Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
Ann Vasc Surg. 2022 Mar;80:50-59. doi: 10.1016/j.avsg.2021.09.047. Epub 2021 Nov 12.
Endovascular aortic repair (EVAR) has advanced the care of patients with ruptured abdominal aortic aneurysms (rAAA) with improved early postoperative morbidity and mortality. However, this comes at the cost of a rigorous postoperative surveillance schedule to monitor for further aneurysmal degeneration. Adherence to surveillance recommendations is known to be poor in the elective setting, but has yet to be studied in the ruptured population. The aim of this study is to investigate predictors of incomplete surveillance after EVAR for rAAA (rEVAR) and examine how adherence impacts outcomes.
This was a retrospective case control study of patients undergoing rEVAR at a multiple hospital single healthcare center (2003-2020). Patients were excluded if they underwent open conversion during their index hospitalization or died within 60 days of surgery. Follow-up was broadly categorized as complete surveillance (60-day postoperative visit and annually thereafter) or incomplete surveillance, comprising both patients with less than recommended surveillance (minimal surveillance) and completely lost to follow-up (LTF). Any follow-up was defined as patients with complete or minimal surveillance. We investigated predictors of complete versus incomplete surveillance by multivariate logistic regression. Secondary outcomes included overall survival and cumulative incidence of reintervention controlling for the competing risk of mortality, generating hazard ratios (HR) and subdistribution hazard ratios (SHR).
One-hundred and sixty patients (mean age 74 ± 10.1 years, 81.2% male) out of 673 total rAAA met study inclusion criteria. Complete surveillance was seen in 41.3% of our cohort, with the remainder with minimal surveillance (29.4%) or LTF (29.4%). Incomplete surveillance was associated with male sex (odds ratio [OR] 2.56; 95% CI 1.02-6.43), lack of a primary care provider (PCP; OR 0.20; 95% CI 0.04-0.99), and longer driving distance from home to treating hospital (OR 2.37; 95% CI 1.08-5.20). Survival was not different between complete and incomplete surveillance groups, however any follow-up conferred improved survival over LTF (HR 0.57; 95% CI 0.331-0.997; P = 0.049). Reintervention was associated with incomplete surveillance (SHR 0.29; 95% CI 0.11-0.75), and discharge to a facility (SHR 0.25; 95% CI 0.067-0.94).
Incomplete surveillance was observed in over 50% of patients who underwent rEVAR and was associated with male sex, lack of PCP, and longer driving distance. Any follow-up conferred a survival benefit, yet incomplete surveillance was associated with a lower risk of reintervention. Targeted strategies to prevent LTF, and less stringent, personalized follow-up plans that may confer similar survival benefit with better patient adherence should be investigated.
血管内主动脉修复术（EVAR）通过改善破裂性腹主动脉瘤（rAAA）患者的术后早期发病率和死亡率，推进了患者的治疗。然而，这是以严格的术后监测计划为代价的，以监测进一步的动脉瘤退行性变。众所周知，在择期治疗中，对监测的依从性很差，但尚未在破裂人群中进行研究。本研究旨在探讨 rAAA（rEVAR）后行 EVAR 患者不完全监测的预测因素，并研究依从性对结果的影响。
这是一项在多医院单一医疗中心（2003-2020 年）进行的 rEVAR 回顾性病例对照研究。排除了在指数住院期间接受开放手术转换或术后 60 天内死亡的患者。随访广泛分为完全监测（术后 60 天就诊和此后每年一次）或不完全监测，包括监测不足（最小监测）和完全失访（LTF）的患者。任何随访均定义为具有完全或最小监测的患者。我们通过多变量逻辑回归研究了完全与不完全监测的预测因素。次要结果包括总生存率和再干预累积发生率，控制死亡率的竞争风险，生成风险比（HR）和亚分布风险比（SHR）。
在总共 673 例 rAAA 中，有 160 例（平均年龄 74 ± 10.1 岁，81.2%为男性）符合研究纳入标准。我们队列中有 41.3%的患者接受了完全监测，其余患者接受了最小监测（29.4%）或 LTF（29.4%）。不完全监测与男性（比值比[OR] 2.56；95%置信区间[CI] 1.02-6.43）、缺乏初级保健提供者（PCP；OR 0.20；95%CI 0.04-0.99）和从家到治疗医院的距离较长（OR 2.37；95%CI 1.08-5.20）有关。完全监测组和不完全监测组的生存率无差异，但任何随访均优于 LTF（HR 0.57；95%CI 0.331-0.997；P=0.049）。再干预与不完全监测（SHR 0.29；95%CI 0.11-0.75）和出院到医疗机构（SHR 0.25；95%CI 0.067-0.94）有关。
rEVAR 后超过 50%的患者存在不完全监测，与男性、缺乏 PCP 和距离较远有关。任何随访都能带来生存获益，但不完全监测与较低的再干预风险相关。应调查预防 LTF 的针对性策略，以及更宽松、个性化的随访计划，这些计划可能具有相似的生存获益，同时提高患者的依从性。
