Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
J Vasc Surg. 2023 Jul;78(1):77-88.e3. doi: 10.1016/j.jvs.2023.03.019. Epub 2023 Mar 12.
Much attention has been given to the influence of anatomic and technical factors, such as maximum abdominal aortic aneurysm diameter and proximal clamp position, in open abdominal aortic aneurysm repair (OSR). However, no studies have rigorously examined the correlation between site of distal anastomosis and OSR outcomes despite conventional wisdom that more proximal sites of anastomosis are preferrable when technically feasible. This study aimed to test the association between sites of distal anastomosis and clinical outcomes for patients undergoing primary elective OSR.
Our study included 5683 patients undergoing primary elective OSR at 233 centers from 2014 to 2020. Using a variety of statistical methods to account for potential confounders, including multivariable logistic regression and Cox proportional hazards modeling, as well as subgroup analysis, we examined the association between site of distal anastomosis and clinical outcomes in elective OSR. Primary outcomes were major in-hospital complication rate, 30-day mortality, and long-term survival.
Patients undergoing elective aortobifemoral reconstruction (n = 672) exhibited significantly increased rates of smoking, chronic obstructive pulmonary disease, and peripheral artery disease in comparison to patients undergoing elective OSR with distal anastomosis to the aorta (n = 2298), common iliac artery (n = 2163), or external iliac artery (n = 550). Patients undergoing aorto-aortic tube grafting were significantly less likely to exhibit iliac aneurysmal disease and significantly more likely to be undergoing elective OSR with a suprarenal or supraceliac proximal clamp position. Using multivariable logistic regression and Cox proportional hazards analysis to control for important confounders, such as age, smoking status, and medical history, we found that distal anastomosis to the common femoral artery was associated with increased odds of major in-hospital complications (adjusted odds ratio, 1.79; 95% confidence interval, 1.46-2.18; P < .001) and reduced long-term survival (adjusted hazard ratio, 1.44; 95% confidence interval, 1.09-1.89; P = .010). We observed no significant differences in 30-day mortality across sites of distal anastomosis in our study population.
It is generally accepted that more proximal sites of distal anastomosis should be selected in OSR when technically feasible. Our findings support this hypothesis by demonstrating that distal anastomosis to the common femoral artery is associated with increased perioperative morbidity and reduced long-term survival. Careful diligence regarding optimization of preoperative health status, perioperative care, and long-term follow-up should be applied to mitigate major complications in this patient population.
人们已经关注到解剖和技术因素的影响，例如最大腹主动脉瘤直径和近端夹闭位置，这些因素在开放腹主动脉瘤修复（OSR）中很重要。然而，尽管传统观点认为在技术上可行时，更靠近近端的吻合部位是可取的，但仍没有研究严格检查吻合部位与 OSR 结果之间的相关性。本研究旨在检验初次择期 OSR 患者吻合部位与临床结局之间的关系。
我们的研究纳入了 2014 年至 2020 年间 233 个中心的 5683 例初次择期 OSR 患者。我们使用多种统计方法来考虑潜在的混杂因素，包括多变量逻辑回归和 Cox 比例风险模型，以及亚组分析，来检验吻合部位与初次择期 OSR 的临床结局之间的关系。主要结局是主要住院并发症发生率、30 天死亡率和长期生存率。
与行吻合于主动脉的初次择期 OSR 患者（n=2298）、吻合于髂总动脉的患者（n=2163）或吻合于髂外动脉的患者（n=550）相比，行初次择期腹主动脉-股动脉重建的患者（n=672）的吸烟、慢性阻塞性肺疾病和外周动脉疾病发生率显著更高。行主动脉-主动脉套管移植的患者髂动脉瘤病变的发生率显著较低，行肾或肾以上近端夹闭的概率显著较高。使用多变量逻辑回归和 Cox 比例风险分析来控制重要的混杂因素，如年龄、吸烟状况和病史，我们发现吻合于股总动脉与主要住院并发症的发生几率增加相关（校正比值比，1.79；95%置信区间，1.46-2.18；P<0.001），并且与长期生存率降低相关（校正风险比，1.44；95%置信区间，1.09-1.89；P=0.010）。在我们的研究人群中，不同吻合部位之间 30 天死亡率无显著差异。
一般认为，在技术上可行时，OSR 应选择更靠近近端的吻合部位。我们的研究结果支持这一假设，即吻合于股总动脉与围手术期发病率增加和长期生存率降低相关。在这个患者群体中，应谨慎关注术前健康状况的优化、围手术期护理和长期随访，以减轻主要并发症。
