Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY.
Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY.
J Vasc Surg. 2023 Feb;77(2):432-439.e1. doi: 10.1016/j.jvs.2022.09.010. Epub 2022 Sep 18.
Endovascular intervention has become the first-line treatment of patients with abdominal aortic aneurysms (AAAs) or aortoiliac occlusive disease (AIOD). However, open abdominal aortic repair remains a valuable treatment option for patients who are younger, those with unfavorable anatomy, and patients for whom endovascular intervention has failed. The cohort of patients undergoing open repair has become highly selected; nevertheless, updated outcomes or patient selection recommendations have been unavailable. In the present study, we explored and compared the characteristics and postoperative outcomes of patients who had undergone open abdominal aortic repair from 2009 to 2018.
Patients who had undergone open AAA (n = 9481) or AIOD (n = 9257) repair were collected from the National Surgical Quality Improvement Program database. The primary outcome was the 30-day mortality. The secondary outcomes included 30-day return to the operating room, total operative time, total hospital stay, and postoperative complications. Unmatched and matched differences between the two groups and changes over time were analyzed. Univariate and multivariate regression analyses were conducted to assess the risk factors predicting for 30-day mortality.
After propensity matching (n = 4980), those in the AIOD group had had a higher 30-day mortality rate (5.1% vs 4.1%; P = .021), a higher incidence of wound complications (7.4% vs 5.1%; P<.0001) and an increased 30-day return to the operating room (14.2% vs 9.1%; P < .0001). More open AIOD cases (P = .02) and fewer open AAA cases (P = .04) had been treated in the second half of the decade than in the first. The factors associated with an increased odds of 30-day mortality included advanced age, American Society of Anesthesiologists score ≥III, functional dependence, blood transfusion <72 hours before surgery, weight loss in previous 6 months, and a history of chronic obstructive pulmonary disease.
From 2009 to 2018, the number of open AAA repairs decreased and the proportion of open abdominal AIOD cases increased. Open AIOD surgery was associated with higher 30-day mortality, increased return to the operating room, and increased wound complications vs open AAA repair. Multiple risk factors increased the odds for perioperative mortality. Thus, open abdominal aortic repair should be selectively applied to patients with fewer risk factors.
血管内介入治疗已成为腹主动脉瘤（AAA）或主髂动脉闭塞性疾病（AIOD）患者的一线治疗方法。然而，对于较年轻、解剖结构不佳或血管内介入治疗失败的患者，开放腹主动脉修复仍然是一种有价值的治疗选择。接受开放修复的患者人群已经高度选择；然而，最新的结果或患者选择建议尚不可用。在本研究中，我们探讨并比较了 2009 年至 2018 年期间接受开放腹主动脉修复的患者的特征和术后结果。
从国家手术质量改进计划数据库中收集接受开放 AAA（n=9481）或 AIOD（n=9257）修复的患者。主要结局是 30 天死亡率。次要结局包括 30 天重返手术室、总手术时间、总住院时间和术后并发症。分析两组之间的未匹配和匹配差异以及随时间的变化。进行单变量和多变量回归分析，以评估预测 30 天死亡率的危险因素。
在倾向匹配后（n=4980），AIOD 组的 30 天死亡率较高（5.1% vs. 4.1%；P=0.021），伤口并发症发生率较高（7.4% vs. 5.1%；P<.0001），30 天重返手术室的比例较高（14.2% vs. 9.1%；P<.0001）。在十年的下半年，接受开放 AIOD 治疗的病例（P=0.02）更多，而接受开放 AAA 治疗的病例（P=0.04）更少。与 30 天死亡率增加相关的因素包括年龄较大、美国麻醉医师协会评分≥III 级、功能依赖、术前 72 小时内输血、过去 6 个月体重减轻以及慢性阻塞性肺疾病史。
从 2009 年到 2018 年，接受开放 AAA 修复的患者数量减少，而接受开放腹主动脉 AIOD 修复的患者比例增加。与开放 AAA 修复相比，开放 AIOD 手术与 30 天死亡率增加、重返手术室增加和伤口并发症增加相关。多个危险因素增加了围手术期死亡率的几率。因此，开放腹主动脉修复应选择性地应用于风险因素较少的患者。
