目的:胸主动脉腔内修复术(TEVAR)后的呼吸不良事件(RAEs)特征仍然不明确,因为缺乏全面的研究来确定容易发生这些并发症的个体。这项研究旨在确定发病率,相关因素,TEVAR后RAE的结果。
方法:我们确定了2010年至2023年接受TEVAR隔离至0-5区的非创伤性病变的血管质量倡议患者。在确定术后RAE的发生率后,我们评估了基线特征,病理学,程序细节,术后并发症按呼吸道并发症状态分层:无,只有肺炎,只有再插管,或者两者兼而有之。然后,我们使用多变量改进的Poisson回归检查了与术后RAE发展独立相关的术前和术中变量。Kaplan-Meier分析和Cox比例风险回归模型用于确定术后RAE和5年生存率之间的关联,并在单独的模型中调整术前变量和其他非呼吸道术后并发症。
结果:在10,708名患者中,8.3%有任何RAE(仅肺炎:2.1%,仅再插管:4.8%,两者:1.4%)。有任何RAE的患者更有可能出现主动脉夹层(任何呼吸并发症:46%vs无呼吸并发症:35%;p<.001),并且有症状(58%vs48%;p<.001)。TEVAR后发展RAE与男性相关(aRR:1.19[95%CI:1.01-1.41];p=0.037),肥胖(1.31[1.07-1.61];p=0.009),病态肥胖(1.68[1.20-2.32];p=0.002),肾功能不全(eGFR30-45:1.45[1.15-1.82];p=0.002;eGFR<30/血液透析:1.7[1.37-2.11];p<0.001),贫血(1.31[1.09-1.58];p=0.003),主动脉直径>65mm(1.54[1.25-1.89];p<0.001),主动脉弓(1.23[1.03-1.48];p=0.025)或升主动脉(1.61[1.19-2.14];p=0.002)的近端疾病,急性主动脉夹层(2.13[1.72-2.63];p<0.001),破裂的表现(3.07[2.43-3.87];p<0.001),同一天手术胸科治疗(1.51[1.25-1.82];p<0.001),COPD在家庭氧气(1.58[1.08-2.25];p=0.014),有限的自我护理或卧床状态(2.12[1.45-3.03];p<0.001),术中输血(1.88[1.47-2.40];p<0.001)。术后发生RAE的患者30天死亡率(27%vs4%;p<.001)和5年死亡率高于无呼吸道并发症的患者(46%vs20%;p<0.001)。在术前和术后变量调整后,术后发生任何RAE的患者的5年死亡率更高(aHR:1.8[1.6,2.1];p<.001),仅术后肺炎(1.4[1.0,1.8];p=.046),仅再插管(2.2[1.8,2.6];p<.001)或两者(1.5[1.1,2.0];p=.008)。
结论:TEVAR后的RAE很常见,更可能发生在男性肥胖患者中,肾功能不全,贫血,COPD对家庭氧气,急性主动脉夹层,破裂的演示文稿,同一天外科胸科治疗,接受术中输血的人,与5年死亡率增加2倍相关,而与其他术后并发症的发生无关.在评估TEVAR程序的风险和收益时考虑到这些因素,随着实施定制的术后护理,可能会改善临床结果。
OBJECTIVE: Respiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized due to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR.
METHODS: We identified Vascular Quality Initiative patients undergoing TEVAR isolated to zones 0-5 from 2010 to 2023 for non-traumatic pathologies. After determining the incidence of post-operative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined pre- and intra-operative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression model were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other non-respiratory post-operative complications in a separate model.
RESULTS: Of 10,708 patients, 8.3% had any RAE (pneumonia only: 2.1%, reintubation only: 4.8%, both: 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication: 46% vs no respiratory complication: 35%; p<.001), and be symptomatic (58% vs 48%;p<.001). Developing RAEs post-TEVAR was associated with male sex (aRR: 1.19 [95% CI: 1.01-1.41]; p=0.037), obesity (1.31[1.07-1.61]; p=0.009), morbid obesity (1.68[1.20-2.32]; p=0.002), renal dysfunction (eGFR 30-45: 1.45[1.15-1.82]; p=0.002; eGFR <30/hemodialysis: 1.7[1.37-2.11]; p<0.001), anemia (1.31[1.09-1.58]; p=0.003), aortic diameter >65mm (1.54[1.25-1.89]; p<0.001), proximal disease in the aortic arch (1.23[1.03-1.48]; p=0.025) or ascending aorta (1.61[1.19-2.14]; p=0.002), acute aortic dissection (2.13[1.72-2.63]; p<0.001), ruptured presentation (3.07[2.43-3.87]; p<0.001), same-day surgical thoracic branch treatment (1.51[1.25-1.82]; p<0.001), COPD on home oxygen (1.58[1.08-2.25]; p=0.014), limited self-care or bed-bound status (2.12[1.45-3.03]; p<0.001), and intraoperative transfusion (1.88[1.47-2.40]; p<0.001). Patients who developed post-operative RAEs had higher 30-day mortality (27% vs 4%; p<.001) and 5-year mortality than patients without respiratory complications (46% vs 20%; p<0.001). After adjusting for pre-operative and post-operative variables, 5-year mortality was higher in patients who developed any post-operative RAE (aHR: 1.8[1.6, 2.1]; p<.001), post-operative pneumonia only (1.4[1.0, 1.8];p=.046), reintubation only (2.2[1.8, 2.6]; p<.001) or both (1.5[1.1, 2.0]; p=.008).
CONCLUSIONS: RAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, COPD on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intra-operative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other post-operative complications. Considering these factors in assessing risks and benefits of TEVAR procedures, along with implementing customized post-operative care, can potentially improve clinical outcomes.