Hosaka Akihiro, Takahashi Arata, Kumamaru Hiraku, Azuma Nobuyoshi, Obara Hideaki, Miyata Tetsuro, Obitsu Yukio, Zempo Nobuya, Miyata Hiroaki, Komori Kimihiro
Department of Vascular Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan.
J Vasc Surg. 2024 Jun;79(6):1379-1389. doi: 10.1016/j.jvs.2024.01.199. Epub 2024 Jan 26.
Infected native aneurysms (INAs) of the abdominal aorta and iliac arteries are uncommon, but potentially fatal. Endovascular aneurysm repair (EVAR) has recently been introduced as a durable treatment option, with outcomes comparable to those yielded by conventional open repair. However, owing to the rarity of the disease, the strengths and limitations of each treatment remain uncertain. The present study aimed to separately assess post-open repair and post-EVAR outcomes and to clarify factors affecting the short-term and late prognosis after each treatment.
Using a nationwide clinical registry, we investigated 600 patients treated with open repair and 226 patients treated with EVAR for INAs of the abdominal aorta and/or common iliac artery. The relationships between preoperative or operative factors and postoperative outcomes, including 90-day and 3-year mortality and persistent or recurrent aneurysm-related infection, were examined.
Prosthetic grafts were used in >90% of patients treated with open repair, and in situ and extra-anatomic arterial reconstruction was performed in 539 and 57 patients, respectively. Preoperative anemia and imaging findings suggestive of aneurysm-enteric fistula were independently associated with poor outcomes in terms of both 3-year mortality (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.01-2.62; P = .046, and HR, 2.24; 95% CI, 1.12-4.46; P = .022, respectively) and persistent or recurrent infection (odds ratio [OR], 2.16; 95% CI, 1.04-4.49; P = .039, and OR, 4.96; 95% CI, 1.81-13.55; P = .002, respectively) after open repair, whereas omental wrapping or packing and antibiotic impregnation of the prosthetic graft for in situ reconstruction contributed to improved 3-year survival (HR, 0.60; 95% CI, 0.39-0.92; P = .019, and HR, 0.53; 95% CI, 0.32-0.88; P = .014, respectively). Among patients treated with EVAR, abscess formation adjacent to the aneurysm was significantly associated with the occurrence of persistent or recurrent infection (OR, 2.24; 95% CI, 1.06-4.72; P = .034), whereas an elevated preoperative white blood cell count was predictive of 3-year mortality (HR, 1.77; 95% CI, 1.00-3.13; P = .048).
Profiles of prognostic factors differed between open repair and EVAR in the treatment of INAs of the abdominal aorta and common iliac artery. Open repair may be more suitable than EVAR for patients with concurrent abscess formation.
腹主动脉和髂动脉感染性真性动脉瘤（INA）并不常见，但可能致命。血管内动脉瘤修复术（EVAR）最近已作为一种持久的治疗选择被引入，其疗效与传统开放修复相当。然而，由于该疾病罕见，每种治疗方法的优缺点仍不明确。本研究旨在分别评估开放修复和EVAR术后的结果，并阐明影响每种治疗后短期和长期预后的因素。
利用全国性临床登记系统，我们调查了600例接受开放修复治疗的患者和226例接受EVAR治疗的腹主动脉和/或髂总动脉INA患者。研究了术前或手术因素与术后结果之间的关系，包括90天和3年死亡率以及持续性或复发性动脉瘤相关感染。
超过90%接受开放修复治疗的患者使用了人工血管，原位和解剖外动脉重建分别在539例和57例患者中进行。术前贫血和提示动脉瘤-肠瘘的影像学表现与开放修复术后3年死亡率（风险比[HR]，1.62；95%置信区间[CI]，1.01-2.62；P = 0.046，以及HR，2.24；95% CI，1.12-4.46；P = 0.022）和持续性或复发性感染（优势比[OR]，2.16；95% CI，1.04-4.49；P = 0.039，以及OR，4.96；95% CI，1.81-13.55；P = 0.002）方面的不良结果独立相关，而原位重建时使用网膜包裹或填塞以及人工血管抗生素浸渍有助于提高3年生存率（HR，0.60；95% CI，0.39-0.92；P = 0.019，以及HR, 0.53；95% CI，0.32-0.88；P = 0.014）。在接受EVAR治疗的患者中，动脉瘤旁脓肿形成与持续性或复发性感染的发生显著相关（OR，2.24；95% CI，1.06-4.72；P = 0.034），而术前白细胞计数升高可预测3年死亡率（HR，1.77；95% CI，1.00-3.13；P = 0.048）。
在腹主动脉和髂总动脉INA的治疗中，开放修复和EVAR的预后因素特征不同。对于并发脓肿形成的患者，开放修复可能比EVAR更合适。
