背景:鉴于干预指南的变化和主动脉瘤血管内治疗的日益普及,我们检查了腹主动脉瘤(AAA)的入院和修复趋势,胸腹主动脉瘤(TAAA),和胸主动脉瘤(TAA)。
方法:我们确定了2004-2019年间在全国住院患者样本(NIS)中所有主动脉瘤破裂和完整主动脉瘤修复的患者。然后我们检查了开放的利用,血管内,和复杂的血管内修复(OAR,EVAR,cEVAR)用于每个主动脉瘤位置(AAA,TAAA,TAA),除了他们导致的住院死亡率,随着时间的推移。cEVAR包括分支,开窗的,和医生改良的内移植物。
结果:715,570例患者被确定为AAA(87%完整修复,13%破裂-入学)。2004年至2019年期间,完整的AAA修复和破裂的AAA接纳率均显着下降(完整的41,060-34,215,p<.01;破裂的7,175-4,625,p=.02)。在给定年份完成的所有AAA维修中,EVAR的使用增加(2004-2019年:完整的45%-66%,p<.01;破裂10%-55%,p<0.01)以及cEVAR(2010-2019年:完好无损0%-23%,p<.01;破裂0%-14%,p<.01)。完整AAAsEVAR后死亡率显著下降29%(2004-2019年,0.73%-0.52%,p<0.01),而OAR后的死亡率显着增加了16%(2004-2019年,4.4%-5.1%,p<.01)。在研究中,27,443例患者被确定为TAAA(80%完整,20%破裂)。在同一时期,完整的TAAA修复呈上升趋势(2004-2019年1,435-1,640,p=.055),cEVAR成为最常见的方法(2004-2019年,3.8%-72%,p=.055)。141,651名患者被确定为上升,拱门,或下降的TAA(90%完整,10%破裂)。完整的TAA维修大幅增加(2004-2019年4380-10855,p<0.01)。从2017年至2019年,下降的TAA的OAR后死亡率增加,TEVAR后死亡率下降(2017年至2019年:OAR1.6%-3.1%;TEVAR5.2%-3.8%)。
结论:在2004年至2019年期间,完整的AAA修复和破裂的AAA入院率均显着下降。使用血管内技术修复所有主动脉瘤位置,既完整又破裂,在过去的二十年里增加了。最近在2019年,89%的完整AAAs修复,肾下通过肾上,血管内(EVAR或cEVAR,分别)。仅cEVAR一项就从十年前的0%上升到2019年完整AAA修复的23%。在这个创新时期,有许多新的选择来修复主动脉瘤,同时保持动脉分支,目前,血管内修复术已用于所有完整的主动脉瘤修复术中的大多数。需要长期数据来评估这些程序的持久性。
BACKGROUND: Given changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of abdominal aortic aneurysms (AAAs), thoracoabdominal aortic aneurysms (TAAAs), and thoracic aortic aneurysms (TAAs).
METHODS: We identified all patients admitted with ruptured aortic aneurysms and intact aortic aneurysms repaired in the Nationwide Inpatient Sample between 2004 and 2019. We then examined the use of open, endovascular, and complex endovascular repair (OAR, EVAR, and cEVAR) for each aortic aneurysm location (AAA, TAAA, and TAA), alongside their resulting in-hospital mortality, over time. cEVAR included branched, fenestrated, and physician-modified endografts.
RESULTS: 715,570 patients were identified with AAA (87% intact repairs and 13% rupture admissions). Both intact AAA repairs and ruptured AAA admissions decreased significantly between 2004 and 2019 (intact 41,060-34,215, P < .01; ruptured 7175-4625, P = .02). Of all AAA repairs performed in a given year, the use of EVAR increased (2004-2019: intact 45%-66%, P < .01; ruptured 10%-55%, P < .01) as well as cEVAR (2010-2019: intact 0%-23%, P < .01; ruptured 0%-14%, P < .01). Mortality after EVAR of intact AAAs decreased significantly by 29% (2004-2019, 0.73%-0.52%, P < .01), whereas mortality after OAR increased significantly by 16% (2004-2019, 4.4%-5.1%, P < .01). In the study, 27,443 patients were identified with TAAA (80% intact and 20% ruptured). In the same period, intact TAAA repairs trended upward (2004-2019, 1435-1640, P = .055), and cEVAR became the most common approach (2004-2019, 3.8%-72%, P = .055). A total of 141,651 patients were identified with ascending, arch, or descending TAAs (90% intact and 10% ruptured). Intact TAA repairs increased significantly (2004-2019, 4380-10,855, P < .01). From 2017 to 2019, the mortality after OAR of descending TAAs increased and mortality after thoracic endovascular aneurysm repair decreased (2017-2019, OAR 1.6%-3.1%; thoracic endovascular aneurysm repair 5.2%-3.8%).
CONCLUSIONS: Both intact AAA repairs and ruptured AAA admissions significantly decreased between 2004 and 2019. The use of endovascular techniques for the repair of all aortic aneurysm locations, both intact and ruptured, increased over the past two decades. Most recently in 2019, 89% of intact AAA repairs, infrarenal through suprarenal, were endovascular (EVAR or cEVAR, respectively). cEVAR alone increased to 23% of intact AAA repairs in 2019, from 0% a decade earlier. In this period of innovation, with many new options to repair aortic aneurysms while maintaining arterial branches, endovascular repair is now used for the majority of all intact aortic aneurysm repairs. Long-term data are needed to evaluate the durability of these procedures.