Department of Surgery, University of California, San Francisco, Calif.
Department of Surgery, University of California, San Francisco-East Bay, Oakland, Calif.
J Vasc Surg. 2022 Jan;75(1):109-117. doi: 10.1016/j.jvs.2021.07.125. Epub 2021 Jul 26.
Contemporary data on the natural history of large abdominal aortic aneurysms (AAAs) in patients undergoing delayed or no repair are lacking. In this study, we examine the impact of large AAA size on the incidence of rupture and mortality.
From a prospectively maintained aneurysm surveillance registry, patients with an unrepaired, large AAA (≥5.5 cm in men and ≥5.0 cm in women) at baseline (ie, index imaging) or who progressed to a large size from 2003 to 2017 were included, with follow-up through March 2020. Outcomes of interest obtained by manual chart review included rupture (confirmed by imaging/autopsy), probable rupture (timing/findings consistent with rupture without more likely cause of death), repair, reasons for either no or delayed (>1 year after diagnosis of large AAA) repair and total mortality. Cumulative incidence of rupture was calculated using a nonparametric cumulative incidence function, accounting for the competing events of death and aneurysm repair and was stratified by patient sex.
Of the 3248 eligible patients (mean age, 83.6 ± 9.1 years; 71.2% male; 78.1% white; and 32.0% current smokers), 1423 (43.8%) had large AAAs at index imaging, and 1825 progressed to large AAAs during the follow-up period, with a mean time to qualifying size of 4.3 ± 3.4 years. In total, 2215 (68%) patients underwent repair, of which 332 were delayed >1 year; 1033 (32%) did not undergo repair. The most common reasons for delayed repair were discrepancy in AAA measurement between surgeon and radiologist (34%) and comorbidity (20%), whereas the most common reasons for no repair were patient preference (48%) and comorbidity (30%). Among patients with delayed repair (mean time to repair, 2.6 ± 1.8 years), nine (2.7%) developed symptomatic aneurysms, and an additional 11 (3.3%) ruptured. Of patients with no repair, 94 (9.1%) ruptured. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 3-year cumulative incidence of rupture of 12.8% (95% confidence interval, 7.5%-19.6%) compared with 4.5% (95% confidence interval, 3.0%-6.5%) in men (P = .002).
In this large cohort of AAA registry patients over 17 years, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. Further analyses are ongoing to identify those at increased risk for aneurysm rupture and may provide targeted surveillance regimens and improve patient counseling.
目前缺乏关于接受延迟或不修复的大腹主动脉瘤（AAA）患者自然病史的当代数据。在这项研究中，我们研究了大 AAA 大小对破裂和死亡率的影响。
从一个前瞻性维护的动脉瘤监测登记处，纳入了基线时（即索引成像）未修复的、大 AAA（男性≥5.5cm，女性≥5.0cm）或 2003 年至 2017 年期间从 2003 年至 2017 年期间进展为大 AAA 的患者，随访至 2020 年 3 月。通过手动图表审查获得的感兴趣的结果包括破裂（通过影像学/尸检证实）、可能破裂（时间/发现与破裂一致，没有更可能的死亡原因）、修复、未修复或延迟修复（诊断为大 AAA 后超过 1 年）的原因（≥1 年）以及总死亡率。使用非参数累积发生率函数计算破裂的累积发生率，考虑到死亡和动脉瘤修复的竞争事件，并按患者性别分层。
在 3248 名合格患者中（平均年龄 83.6±9.1 岁；71.2%为男性；78.1%为白人；32.0%为当前吸烟者），1423 名（43.8%）在索引成像时患有大 AAA，1825 名在随访期间进展为大 AAA，平均达到合格大小的时间为 4.3±3.4 年。共有 2215 名（68%）患者接受了修复，其中 332 名延迟超过 1 年；1033 名（32%）未进行修复。延迟修复的最常见原因是外科医生和放射科医生之间的 AAA 测量差异（34%）和合并症（20%），而未修复的最常见原因是患者偏好（48%）和合并症（30%）。在延迟修复的患者中（平均修复时间 2.6±1.8 年），有 9 名（2.7%）出现症状性动脉瘤，另外有 11 名（3.3%）破裂。未修复的患者中，有 94 名（9.1%）破裂。初始 AAA 大小为 5.0 至 5.4cm（仅限女性）的患者 3 年破裂累积发生率为 3.4%，5.5 至 6.0cm 为 2.2%，6.1 至 7.0cm 为 6.0%，>7.0cm 为 18.4%。AAA 大小为 6.1 至 7.0cm 的女性 3 年破裂累积发生率为 12.8%（95%置信区间，7.5%-19.6%），而男性为 4.5%（95%置信区间，3.0%-6.5%）（P=0.002）。
在这项超过 17 年的大型 AAA 登记患者队列中，大 AAA 的年破裂率低于先前报道的水平，女性的风险可能增加。正在进行进一步分析以确定那些破裂风险增加的患者，这可能为动脉瘤破裂提供有针对性的监测方案，并改善患者咨询。
