Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville (B.F.G., S.T.S., D.N., T.S.H.).
Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Italy (M.D.O.).
Circ Cardiovasc Qual Outcomes. 2024 Jun;17(6):e010374. doi: 10.1161/CIRCOUTCOMES.123.010374. Epub 2024 May 22.
Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care.
The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used.
In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; =0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; <0.0001).
There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.
血管内主动脉瘤修复术（EVAR）对腹主动脉瘤（AAA）的治疗产生了深远的影响，通常取代了开放型AAA 修复术（OAR）。因此，美国的 AAA 管理通常以患者选择和指南遵循方面的差异为特点。本分析的目的是确定 AAA 治疗的长期趋势。
从血管外科学会血管质量倡议中查询所有 EVAR 和 OAR（2011-2021 年）。终点包括手术使用率、死亡率变化、患者风险特征、血管外科学会认可的直径合规性、非适应证 EVAR 使用率、夹闭位置、失血量、住院并发症和 EVAR 后随访缺失。除死亡率和并发症外，所有终点均使用无风险调整的线性回归，对于需要风险调整的死亡率和并发症，使用逻辑回归。
共分析了 66609 例 EVAR（择期，85%[n=55805]和非择期，15%[n=9976]）和 13818 例 OAR（择期，70%[n=9706]和非择期，30%[n=4081]）。择期 EVAR：OAR 比值增加（每年 0.2[95%CI，0.01-0.32]），而非择期比值保持不变。OAR 的非适应证直径阈值不达标率下降（24%→17%；=0.01），而非适应证 EVAR 未下降（平均，37%）。低风险患者越来越多地接受择期修复（EVAR，每年增加 0.4%[95%CI，0.2-0.6]；OAR，每年增加 0.6 分[95%CI，0.2-1.0]）。非适应证 EVAR 的频率保持不变（平均 39%），但术中并发症减少（每年 0.5%[95%CI，0.2-0.9]）。OAR 的复杂性增加，反映出更高的肾上腹主动脉夹闭率（每年 0.4%[95%CI，0.1-0.8]）和失血量（33mL/y[95%CI，19-47]）。择期（每年 0.7%[95%CI，0.4-0.9]）和非择期 EVAR（每年 1.7%[95%CI，1.1-2.3]）的住院并发症减少，但 OAR 没有（平均 42%）。择期 OAR（平均 4%）和 EVAR（平均 1%）的 30 天死亡率保持不变。在非择期 OAR 中，30 天（每年 0.8%[95%CI，0.1-1.5]）和 1 年死亡率（每年 0.8%[95%CI，0.3-1.6]）均增加。术后 EVAR 随访获取率下降（67%→49%），而无影像学检查的患者 1 年死亡率增加了 4 倍（9.2%与影像学检查相比，2.0%；比值比，4.1[95%CI，3.8-4.3]；<0.0001）。
尽管存在围绕指南遵循、再干预、随访和成本的担忧，但美国的 EVAR 数量增加，而 OAR 数量相应减少。尽管 EVAR 的发病率有所下降，但 OAR 的并发症发生率保持不变，且出乎意料地很高。仍有机会改善 AAA 治疗的提供、患者和手术选择、指南遵循和监测。
