Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
J Vasc Surg. 2022 Jun;75(6):1821-1828.e1. doi: 10.1016/j.jvs.2021.11.041. Epub 2021 Nov 15.
The aim of the present study was to evaluate the frequency and type of adverse events that can occur during the waiting period to complex aortic endovascular repair.
We performed a retrospective study of all elective patients with complex aortic aneurysms (including pararenal, suprarenal, thoracoabdominal, and aortic arch aneurysms) that had required a custom-made device (CMD) from Cook Medical (Bloomington, Ind) at a tertiary referral vascular center (November 2010 to May 2020). The waiting period was defined as the interval between the date of the stent graft order and the date of the procedure or cancellation. Interval adverse events were defined as any event that had occurred during the waiting period and led to either mortality, aneurysm rupture, or cancellation of the planned procedure.
A total of 235 patients (mean age, 72 years; 25% female) had had a CMD graft ordered (201 planned as a single-stage procedure). The median waiting time until surgery was 106 days (interquartile range [IQR], 77-146 days) in the whole cohort and 101 days (IQR, 77-140 days) for the single-stage cohort. The planned procedure was performed electively in 219 patients (93%), with an overall 30-day elective mortality of 2% (n = 5). A total of 16 interval adverse events occurred during the waiting period. Of these 16 events, 10 were aneurysm ruptures and 6 were cancellations of the procedure owing to non-aneurysm-related deaths (3% of the entire cohort). A total of 10 interval deaths were registered (4.2%), 4 of which were aneurysm related. The risk of rupture during the waiting period (Kaplan-Meier) was 6.1% ± 2.3% at 180 days. The median interval from the stent graft order to aneurysm rupture was 101 days (IQR, 54-200 days). Of the 10 aneurysm ruptures that had occurred, 6 had undergone emergent repair, with 0% mortality at 30 days (one open repair, one t-Branch, one physician-modified endograft, two cases for which the CMD was already available, one case for which a different CMD was available).
The median waiting time from the stent graft order to implantation was ∼15 weeks. During this waiting period, a substantial proportion of patients could experience adverse events, either related to aneurysm rupture or underlying comorbidities. The risk of rupture during the waiting period exceeded the risk of perioperative mortality. Thus, efforts to decrease this risk could significantly improve the outcomes. A combination of different techniques might play a vital role in reducing the mortality after cases of interval rupture.
本研究旨在评估复杂主动脉血管腔内修复术等待期内可能发生的不良事件的频率和类型。
我们对所有需要库克医疗公司（美国印第安纳州布卢明顿）定制设备（CMD）的复杂主动脉瘤（包括肾周、肾上、胸腹主动脉和主动脉弓动脉瘤）的择期患者进行了回顾性研究，这些患者均在三级转诊血管中心就诊（2010 年 11 月至 2020 年 5 月）。等待期定义为支架移植物订单日期与手术日期或取消日期之间的间隔。间期不良事件定义为在等待期内发生的任何导致死亡、动脉瘤破裂或计划手术取消的事件。
共 235 例患者（平均年龄 72 岁，25%为女性）接受了 CMD 移植物的订单（201 例计划进行单阶段手术）。整个队列中，手术前中位等待时间为 106 天（四分位距[IQR]，77-146 天），单阶段队列中为 101 天（IQR，77-140 天）。219 例（93%）患者择期进行了计划手术，整个队列中 30 天择期死亡率为 2%（n=5）。等待期间共发生 16 次间期不良事件。其中 10 例为动脉瘤破裂，6 例为非动脉瘤相关死亡而取消手术（占整个队列的 3%）。共登记 10 例间期死亡（4.2%），其中 4 例与动脉瘤相关。等待期内破裂的风险（Kaplan-Meier）为 180 天时 6.1%±2.3%。从支架移植物订单到动脉瘤破裂的中位时间间隔为 101 天（IQR，54-200 天）。10 例动脉瘤破裂中有 6 例进行了紧急修复，30 天死亡率为 0%（1 例开放修复，1 例 t-Branch，1 例医生改良的移植物，2 例 CMD 已备好，1 例可用不同的 CMD）。
从支架移植物订单到植入的中位等待时间约为 15 周。在此等待期间，相当一部分患者可能会发生不良事件，这些不良事件与动脉瘤破裂或基础合并症有关。等待期内破裂的风险超过了围手术期死亡率。因此，降低这种风险的努力可能会显著改善结果。不同技术的结合可能在降低间期破裂后的死亡率方面发挥重要作用。
