Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Surgery, University of California San Francisco - East Bay, Oakland, CA.
Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA.
J Vasc Surg. 2022 Dec;76(6):1511-1519. doi: 10.1016/j.jvs.2022.04.054. Epub 2022 Jun 14.
As endovascular aortic aneurysm repair (EVAR) matures into its third decade, measures such as long-term reintervention and readmission have become a focus of quality improvement efforts. Within a large United States integrated health care system, we describe time trends in the rates of long-term reinterventions utilization measures.
Data from a United States multiregional EVAR registry was used to perform a descriptive study of 3891 adults who underwent conventional infrarenal EVAR for infrarenal abdominal aortic aneurysm between 2010 and 2019. Three-year follow-up was 96.7%. Outcomes included 1-, 3-, and 5-year graft revision (defined as a procedure involving placement of a new endograft component), secondary interventions (defined as a procedure necessary for maintenance of EVAR integrity [eg, coil embolization and balloon angioplasty/stenting]), conversion to open, interventions for type II endoleaks alone, and 90-day readmission. Crude cause-specific reintervention probabilities were calculated by operative year using the Aalen-Johansen estimator, with death as a competing risk and December 31, 2020 as the study end date.
Excluding interventions for type II endoleak alone, 1-year secondary intervention incidence decreased from 5.9% for EVARs in 2010 to 2.0% in 2019 (P < .001) and 3-year incidence decreased from 7.2% to 3.6% from 2010 to 2017 (P = .03). The 3-year incidences of graft revision (mean incidence, 3.4%) and conversion to open remained fairly stable (mean incidence, 0.6%) over time. The 3-year incidence of interventions for type II endoleak alone also decreased from 3.4% in 2010 to 0.7% in 2017 (P = .01). Ninety-day readmission rates decreased from 19.3% for index EVAR in 2010 to 9.2% in 2019 (P = .03).
Comprehensive data from a multiregional health care system demonstrates decreasing long-term secondary intervention and readmission rates over time in patients undergoing EVAR. These trends are not explained by evolving management of type II endoleaks and suggest improving graft durability, patient selection, or surgical technique. Further study is needed to define implant and anatomic predictors of different types of long-term reintervention.
随着血管内主动脉瘤修复术（EVAR）进入第三个十年，长期再干预和再入院等措施已成为质量改进工作的重点。在美国一个大型综合医疗保健系统中，我们描述了长期再干预利用措施的发生率的时间趋势。
使用来自美国多区域 EVAR 注册处的数据，对 2010 年至 2019 年间接受传统肾下 EVAR 治疗肾下腹主动脉瘤的 3891 名成年人进行描述性研究。3 年随访率为 96.7%。研究结果包括 1 年、3 年和 5 年移植物翻修（定义为涉及放置新的血管内移植物组件的手术）、二次干预（定义为维持 EVAR 完整性所需的手术[例如，线圈栓塞和球囊血管成形术/支架置入术]）、转为开放手术、仅治疗 II 型内漏的干预措施以及 90 天再入院。使用 Aalen-Johansen 估计器，根据手术年份计算出纯病因特异性再干预概率，以死亡为竞争风险，研究截止日期为 2020 年 12 月 31 日。
排除仅治疗 II 型内漏的干预措施，2010 年 EVAR 的 1 年二次干预发生率从 5.9%降至 2019 年的 2.0%（P<.001），3 年发生率从 7.2%降至 2017 年的 3.6%（P=.03）。3 年移植物翻修（平均发生率 3.4%）和转为开放手术的发生率相对稳定（平均发生率 0.6%）。2010 年至 2017 年，仅治疗 II 型内漏的 3 年干预发生率也从 3.4%降至 0.7%（P=.01）。2010 年索引 EVAR 的 90 天再入院率从 19.3%降至 2019 年的 9.2%（P=.03）。
来自多区域医疗保健系统的综合数据表明，EVAR 患者的长期二次干预和再入院率随着时间的推移呈下降趋势。这些趋势不能用 II 型内漏的不断演变的管理来解释，这表明移植物耐久性、患者选择或手术技术得到了改善。需要进一步研究以确定不同类型的长期再干预的植入物和解剖学预测因素。
