Department of Vascular Surgery, Karolinska University Hospital, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
Ann Vasc Surg. 2022 Oct;86:313-319. doi: 10.1016/j.avsg.2022.01.035. Epub 2022 Mar 3.
Ruptured abdominal aortic aneurysm (rAAA) repair is still associated with high mortality. The aim of this population-based study was to analyze the time distribution of mortality and short-term mortality trends after rAAA repair.
This was a nationwide retrospective registry study including all patients (n = 3,927) who underwent endovascular (EVAR) (n = 935) or open surgical repair (OSR) (n = 2,992) for rAAA between 2000 and 2018. The National Patient Register was used as a source to extract patient and medical data. The register was cross-linked with the national all-cause mortality registry. The postoperative time of death was divided into <48 hours, 2 to 5 days, 6 to 10 days, 11 to 20 days, 21 to 30 days, and 31 to 90 days during the year intervals 2000-2004, 2005-2009, 2010-2014, and 2015-2018, respectively. The proportion of patients who died within each postoperative time interval was calculated.
The overall median age was 75.0 years (interquartile range [IQR] 69.0-80.0) and females were 19.6% (n = 769). The EVAR cohort was older (77 vs. 65 years; P < 0.001) and had significantly more cardiovascular risk factors and a history of malignancy. The overall postoperative 90-day mortality was 33.2%, EVAR 25.7%, and OSR 35.5%. There was an overall improvement in 90-day mortality over time (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.57-0.87; P = 0.001) but not separately for EVAR or OSR. Analyzing all postoperative mortalities within 90 days, 43.4% of deaths occurred within 48 hours followed by 16.3% in 2-5 days. The distribution of mortality proportions in each time interval after OSR was 15.4% in < 48 hours, 7.3% in 2-5 days, 4.4% in 6-10 days, 8.6% in 11-30 days, and 6.0% in 31-90 days and after EVAR 11.1% < 48 hours, 3.6% 2-5 days, 3.1% 6-10 days, 4.6% 11-30 days, and 6% 31-90 days. The overall mortality proportions for patients who died <48 hours after aortic repair had decreased over time (P = 0.024). A logistic regression analysis found the following risk factors associated with mortality <48 hours after rAAA, open repair (OR 1.48; 95% CI 1.17-1.89; P = 0.001), female gender (OR 1.41; 95% CI 1.14-1.75; P = 0.002), and history of heart failure (OR 1.63; 95% CI 1.19-2.22; P = 0.002) or angina pectoris (OR 1.37; 95% CI 1.03-1.81; P = 0.03). The recent operative year interval, 2015-2018, was associated with a lower risk for mortality <48 hours (OR 0.72; 95% 0.53-0.98; P = 0.04) and <90-days (OR 0.63; 95% CI 0.49-0.80; P < 0.001).
Overall mortality after rAAA repair had decreased but early deaths remained a significant challenge. The mortality was highest within two days of surgery but the proportion of patients who died <48 hours after aortic repair had decreased in recent years. Open repair, female gender, and cardiovascular comorbidities were associated with mortality within 48 hours after surgery. More focused research in the early postoperative phase after rAAA is warranted.
破裂性腹主动脉瘤（rAAA）修复后仍与高死亡率相关。本基于人群的研究旨在分析 rAAA 修复后死亡率的时间分布和短期死亡率趋势。
这是一项全国性回顾性登记研究，纳入了 2000 年至 2018 年间接受血管内修复（EVAR）（n=935）或开放手术修复（OSR）（n=2992）的所有 rAAA 患者（n=3927）。国家患者登记处被用作提取患者和医疗数据的来源。该登记处与全国全因死亡率登记处进行了交叉链接。术后时间分为<48 小时、2 至 5 天、6 至 10 天、11 至 20 天、21 至 30 天和 31 至 90 天，分别对应 2000-2004 年、2005-2009 年、2010-2014 年和 2015-2018 年的年间隔。计算了每个术后时间间隔内死亡的患者比例。
总体中位年龄为 75.0 岁（四分位距 [IQR] 69.0-80.0），女性占 19.6%（n=769）。EAVR 队列年龄较大（77 岁 vs. 65 岁；P<0.001），且心血管风险因素和恶性肿瘤病史显著更多。总体术后 90 天死亡率为 33.2%，EAVR 为 25.7%，OSR 为 35.5%。随着时间的推移，90 天死亡率整体有所改善（优势比 [OR] 0.70；95%置信区间 [CI] 0.57-0.87；P=0.001），但 EAVR 或 OSR 单独分析时并非如此。分析所有术后 90 天内的死亡率，43.4%的死亡发生在 48 小时内，其次是 16.3%在 2-5 天内。OSR 后各时间间隔死亡率分布为：<48 小时内 15.4%，2-5 天内 7.3%，6-10 天内 4.4%，11-30 天内 8.6%，31-90 天内 6.0%；EAVR 后分别为 11.1%<48 小时，3.6%2-5 天，3.1%6-10 天，4.6%11-30 天，6%31-90 天。主动脉修复后 48 小时内死亡的患者总体死亡率随着时间的推移有所下降（P=0.024）。逻辑回归分析发现，rAAA 后<48 小时死亡的相关危险因素包括开放修复（OR 1.48；95% CI 1.17-1.89；P=0.001）、女性（OR 1.41；95% CI 1.14-1.75；P=0.002）和心力衰竭（OR 1.63；95% CI 1.19-2.22；P=0.002）或心绞痛（OR 1.37；95% CI 1.03-1.81；P=0.03）病史。最近的手术年份间隔（2015-2018 年）与<48 小时（OR 0.72；95% 0.53-0.98；P=0.04）和<90 天（OR 0.63；95% CI 0.49-0.80；P<0.001）的死亡率降低相关。
rAAA 修复后总体死亡率有所下降，但早期死亡仍是一个重大挑战。术后两天内死亡率最高，但近年来主动脉修复后 48 小时内死亡的患者比例有所下降。开放修复、女性和心血管合并症与术后 48 小时内的死亡率相关。需要对 rAAA 后早期术后阶段进行更有针对性的研究。
