Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
School of Medicine, Case Western Reserve University, Cleveland, OH.
J Vasc Surg. 2023 Mar;77(3):778-784. doi: 10.1016/j.jvs.2022.10.031. Epub 2022 Oct 29.
The Society for Vascular Surgery published abdominal aortic aneurysm (AAA) practice guidelines in 2003, 2009, and 2018 to improve the management and treatment of AAAs. In 2014, our vascular surgery department implemented a quarterly AAA dashboard (AAAdb) to record the perioperative outcomes and guideline compliance with a focus on intervention appropriateness and procedural follow-up, which supplemented our Vascular Quality Initiative data. From the available reported evidence and expert consensus opinions, nine additional criteria for the appropriate treatment of AAAs <5 cm in women and <5.5 cm in men were noted, when applicable. The purpose of our study was to assess the effects of AAAdb implementation on adherence to society and institutional guidelines, documentation of treatment rationale, and the quality of follow-up.
We performed a retrospective review of elective open and endovascular AAA repair at a single institution from 2010 to 2018. The AAAdb was implemented in the middle of this period in 2014. The patient demographics, aortic size, repair indication, repair type, 30-day mortality, and postoperative and 1-year follow-up imaging findings were analyzed. The primary outcome was adherence to intervention appropriateness and the follow-up guidelines. The categorical factors were summarized using frequencies and percentages and compared using the Pearson χ test or Fisher exact test. Continuous measures were summarized using the mean ± standard deviation and compared between study periods using two-sample t tests.
From 2010 to 2018, 1549 patients had undergone elective AAA repair: 657 before and 892 after AAAdb implementation. No differences were found in AAA size after AAAdb (5.6 ± 1.2 cm vs 5.6 ± 1.1 cm; P = .88). However, the proportion of size-appropriate repairs increased (64.1% vs 71.3%; P = .003). The proportion of small AAA repairs with a documented rationale had increased (64.4% vs 80.5%; P < .001), with rapid disease progression cited most often. No difference was found in 30-day mortality (1.2% vs 1.5%; P = .69). Follow-up imaging after endovascular abdominal aortic aneurysm repair increased at <60 days postoperatively (76% vs 84%; P = .004) and at 1 year of follow-up (78% vs 86%; P = .0005). The proportion of patients with endoleak at <60 days postoperatively had increased in the post-AAAdb cohort (21% vs 29%; P = .012).
The AAAdb served as a centerpiece for improving the appropriateness of care and compliance with national and institutional guidelines, including treatment of small AAAs in special circumstances. Its implementation was associated with higher quality follow-up and surveillance in a high-volume, regional aortic center. Consideration should be given to adding additional criteria to the Society for Vascular Surgery guidelines and Vascular Quality Initiative reporting.
血管外科学会于 2003 年、2009 年和 2018 年发布了腹主动脉瘤（AAA）实践指南，以改善 AAA 的管理和治疗。2014 年，我们的血管外科部门实施了季度 AAA 仪表板（AAAdb），以记录围手术期结果和指南遵守情况，重点关注介入的适当性和程序随访，这补充了我们的血管质量倡议数据。根据现有报告的证据和专家共识意见，注意到在女性 AAA<5cm 和男性 AAA<5.5cm 的情况下，有九个额外的 AAA 适当治疗标准。我们研究的目的是评估 AAAdb 的实施对遵守社会和机构指南、治疗理由记录以及随访质量的影响。
我们对单机构 2010 年至 2018 年期间的择期开放和血管内 AAA 修复进行了回顾性研究。AAAdb 于 2014 年中期实施。分析了患者人口统计学、主动脉大小、修复指征、修复类型、30 天死亡率以及术后和 1 年随访的影像学发现。主要结果是遵守介入适当性和随访指南。分类因素采用频率和百分比进行总结，并使用 Pearson χ 检验或 Fisher 确切检验进行比较。连续测量值采用平均值±标准差表示，并使用两样本 t 检验比较两个研究期间的差异。
2010 年至 2018 年间，共有 1549 例患者接受了择期 AAA 修复：AAAdb 实施前 657 例，实施后 892 例。AAAdb 实施后，AAA 大小无差异（5.6±1.2cm 比 5.6±1.1cm；P=0.88）。然而，大小适当的修复比例增加（64.1%比 71.3%；P=0.003）。具有记录充分治疗理由的小 AAA 修复比例增加（64.4%比 80.5%；P<0.001），最常引用的是疾病快速进展。30 天死亡率无差异（1.2%比 1.5%；P=0.69）。血管内腹主动脉瘤修复后的随访影像学检查在术后<60 天（76%比 84%；P=0.004）和 1 年随访时（78%比 86%；P=0.0005）增加。在 AAAdb 实施后的队列中，术后<60 天的内漏患者比例增加（21%比 29%；P=0.012）。
AAAdb 是改善护理适当性和遵守国家和机构指南的核心，包括特殊情况下的小 AAA 治疗。其实施与高容量、区域性主动脉中心的更高质量随访和监测相关。应考虑在血管外科学会指南和血管质量倡议报告中增加其他标准。
