University of California, San Diego, La Jolla.
JAMA Netw Open. 2022 May 2;5(5):e2212081. doi: 10.1001/jamanetworkopen.2022.12081.
Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair.
To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018.
First-time elective endovascular or open repair for abdominal aortic aneurysm.
The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications.
Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications.
These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.
与开放型腹主动脉瘤修复相比，血管内修复术在治疗腹主动脉瘤方面可显著降低围手术期的死亡率和发病率。然而，由于血管内修复后的再干预和晚期动脉瘤破裂增加，这种益处会随着时间的推移而减少。
比较血管内与开放修复腹主动脉瘤的长期结果。
设计、设置和参与者：这是一项多中心回顾性队列研究，使用了来自医疗保险匹配的血管质量倡议血管植入物监测和干预结果网络数据库的 6 年随访的匿名数据。对 2003 年至 2018 年期间首次进行择期血管内或开放腹主动脉瘤修复的患者进行倾向评分匹配。排除破裂性腹主动脉瘤、同时进行的手术或既往腹主动脉瘤修复史的患者。数据分析时间为 2003 年 1 月 1 日至 2018 年 12 月 31 日。
首次择期血管内或开放修复腹主动脉瘤。
主要的长期结果是 6 年全因死亡率、破裂和再干预。次要结果包括 30 天死亡率和围手术期并发症。
在总共 32760 名接受手术腹主动脉瘤修复的患者中（中位数[IQR]年龄，75[70-80]岁；25706[78.5%]为男性），28281 名患者接受了血管内修复，4479 名患者接受了开放修复。在进行倾向评分匹配后，每组各有 2852 名患者。与血管内修复相比，开放修复的 6 年死亡率显著降低（548 例死亡[35.6%]与 608 例死亡[41.2%]；风险比[HR]，0.83；95%置信区间[CI]，0.74-0.94；P=0.002），死亡率从 1 年至 2 年（84 例死亡[4.3%]与 126 例死亡[6.7%]；HR，0.63；95%CI，0.48-0.83；P=0.001）和 2 年至 6 年（211 例死亡[25.8%]与 241 例死亡[30.6%]；HR，0.73；95%CI，0.61-0.88；P=0.001）开始增加。与血管内修复相比，开放修复还与 6 年破裂率（117 例患者[5.8%]与 149 例患者[8.3%]；HR，0.76；95%CI，0.60-0.97；P<0.001）和再干预率（190 例患者[11.6%]与 267 例患者[16.0%]；HR，0.67；95%CI，0.55-0.80；P<0.001）显著降低相关。开放修复与 30 天死亡率（OR，3.56；95%CI，2.41-5.26；P<0.001）和并发症的发生率显著升高相关。
这些发现表明，尽管血管内修复术后 30 天的死亡率和围手术期发病率降低，但与开放修复相比，择期腹主动脉瘤修复后的总体死亡率更高。此外，血管内修复还与长期破裂和再干预率显著升高相关。这些发现强调了对接受血管内修复的患者进行仔细的患者选择和长期随访监测的重要性。
