Straus Sabrina, Gomez-Mayorga Jorge L, Sanders Andrew P, Yadavalli Sai Divya, Allievi Sara, McGinigle Katharine L, Stangenberg Lars, Schermerhorn Marc
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA.
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
J Vasc Surg. 2025 Jan;81(1):137-147.e4. doi: 10.1016/j.jvs.2024.08.060. Epub 2024 Sep 3.
This study aims to identify preoperative factors associated with nonhome discharge (NHD) after endovascular aneurysm repair (EVAR). NHD has implications for patient care, readmission, and long-term mortality; nevertheless, the existing literature lacks information regarding factors associated with NHD for patients undergoing EVAR. In contrast, our study assesses preoperative factors associated with NHD for this population by using national data from the Vascular Quality Initiative.
We identified adult patients who underwent elective EVAR in the Vascular Quality Initiative (2003-2022) and excluded those who were not living at home preoperatively. Multivariable logistic regression was used to identify preoperative factors associated with NHD. Kaplan-Meier methods and Cox-regression analyses were used to assess the impact of NHD on 5-year survival as a secondary outcome.
We included 61,792 patients, of which 3155 (5.1%) had NHD. NHD patients were more likely to be older (79 years [interquartile range, 73-18 years] vs 73 years [interquartile range, 67-79 years]), female (33.7% vs 18.2%; P < .001), non-White (16.0% vs 11.7%; P < .001), and have more comorbidities. NHD patients had higher rates of postoperative complications (acute kidney injury, 11.9% vs 2.0% [P < .001]; myocardial infarction, 3.8% vs 0.5% [P < .001]; and in-hospital reintervention, 4.7% vs 0.5% [P = .033]). Multivariable analysis revealed many preoperative characteristics were associated with higher odds of NHD: most notably, age (per additional decade: odds ratio [OR], 2.15; 95% confidence interval [CI], 2.03-2.28; P < .001), female sex (OR, 1.79; 95% CI, 1.63-1.95; P < .001) and aneurysm diameter >65 mm (OR, 2.18; 95% CI, 1.98-2.39; P < .001), along with potentially modifiable factors, including anemia, chronic obstructive pulmonary disease, chronic heart failure, weight, and diabetes. In contrast, aspirin, statin, and angiotensin-converting enzyme inhibitor/angiotensin II receptor blocekr use were associated with lower odds of NHD. NHD was associated with higher hazards of 5-year mortality, even after adjusting for confounders (40% vs 14%; adjusted hazard ratio, 2.13; 95% CI, 1.86-2.44; P < .001).
Several factors were associated with higher odds of NHD after elective EVAR, including nonmodifiable factors such as female sex and larger aortic diameter, and potentially modifiable factors such as anemia, chronic obstructive pulmonary disease, chronic heart failure, body mass index, and diabetes. Special attention should be given to populations with nonmodifiable factors, and efforts at optimizing medical conditions with higher NHD likelihood seems appropriate to improve patient outcomes and quality of life after EVAR.
本研究旨在确定血管内动脉瘤修复术（EVAR）后与非家庭出院（NHD）相关的术前因素。非家庭出院对患者护理、再入院和长期死亡率有影响；然而，现有文献缺乏关于接受EVAR治疗的患者非家庭出院相关因素的信息。相比之下，我们的研究通过使用来自血管质量倡议组织的全国性数据，评估了该人群中与非家庭出院相关的术前因素。
我们在血管质量倡议组织（2003 - 2022年）中确定了接受择期EVAR的成年患者，并排除了术前不住在家中的患者。使用多变量逻辑回归来确定与非家庭出院相关的术前因素。采用Kaplan - Meier方法和Cox回归分析来评估非家庭出院作为次要结局对5年生存率的影响。
我们纳入了61792例患者，其中3155例（5.1%）有非家庭出院情况。非家庭出院的患者更可能年龄较大（79岁[四分位间距，73 - 81岁]对73岁[四分位间距，67 - 79岁]）、女性（33.7%对18.2%；P <.001）、非白人（16.0%对11.7%；P <.001），且合并症更多。非家庭出院的患者术后并发症发生率更高（急性肾损伤，11.9%对2.0%[P <.001]；心肌梗死，3.8%对0.5%[P <.001]；院内再次干预，4.7%对0.5%[P =.033]）。多变量分析显示，许多术前特征与非家庭出院的较高几率相关：最显著的是年龄（每增加十岁：比值比[OR]，2.15；95%置信区间[CI]，2.03 - 2.28；P <.001）、女性性别（OR，1.79；95% CI，1.63 - 1.95；P <.001）和动脉瘤直径>65 mm（OR，2.18；95% CI，1.98 - 2.39；P <.001），以及一些可能可改变的因素，包括贫血、慢性阻塞性肺疾病、慢性心力衰竭、体重和糖尿病。相比之下，使用阿司匹林、他汀类药物和血管紧张素转换酶抑制剂/血管紧张素II受体阻滞剂与非家庭出院的较低几率相关。即使在调整混杂因素后，非家庭出院也与5年死亡率的较高风险相关（40%对14%；调整后的风险比，2.13；95% CI，1.86 - 2.44；P <.001）。
择期EVAR后，有几个因素与非家庭出院的较高几率相关，包括女性性别和主动脉直径较大等不可改变的因素，以及贫血、慢性阻塞性肺疾病、慢性心力衰竭、体重指数和糖尿病等可能可改变的因素。应特别关注具有不可改变因素的人群，努力优化非家庭出院可能性较高的医疗状况似乎有助于改善EVAR后患者的结局和生活质量。
