Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
J Vasc Surg. 2022 Aug;76(2):437-444.e2. doi: 10.1016/j.jvs.2022.01.144. Epub 2022 Feb 25.
Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm.
Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm.
There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants.
These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.
在血管内动脉瘤修复术（EVAR）的背景下，抗凝治疗对内漏发展和随后再干预的作用尚不清楚，文献中有相互矛盾的数据。本研究的假设是，长期抗凝与持续的 II 型内漏和未破裂的腹主动脉瘤腔内修复术后瘤囊消退失败有关。
从血管质量倡议索引住院和长期随访数据集（2003-2017 年）中回顾性提取分析纳入研究的患者。排除术前和术后未服用阿司匹林的患者。将指数手术后同时服用抗凝和阿司匹林的患者（治疗组）与单独服用阿司匹林的患者（对照组）进行比较。抗凝治疗包括华法林和新型口服抗凝剂，包括 Xa 因子抑制剂和直接凝血酶抑制剂。采用倾向评分进行一对一贪婪匹配。主要终点是瘤囊消退失败、瘤囊扩张、内漏风险和随访时内漏再干预率。瘤囊消退定义为至少减少 5mm，瘤囊扩张定义为至少增加 5mm。
有 9004 例患者单独服用阿司匹林，332 例患者同时服用阿司匹林和抗凝剂。采用倾向评分创建了 301 个匹配对，以解释治疗组和对照组之间的基线特征和合并症差异，包括但不限于年龄、性别、吸烟、冠心病、心力衰竭和慢性肾脏病。在调整了协变量后，抗凝治疗的使用与显著降低的腹主动脉瘤瘤囊消退率（41.59%对 58.41%；P=0.001）独立相关，但长期抗凝治疗的瘤囊扩张率无统计学差异（9.7%对 4.9%；P=0.056）。II 型内漏的风险增加（11.96%对 6.31%；P=0.023；相对风险，1.89；95%置信区间，1.11-3.23；P=0.016），但 I 型、III 型或不确定型内漏无显著差异。2 年再干预率无统计学差异（4.32%对 2.66%；危险比，1.43；95%置信区间，0.55-3.77；P=0.461）。华法林和新型口服抗凝剂在任何主要结局上均无差异。
这些数据表明，长期阿司匹林加抗凝治疗与主动脉瘤囊缩小失败和持续的 II 型内漏有关，但与随后的再干预风险增加无关。由于先前的研究表明瘤囊消退是生存的相关因素，这些与消退失败相关的发现提示 EVAR 后需要长期抗凝治疗的患者可能存在治疗失败。虽然不是禁忌症，但对于有手术指征的主动脉瘤患者，在进行抗凝治疗时应考虑长期抗凝治疗。
