Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada.
Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada.
J Vasc Surg. 2022 Mar;75(3):894-905. doi: 10.1016/j.jvs.2021.08.091. Epub 2021 Sep 29.
Previous studies have demonstrated significant geographic variations in the management of abdominal aortic aneurysms (AAA) despite standard guidelines. Differences in patient selection, operative technique, and outcomes for AAA repair in Canada versus United States were assessed.
The Vascular Quality Initiative was used to identify all patients who underwent elective endovascular or open AAA repair between 2010 and 2019 in Canada and the United States. Demographic, clinical, and procedural characteristics were recorded and differences between countries were assessed using independent t test and χ test. The primary outcome was the percentage of AAA repaired below recommended diameter thresholds (men, <5.5 cm; women, <5.0 cm). The secondary outcomes were in-hospital and 1-year mortality rates. Associations between region and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis.
There were 51,455 U.S. patients and 1451 Canadian patients who underwent AAA repair in Vascular Quality Initiative sites during the study period. There was a higher proportion of endovascular repairs in the United States (83.7% vs 68.4%; odds ratio [OR], 2.38; 95% confidence interval [CI], 2.13-2.63; P < .001). U.S. patients had more comorbidities, including hypertension, congestive heart failure, chronic kidney disease, and prior revascularization. The percentage of AAA repaired below recommended thresholds was significantly higher in the United States (38.8% vs 15.2%; OR, 3.57; 95% CI, 3.03-4.17; P < .001). This difference persisted after controlling for demographic, clinical, and procedural characteristics (adjusted OR, 3.57; 95% CI, 2.63-4.17; P < .001). Factors that predicted AAA repair below recommended thresholds were U.S. region (adjusted OR, 3.57; 95% CI, 3.03-4.17), male sex (adjusted OR, 2.89; 95% CI, 2.72-3.07), and endovascular repair (adjusted OR, 2.08; 95% CI, 1.95-2.21). The in-hospital mortality rate was low (1.0% vs 0.8%) and the 1-year rate mortality was similar between countries (hazard ratio, 0.96; 95% CI, 0.70-1.31; P = .79).
There are significant variations in AAA management between Canada and the United States. A greater proportion of U.S. patients underwent AAA repair below the recommended diameter thresholds. This finding is partly driven by a higher percentage of endovascular repairs. Despite these differences, the perioperative and 1-year mortality rates are similar. Future studies should investigate reasons for these variations and quality improvement projects are needed to standardize care.
尽管有标准指南，但先前的研究表明，尽管有标准指南，但在管理腹主动脉瘤（AAA）方面仍存在显著的地域差异。评估了加拿大与美国之间在 AAA 修复的患者选择、手术技术和结果方面的差异。
利用血管质量倡议（Vascular Quality Initiative），确定了 2010 年至 2019 年间在加拿大和美国接受择期腔内或开放 AAA 修复的所有患者。记录了人口统计学、临床和手术特征，并使用独立 t 检验和 χ 检验评估了国家之间的差异。主要结局是 AAA 修复低于推荐直径阈值（男性，<5.5cm；女性，<5.0cm）的百分比。次要结局是住院和 1 年死亡率。使用单变量/多变量逻辑回归和 Cox 比例风险分析评估了区域与结局之间的关系。
在研究期间，血管质量倡议网站中共有 51455 名美国患者和 1451 名加拿大患者接受了 AAA 修复。美国的腔内修复比例更高（83.7%比 68.4%；优势比[OR]，2.38；95%置信区间[CI]，2.13-2.63；P<0.001）。美国患者有更多的合并症，包括高血压、充血性心力衰竭、慢性肾脏病和先前的血运重建。美国 AAA 修复低于推荐阈值的比例明显更高（38.8%比 15.2%；OR，3.57；95% CI，3.03-4.17；P<0.001）。在控制人口统计学、临床和手术特征后，这种差异仍然存在（调整后的 OR，3.57；95% CI，2.63-4.17；P<0.001）。预测 AAA 修复低于推荐阈值的因素包括美国地区（调整后的 OR，3.57；95% CI，3.03-4.17）、男性（调整后的 OR，2.89；95% CI，2.72-3.07）和腔内修复（调整后的 OR，2.08；95% CI，1.95-2.21）。住院死亡率较低（1.0%比 0.8%），两国 1 年死亡率相似（风险比，0.96；95% CI，0.70-1.31；P=0.79）。
加拿大和美国在 AAA 管理方面存在显著差异。美国有更大比例的患者接受了低于推荐直径阈值的 AAA 修复。这一发现部分归因于腔内修复比例较高。尽管存在这些差异，但围手术期和 1 年死亡率相似。未来的研究应该调查这些差异的原因，并需要开展质量改进项目以规范护理。
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