and 30-day complications were evaluated as secondary endpoints. The patient cohort was divided into four 4-year groups (2004-2007, 2008-2011, 2012-2015, 2016-2019) to assess the outcome changes over time. Statistical analysis included χ tests and univariate and linear regression analyses.
A total of 74 patients (57% male; median age, 64.5 years) with an acute AAO were identified. Arterial thrombosis was the most common etiology (66%). The extent of ischemia was TASC I, IIa, IIb, and III in 7%, 39%, 40%, and 14%, respectively. The patient numbers had increased significantly over time (P = .016). Of the patients, 42% had undergone open transfemoral recanalization (including hybrid procedures), 35% open aortic surgery, 15% extra-anatomic bypass surgery, and 5% (four patients) endovascular therapy alone. The overall 30-day mortality rate was 23%, and the 6-month amputation and/or death rate was 43%. The 30-day mortality rate had declined significantly from 54% for 2004 to 2007 to 10% for 2011 to 2015 (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.001-0.52) and 20% for 2016 to 2019 (OR, 0.21; 95% CI, 0.05-0.90), a statistically nonsignificant trend showing that the relative decline in the use of open aortic procedures was associated with decreased 30-day mortality (P = .06). Univariate analysis indicated that elevated serum lactate on admission (OR, 3.33; 95% CI, 1.06-10.48) and an advanced stage of limb ischemia (OR, 4.33), were strongly associated with an increased 30-day mortality rate. The incidence of severe postoperative systemic complications also indicated a greater incidence of both primary endpoints. The 6-month amputation and/or mortality rates were also affected by the presence of atrial fibrillation (OR, 3.63; 95% CI, 1.34-9.79) and increased patient age (OR, 3.96; 95% CI, 1.49-10.53).
Acute AAO remains a life-threatening emergency. Immediate transfemoral open or endovascular techniques should be preferred, if technically possible and proper intraoperative imaging is available.
急性腹主动脉闭塞（AAO）是一种罕见的血管急症，与高发病率和死亡率相关。在本研究中，我们分析了在 16 年期间连续患者系列的临床管理和结局。
我们纳入了所有在 2004 年至 2019 年期间接受治疗的急性 AAO 和双侧急性肢体缺血的患者。排除夹层、动脉瘤破裂或慢性闭塞性疾病的患者。从前瞻性主动脉数据库、电子患者档案和门诊检查记录中回顾性提取患者特征、手术程序和结局。根据 TASC II（外周动脉疾病管理的国际共识）关于急性肢体缺血的部分对缺血程度进行分类。主要终点是 30 天死亡率（安全性终点）和 6 个月截肢和/或死亡率的复合率（疗效终点）。次要终点评估了随访结局、截肢率和 30 天并发症。将患者队列分为四个 4 年组（2004-2007 年、2008-2011 年、2012-2015 年、2016-2019 年），以评估随时间的变化。统计分析包括 χ 检验和单变量及线性回归分析。
共确定了 74 例急性 AAO 患者（57%为男性；中位年龄 64.5 岁）。动脉血栓形成是最常见的病因（66%）。缺血程度分别为 TASC I、IIa、IIb 和 III 级的患者分别占 7%、39%、40%和 14%。患者数量随着时间的推移显著增加（P=.016）。接受经股动脉开放再通（包括杂交手术）的患者占 42%，接受开放主动脉手术的患者占 35%，接受外科学旁路手术的患者占 15%，仅接受血管内治疗的患者占 5%（4 例）。总的 30 天死亡率为 23%，6 个月截肢和/或死亡率为 43%。2004 年至 2007 年的 30 天死亡率为 54%，而 2011 年至 2015 年为 10%（比值比[OR]，0.10；95%置信区间[CI]，0.001-0.52），2016 年至 2019 年为 20%（OR，0.21；95% CI，0.05-0.90），统计学上无显著趋势表明，开放主动脉手术使用的相对减少与 30 天死亡率降低相关（P=.06）。单变量分析表明，入院时血清乳酸升高（OR，3.33；95% CI，1.06-10.48）和肢体缺血程度较高（OR，4.33）与 30 天死亡率增加强烈相关。严重术后全身并发症的发生率也表明主要终点的发生率更高。6 个月的截肢和/或死亡率也受到心房颤动（OR，3.63；95% CI，1.34-9.79）和患者年龄增加（OR，3.96；95% CI，1.49-10.53）的影响。
急性 AAO 仍然是一种危及生命的紧急情况。如果技术上可行且有适当的术中影像学检查，则应优先选择经股动脉开放或血管内技术。
