Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA.
Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
J Vasc Surg. 2024 Aug;80(2):379-388.e3. doi: 10.1016/j.jvs.2024.04.021. Epub 2024 Apr 12.
Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs).
Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation.
We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients.
Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.
对于解剖结构合适的腹主动脉瘤（AAA）患者，血管内主动脉修复术（EVAR）比生理应激更大的开放手术修复（OSR）更具侵入性。术后早期结果与患者的生理储备和手术干预的生理应激都有关。在生理储备降低的脆弱患者中，主动脉破裂的压力加上手术修复的压力耐受性较差，增加了并发症和死亡率的风险。本研究旨在评估在接受微创 EVAR 和生理上更具压力的 OSR 治疗破裂性 AAA（rAAA）的患者中，脆弱程度与结果之间的关联差异。
我们的回顾性队列研究纳入了 2010 年至 2022 年血管质量倡议中接受 rAAA 修复的成年人。经验证的风险分析指数（RAI）（健壮，≤20；正常，21-29；脆弱，30-39；非常脆弱，≥40）量化了脆弱程度。使用多变量 Cox 模型比较 1 年死亡率的主要结果与脆弱状态和修复类型之间的关联，生成调整后的危险比（aHR）和 95%置信区间（CI）。交互项评估关联的调节作用。
我们确定了 5806 名患者（年龄 72±9 岁；77%为男性；EVAR 65%；健壮 6%；正常 48%；脆弱 36%；非常脆弱 10%），rAAA 修复后 1 年死亡率为 53%。与 EVAR 相比，OSR（aHR，1.43；95%CI，1.19-1.73）与 1 年死亡率增加相关。脆弱程度增加（脆弱 aHR，1.26；95%CI，1.00-1.59；非常脆弱 aHR，1.64；95%CI，1.26-2.13）与 1 年死亡率增加相关，这种关联受到修复类型的调节（P 交互<.05）。OSR 与正常（aHR，1.49；95%CI，1.20-1.87）和脆弱（aHR，1.51；95%CI，1.20-1.89）患者的 1 年死亡率增加相关，但与健壮（aHR，0.88；95%CI，0.59-1.32）和非常脆弱（aHR，1.29；95%CI，0.97-1.72）患者无关。
脆弱和 OSR 与 rAAA 修复后 1 年死亡率的调整后风险增加相关。在正常和脆弱患者中，与 EVAR 相比，OSR 与 1 年死亡率的调整后风险增加相关。然而，在能够很好耐受 OSR 压力的健壮患者和无法承受 rAAA 手术压力的非常脆弱患者中，OSR 与 EVAR 之间没有差异，无论修复类型如何。
