未达到修复标准的腹主动脉瘤破裂：危险因素和结果。
Precocious Rupture of Abdominal Aortic Aneurysms Below Size Criteria for Repair: Risk Factors and Outcomes.
机构信息
Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Veterans Affairs Healthcare System, Surgical Service Line, Section of Vascular Surgery, Palo Alto, CA.
University Hospital Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH.
出版信息
Ann Vasc Surg. 2023 Nov;97:74-81. doi: 10.1016/j.avsg.2023.05.008. Epub 2023 May 27.
BACKGROUND
Practice guidelines recommend elective repair for abdominal aortic aneurysms (AAAs) ≥ 5.5 cm in men and ≥ 5 cm in women to prevent rupture; however, some rupture at smaller diameters. We identify risk factors for rupture AAA (rAAA) below this threshold and compare outcomes following rAAA repair above/below size criteria.
METHODS
The Vascular Quality Initiative (2013-2019) was queried for patients undergoing repair for rAAA and stratified based on diameter into small and large cohorts [Small: < 5.5 cm (men), < 5.0 cm (women)]. Univariate analysis was performed, and Kaplan-Meier analysis compared overall survival, aneurysm-related mortality, and reintervention at 12 months.
RESULTS
Five thousand one hundred sixty two rAAA were identified. Small rAAA patients [n = 588] were more likely to have hypertension (81.3% vs. 77.0%, P < 0.02), diabetes (18.2% vs. 14.9%, P < 0.04), and end-stage renal disease (2.9% vs. 0.9%, P < 0.01) and be on optimal medical therapy (32.1% vs. 26.8%, P < 0.01). Women were more likely to rupture at smaller diameters compared to men (P < 0.01). Small rAAA patients were more likely to undergo endovascular aortic repair (EVAR) (70.2% vs. 56.0%, P < 0.01) and had lower in-hospital mortality (17.7% vs. 27.7%, P < 0.01) and fewer perioperative complications across all categories. At 12 months, small rAAA patients had better overall survival, freedom from aneurysm-related mortality, and freedom from reintervention, largely driven by EVAR approach.
CONCLUSIONS
More than 11% of patients presenting with ruptured AAA were below the recommended size threshold for repair, and they tended to be younger, non-White, and have hypertension, diabetes, and/or renal failure. Patients with small rAAA experienced lower in-hospital morbidity and mortality and improved 1-year survival, and EVAR was associated with better outcomes than open repair. However, women more frequently rupture at smaller diameters compared to men. Given contemporary elective outcomes for women, a randomized controlled trial for EVAR versus surveillance at a sex-specific size threshold is needed.
背景
临床指南建议对直径≥5.5 厘米的男性和≥5 厘米的女性的腹主动脉瘤（AAA）进行择期修复，以预防破裂；然而，有些瘤体在更小的直径时就会破裂。我们确定了这个阈值以下破裂 AAA（rAAA）的危险因素，并比较了大小标准以上/以下的 rAAA 修复后的结果。
方法
在血管质量倡议（2013-2019 年）中查询接受 rAAA 修复的患者，并根据直径分为小直径和大直径队列[小直径：男性<5.5 厘米，女性<5.0 厘米]。进行单变量分析，并进行 Kaplan-Meier 分析，比较 12 个月时的总体生存率、与动脉瘤相关的死亡率和再干预。
结果
确定了 5162 例 rAAA。小 rAAA 患者[n=588]更可能患有高血压（81.3%比 77.0%，P<0.02）、糖尿病（18.2%比 14.9%，P<0.04）和终末期肾病（2.9%比 0.9%，P<0.01），并接受最佳药物治疗（32.1%比 26.8%，P<0.01）。与男性相比，女性更有可能在较小的直径处破裂（P<0.01）。小 rAAA 患者更有可能接受血管内主动脉修复（EVAR）（70.2%比 56.0%，P<0.01），住院死亡率较低（17.7%比 27.7%，P<0.01），所有类别中围手术期并发症较少。在 12 个月时，小 rAAA 患者的总体生存率、免于动脉瘤相关死亡率和免于再干预的生存率更好，这主要归因于 EVAR 方法。
结论
超过 11%的破裂 AAA 患者的直径低于推荐的修复阈值，他们往往更年轻、非白人，患有高血压、糖尿病和/或肾衰竭。小 rAAA 患者的住院发病率和死亡率较低，1 年生存率提高，EVAR 与开放修复相比，结果更好。然而，与男性相比，女性更常在较小的直径处破裂。鉴于女性的现代择期治疗结果，需要进行一项针对女性特定大小阈值的 EVAR 与监测的随机对照试验。
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