Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
Department of Population Health Sciences, Weill Cornell Medical College, New York, NY.
J Vasc Surg. 2023 Jun;77(6):1607-1617.e7. doi: 10.1016/j.jvs.2023.02.005. Epub 2023 Feb 16.
Recently evolving practice patterns in complex aortic surgery have led to regionalization of care within fewer centers in the United States, and thus patients may have to travel farther for complex aortic care. Travel distance has been associated with inferior outcomes after non-vascular surgery, particularly non-index readmission. This study aims to assess the impact of patient travel distance on perioperative outcomes and readmissions after complex aortic surgery.
A retrospective review was conducted of all patients in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases undergoing complex endovascular aortic repair (EVAR) including internal iliac or visceral vessel involvement, complex thoracic endovascular aortic repair (TEVAR) including zone 0 to 2 proximal extent or branched devices, and complex open abdominal aortic aneurysm (AAA) repair including suprarenal or higher clamp sites. Travel distance was stratified by rural/urban commuting area (RUCA) population-density category. Wilcoxon and χ tests were used to assess relationships between travel distance quintiles and baseline characteristics, mortality, and readmission. Travel distance and other factors were included in multivariable Cox models for survival and Fine-Gray competing risk models for freedom from readmission.
Between 2011 and 2018, 8782 patients underwent complex aortic surgery in the Vascular Quality Initiative and Vascular Implant Surveillance and Interventional Outcomes Network databases, including 4822 complex EVARs, 2672 complex TEVARs, and 1288 complex open AAA repairs. Median travel distance was 22.8 miles (interquartile range [IQR], 8.6-54.8 miles). Median age was 75 years for all distance quintiles, but patients traveling longer distances were more likely female (26.8% in quintile 5 [Q5] vs 19.9% in Q1; P < .001), white (93.8% of Q5 vs 83.8% of Q1; P < .001), to have larger-diameter AAAs (median 59 mm for Q5 vs 55 mm for Q1; P < .001), and to have had prior aortic surgery (20.8% for Q5 vs 5.9% for Q1; P < .001). Overall 30-day readmission was more common at farther distances (18.1% for Q5 vs 14.8% for Q1; P = .003), with higher non-index readmission (11.2% for Q5 vs 2.7% for Q1; P < .001) and conversely lower index readmission (6.9% for Q5 vs 12.0% for Q1; P < .001). Multivariable-adjusted Fine-Gray models confirmed greater hazard of non-index readmission with farther distance, with a Q5 hazard ratio of 3.02 (95% confidence interval, 2.12-4.30; P < .001). Multivariable-adjusted Cox models demonstrated no association between travel distance and long-term survival but found that non-index readmission was associated with increased long-term mortality (hazard ratio, 1.46; 95% confidence interval, 1.20-1.78; P = .0001).
Patients traveling farther for complex aortic surgery demonstrate higher non-index readmission, which, in turn, is associated with increased long-term mortality risk. Aortic centers of excellence should consider targeting these patients for more comprehensive follow-up and care coordination to improve outcomes.
最近复杂主动脉手术的实践模式发生了变化，导致美国的治疗中心集中在少数几个中心，因此患者可能需要到更远的地方进行复杂的主动脉治疗。距离已经与非血管手术后的不良结果相关，尤其是非索引再入院。本研究旨在评估患者旅行距离对复杂主动脉手术后围手术期结果和再入院的影响。
对在血管质量倡议和血管植入物监测和介入结果网络数据库中接受复杂血管内主动脉修复（EVAR）的所有患者进行回顾性分析，包括涉及内脏或内脏血管的内髂动脉或内脏血管，涉及区域 0 至 2 近端范围或分支装置的复杂胸主动脉血管内修复（TEVAR），以及涉及肾上或更高夹闭部位的复杂开放性腹主动脉瘤（AAA）修复。根据农村/城市通勤区（RUCA）人口密度类别对旅行距离进行分层。Wilcoxon 和 χ2 检验用于评估旅行距离五分位数与基线特征、死亡率和再入院之间的关系。将旅行距离和其他因素纳入多变量 Cox 模型以评估生存率和 Fine-Gray 竞争风险模型以评估无再入院率。
在 2011 年至 2018 年期间，血管质量倡议和血管植入物监测和介入结果网络数据库中对 8782 名患者进行了复杂的主动脉手术，包括 4822 例复杂 EVAR、2672 例复杂 TEVAR 和 1288 例复杂开放性 AAA 修复。中位旅行距离为 22.8 英里（四分位距 [IQR]，8.6-54.8 英里）。所有距离五分位数的中位年龄均为 75 岁，但旅行距离较长的患者更有可能是女性（Q5 中的 26.8%与 Q1 中的 19.9%；P<0.001），是白人（Q5 中的 93.8%与 Q1 中的 83.8%；P<0.001），AAA 直径较大（Q5 中的 59mm 与 Q1 中的 55mm；P<0.001），并且有过主动脉手术史（Q5 中的 20.8%与 Q1 中的 5.9%；P<0.001）。总体而言，较远的距离更常见 30 天再入院（Q5 中的 18.1%与 Q1 中的 14.8%；P=0.003），非索引再入院率更高（Q5 中的 11.2%与 Q1 中的 2.7%；P<0.001），而索引再入院率较低（Q5 中的 6.9%与 Q1 中的 12.0%；P<0.001）。多变量调整的 Fine-Gray 模型证实，随着距离的增加，非索引再入院的风险更高，Q5 的风险比为 3.02（95%置信区间，2.12-4.30；P<0.001）。多变量调整的 Cox 模型表明，旅行距离与长期生存率之间没有关联，但发现非索引再入院与长期死亡率增加相关（风险比，1.46；95%置信区间，1.20-1.78；P=0.0001）。
为复杂主动脉手术而长途旅行的患者表现出更高的非索引再入院率，而这反过来又与长期死亡率风险增加相关。卓越的主动脉中心应考虑为这些患者提供更全面的随访和护理协调，以改善结果。
