急性创伤性胸主动脉夹层的早期与延迟血管内修复治疗的比较：倾向评分匹配分析。
Early Versus Delayed Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury: A Propensity Score-Matched Analysis.
机构信息
Division of Trauma and Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
Division of Trauma and Emergency Surgery, Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
出版信息
Ann Surg. 2023 Oct 1;278(4):e848-e854. doi: 10.1097/SLA.0000000000005817. Epub 2023 Feb 13.
OBJECTIVE
We examined early (≤24 h) versus delayed (>24 h) thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), taking the aortic injury severity into consideration.
BACKGROUND
Current trauma surgery guidelines recommend delayed TEVAR following BTAI. However, this recommendation was based on small studies, and specifics regarding recommendation strategies based on aortic injury grades are lacking.
METHODS
Patients undergoing TEVAR for BTAI in the American College of Surgeons Trauma Quality Improvement Program between 2016 and 2019 were included and then stratified into 2 groups (early: ≤24 h vs. delayed: >24 h). In-hospital outcomes were compared after creating 1:1 propensity score-matched cohorts, matching for demographics, comorbidities, concomitant injuries, additional procedures, and aortic injury severity based on the acute aortic syndrome (AAS) classification.
RESULTS
Overall, 1339 patients were included, of whom 1054(79%) underwent early TEVAR. Compared with the delayed group, the early group had significantly less severe head injuries (early vs delayed; 25% vs 32%; P =0.014), fewer early interventions for AAS grade 1 occurred, and AAS grade 3 aortic injuries often were intervened upon within 24 hours (grade 1: 28% vs 47%; grade 3: 49% vs 23%; P <0.001). After matching, the final sample included 548 matched patients. Compared with the delayed group, the early group had a significantly higher in-hospital mortality (8.8% vs 4.4%, relative risk: 2.2, 95% CI: 1.1-4.4; P =0.028), alongside a shorter length of hospital stay (5.0 vs 10 days; P =0.028), a shorter intensive care unit length of stay (4.0 vs 11 days; P <0.001) and fewer days on the ventilator (4.0 vs 6.5 days; P =0.036). Furthermore, regardless of the higher risk of acute kidney injury in the delayed group (3.3% vs 7.7%, relative risk: 0.43, 95% CI: 0.20-0.92; P =0.029), no other differences in in-hospital complications were observed between the early and delayed group.
CONCLUSION
In this propensity score-matched analysis, delayed TEVAR was associated with lower mortality risk, even after adjusting for aortic injury grade.
目的
考虑到主动脉损伤严重程度，我们研究了钝性胸主动脉损伤（BTAI）的早期（≤24 小时）与延迟（>24 小时）胸主动脉腔内修复术（TEVAR）。
背景
目前的创伤外科学指南建议在 BTAI 后进行延迟 TEVAR。然而，这一建议是基于小型研究的，并且缺乏基于主动脉损伤等级的建议策略的具体信息。
方法
纳入了 2016 年至 2019 年期间在美国外科医师学会创伤质量改进计划中接受 TEVAR 治疗的 BTAI 患者，并将其分为两组（早期：≤24 小时 vs. 延迟：>24 小时）。在创建 1:1 倾向评分匹配队列后，比较了住院期间的结果，匹配因素包括人口统计学、合并症、伴随损伤、附加手术以及基于急性主动脉综合征（AAS）分类的主动脉损伤严重程度。
结果
总体而言，纳入了 1339 名患者，其中 1054 名（79%）接受了早期 TEVAR。与延迟组相比，早期组的严重头部损伤明显较少（早期 vs. 延迟；25% vs. 32%；P=0.014），较少发生早期 AAS 1 级干预，且 AAS 3 级主动脉损伤通常在 24 小时内进行干预（AAS 1 级：28% vs. 47%；AAS 3 级：49% vs. 23%；P<0.001）。匹配后，最终样本包括 548 例匹配患者。与延迟组相比，早期组的院内死亡率显著更高（8.8% vs. 4.4%，相对风险：2.2，95%置信区间：1.1-4.4；P=0.028），住院时间更短（5.0 天 vs. 10 天；P=0.028），重症监护病房住院时间更短（4.0 天 vs. 11 天；P<0.001），呼吸机使用天数更少（4.0 天 vs. 6.5 天；P=0.036）。此外，尽管延迟组发生急性肾损伤的风险较高（3.3% vs. 7.7%，相对风险：0.43，95%置信区间：0.20-0.92；P=0.029），但早期组和延迟组之间在院内并发症方面没有观察到其他差异。
结论
在这项倾向评分匹配分析中，即使考虑到主动脉损伤等级，延迟 TEVAR 与较低的死亡率风险相关。
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