肠缺血(BI)是腹主动脉瘤(AAA)修复后的严重并发症。我们试图确定与术后BI发展相关的发生率和危险因素以及接受开放式主动脉修复(OAR)和腔内主动脉修复(EVAR)的患者的BI后结局。
使用血管质量倡议数据库对2003年至2017年接受OAR或EVAR的所有患者进行回顾性分析。单变量(学生t检验,χ2,中位数)和多变量(逻辑回归)分析用于确定与术后BI相关的独立因素,并比较BI后住院结局和死亡率。
我们确定了45,474例接受肾下AAA修复的患者(OAR,21.5%;EVAR,78.5%)。术后BI的总发生率为1.9%(OAR,6.2%与EVAR相比,0.8%;P<.001)。与EVAR相比,OAR与BI的几率增加了三倍(调整后的优势比[aOR],3.24;95%置信区间[CI],2.49-4.22;P<.001)。OAR后与BI相关的独立因素包括年龄较大(AOR/岁,1.02;95%CI,1.00-1.03),充血性心力衰竭(aOR,1.44;95%CI,1.05-1.98),动脉瘤破裂(aOR,4.16;95%CI,2.98-5.81;全部P<0.01)。我们还发现输血≥1U(aOR,1.69;95%CI,1.30-2.20),经腹膜入路(aOR,2.13;95%CI,1.03-1.87),乳糜泻夹紧(aOR,1.58;95%CI,1.08-2.33),和肠系膜下动脉再植(aOR,1.41;95%CI,1.06-1.89)与OAR后BI的几率相关(P<0.01)。同样,我们发现破裂的动脉瘤,更长的手术时间,EVAR后输血≥1U血与BI相关(均P<.001)。对于OAR和EVAR,术后住院时间(中位数,13天[四分位距(IQR),7-26天]vs7天[IQR,5-10天]和11天[IQR,4-23天]vs1天[IQR,1-3天],分别)和30天死亡率(35.0%对6.4%和40.5%对1.9%,分别)显著高于BI患者(全部P<.001)。BI患者死亡率的预测因素是手术治疗(aOR,2.05;95%CI,1.28-3.30),年龄较大(AOR,1.05;95%CI,1.02-1.07),症状性动脉瘤(aOR,1.26;95%CI,[0.60-2.62),动脉瘤破裂(aOR,2.23;95%CI,1.43-3.48),更长的手术时间(AOR,1.11;95%CI,1.01-1.22),和术后肾脏并发症(aOR,2.98;95%CI,1.80-4.96;全部P<0.05)。
确认以前研究的结果,我们发现BI在动脉瘤破裂和OAR后更常见。其他相关的术中因素包括经腹膜入路,乳糜泻夹闭,再植入肠系膜下动脉.在我们的队列中,超过三分之一的术后发生BI的患者在AAA修复后30天内死亡。与BI后死亡率相关的因素包括手术治疗和术后肾功能衰竭。对于存在已确定危险因素的患者,术后应保持对BI体征和症状的高度怀疑。
Bowel ischemia (BI) is a serious complication after abdominal aortic aneurysm (AAA) repair. We sought to identify the incidence and risk factors associated with the development of postoperative BI and the post-BI outcomes for patients undergoing open aortic repair (
OAR) and endovascular aortic repair (EVAR) of AAAs.
A retrospective analysis was conducted for all patients who had undergone
OAR or EVAR from 2003 to 2017 using the Vascular Quality Initiative database. Univariate (Student\'s t test, χ2, median) and multivariable (logistic regression) analyses were used to identify independent factors associated with postoperative BI and compare the post-BI in-hospital outcomes and mortality.
We identified 45,474 patients who had undergone infrarenal AAA repair (
OAR, 21.5%; EVAR, 78.5%). The overall incidence of postoperative BI was 1.9% (
OAR, 6.2% vs EVAR, 0.8%; P < .001).
OAR was associated with a threefold increased odds of BI compared with EVAR (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.49-4.22; P < .001). The independent factors associated with BI after OAR included older age (aOR per year of age, 1.02; 95% CI, 1.00-1.03), congestive heart failure (aOR, 1.44; 95% CI, 1.05-1.98), and ruptured aneurysm (aOR, 4.16; 95% CI, 2.98-5.81; P < .01 for all). We also found that transfusion ≥1 U (aOR, 1.69; 95% CI, 1.30-2.20), a transperitoneal approach (aOR, 2.13; 95% CI, 1.03-1.87), supraceliac clamping (aOR, 1.58; 95% CI, 1.08-2.33), and inferior mesenteric artery reimplantation (aOR, 1.41; 95% CI, 1.06-1.89) were associated with greater odds of BI after OAR (P < .01 for all). Similarly, we found that ruptured aneurysms, a longer operative time, and transfusion of ≥1 U of blood were associated with BI after EVAR (P < .001 for all). For both OAR and EVAR, the postoperative stay (median, 13 days [interquartile range (IQR), 7-26 days] vs 7 days [IQR, 5-10 days] and 11 days [IQR, 4-23 days] vs 1 day [IQR, 1-3 days], respectively) and 30-day mortality (35.0% vs 6.4% and 40.5% vs 1.9%, respectively) were significantly higher for patients with BI (P < .001 for all). The predictors of mortality for patients with BI were surgical management (aOR, 2.05; 95% CI, 1.28-3.30), older age (aOR, 1.05; 95% CI, 1.02-1.07), symptomatic aneurysm (aOR, 1.26; 95% CI, [0.60-2.62), ruptured aneurysm (aOR, 2.23; 95% CI, 1.43-3.48), longer operative time (aOR, 1.11; 95% CI, 1.01-1.22), and postoperative renal complications (aOR, 2.98; 95% CI, 1.80-4.96; P < .05 for all).
Confirming the results from previous studies, we found that BI is more common after a ruptured aneurysm and OAR. Other associated intraoperative factors included a transperitoneal approach, supraceliac clamping, and a reimplanted inferior mesenteric artery. More than one third of patients who developed postoperative BI in our cohort had died within 30 days after AAA repair. The factors associated with mortality after BI included surgical management and postoperative renal failure. A high index of suspicion for the signs and symptoms of BI should be maintained postoperatively for patients presenting with the risk factors identified.