Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich.
Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich.
J Vasc Surg. 2022 Apr;75(4):1223-1233. doi: 10.1016/j.jvs.2021.09.041. Epub 2021 Oct 8.
The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR).
Patients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days.
A total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001).
Nonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.
本研究利用美国外科医师学会国家手术质量改进计划数据集，确定 90 岁以上行腹主动脉瘤腔内修复术（EVAR）或开放手术修复（OSR）患者 30 天死亡率的预测因素。
使用手术代码确定 2005 年至 2017 年接受腹主动脉瘤修复的年龄>90 岁的患者。排除手术时间<15 分钟的患者。比较 30 天内死亡患者与 30 天存活患者的人口统计学、术前合并症和术后并发症。
共有 1356 名 90 岁以上患者符合标准：1229 例（90.6%）行 EVAR，127 例（9.4%）行 OSR。总体 30 天死亡率为 10.4%。30 天内死亡的患者接受 OSR 的比例明显高于 EVAR（40.9%比 7.2%；P<0.001）。他们的依赖功能状态发生率也更高（30 天内死亡的患者为 22.0%，30 天存活的患者为 8.1%；P<0.001），美国麻醉医师协会（ASA）分级≥4（81.2%比 18.8%；P<0.001），围手术期输血（59.6%比 20.3%；P<0.001），术后肺炎（12.1%比 2.9%；P=0.001），机械通气>48 小时（22.7%比 2.6%；P<0.001）和急性肾衰竭（12.1%比 0.5%；P<0.001）。EVAR 组 1008 例择期病例 30 天死亡率为 2.6%，221 例急诊病例 30 天死亡率为 28.6%。OSR 组 47 例择期病例 30 天死亡率为 19.1%，80 例急诊病例 30 天死亡率为 53.7%。在 EVAR 组中，30 天死亡组的依赖功能状态发生率明显更高（30 天内死亡的患者为 17%，30 天存活的患者为 8%；P=0.004），ASA 分级≥4（76.4%比 40.3%；P<0.001），围手术期输血（57%比 19%；P<0.001），急诊手术（71%比 14%；P<0.001）和手术时间更长（150 比 128 分钟；P=0.001）。
与报道的 80 岁和非选择性患者队列相比，90 岁以上患者行 EVAR 择期和急诊手术的 30 天死亡率呈递增趋势，但可接受。我们发现依赖状态、较高的 ASA 分级、急诊修复和 OSR 的患者死亡率更高。这些术前危险因素有助于确定最佳手术候选者。鉴于这些结果，对于高度选择的患者，尤其是对于破裂风险较高的较大腹主动脉瘤直径的择期患者，考虑 EVAR 或 OSR 可能是合理的。
