目的:虽然血管外科学会建议男性≥5.5cm和女性≥5.0cm的腹主动脉瘤(AAA)修复,低于这些阈值的AAA修复已得到充分证明。除了这些严格的尺寸标准外,还有明确的维修迹象。但是这种修理在人们的实践中的预期比例还没有得到研究。我们试图在单个学术中心表征低于直径建议的动脉瘤修复适应症。假设这种现实世界的经验与其他实践相似,然后,我们使用国家数据来推断这些发现.
方法:对所有选择性开放(oAAA)和血管内(EVAR)AAA修复(2010-20)进行了单中心回顾性审查,以评估直径低于建议(男性定义为<5.5cm,女性定义为<5.0cm)的动脉瘤的发生率和修复适应症。这些修复的原因被定义为:1)髂动脉瘤,2)囊状形态,3)快速扩张,4)患者焦虑,5)远端栓塞,6)其他,和7)没有记录的原因。对所有无症状的oAAA和EVAR(2010-20)的血管质量倡议(VQI)进行了查询,并确定了直径建议以下的修复。将单中心分析的结果应用于VQI队列,以推断全国范围内进行维修的原因。在低于推荐范围的患者和符合推荐范围的患者之间比较了院内死亡率和主要不良心脏事件(MACE)。
结果:我们中心的456项AAA选修,147人(32%)低于推荐规模。这对于EVAR更为常见(35%vs28%)。原因是:没有记录(41%),髂动脉瘤(23%),囊状(10%),快速扩张(10%),患者焦虑(7%),其他(6%),远端栓塞(3%)。在VQI的44,820项选择性AAA维修中,17,057(38%)低于尺寸建议(40%平均,26%oAAA)。在建议尺寸以下进行修复的患者住院死亡率较低(oAAA:2.4%vs4.6%p<0.0001;EVAR:0.3%vs0.8%p<0.0001)。当单中心调查结果应用于VQI数据集时,在全国范围内进行了估计10,064次维修,以获得尺寸标准以外的可接受适应症。相反,可能进行了6993次维修(相关35例死亡),但没有记录在案。
结论:在VQI和我们的单中心经验中,低于推荐直径指南的AAA修复约占所有选择性AAA手术的三分之一。假设我们的实践是典型的,由于其他明确的原因,近60%的尺寸建议以下的维修符合标准。剩下的40%缺乏有案可查的理由,这意味着13%的择期AAA修复术是针对直径低于建议的动脉瘤进行的,但没有可接受的指征.随着过度使用/使用不足的意识的提高,这些数据有助于估计不太常见的病变的预期修复比例.它们还为减少过度使用的努力提供了潜在的基线数据点。
Although the Society for Vascular Surgery recommends repair of abdominal aortic aneurysms (AAA) at 5.5 cm or greater in men and 5.0 cm or greater in women, AAA repair below these thresholds has been well-documented. There are clear indications for repair other than these strict size criteria, but the expected proportion of such repairs in one\'s practice has not been studied. We sought to characterize the indications for repairs of aneurysms below diameter recommendations at a single academic center. Using the assumption that this real-world experience would approximate that of other practices, we then used national data to extrapolate these findings.
A single-center retrospective review was conducted of all elective open AAA (oAAA) and endovascular aneurysm repair (EVAR) from 2010 to 2020 to assess the incidence of and indications for repair of aneurysms below diameter recommendations (defined as <5.5 cm in men and <5.0 cm in women). Reasons for these repairs were defined as (1) iliac aneurysm, (2) saccular morphology, (3) rapid expansion, (4) patient anxiety, (5) distal embolization, (6) other, and (7) no documented reason. The Vascular Quality Initiative (VQI) was queried for all asymptomatic oAAA and EVAR (2010-2020) and repairs below diameter recommendations were identified. Findings from the single-center analysis were applied to the VQI cohort to extrapolate estimates of reasons for repairs done nationally. In-hospital mortality and major adverse cardiac events (MACE) were compared between those below size recommendations and those meeting size recommendations.
Of 456 elective AAA repairs at our center, 147 (32%) were below size recommendations. This finding was more common for EVAR (35% vs 28%). Reasons were: not documented (41%), iliac aneurysm (23%), saccular (10%), rapid expansion (10%), patient anxiety (7%), other (6%), and distal embolism (3%). Of 44,820 elective AAA repairs in the VQI, 17,057 (38%) were below size recommendations (40% EVAR, 26% oAAA). Patients who were repaired below size recommendations had lower in-hospital death (oAAA, 2.4% vs 4.6% [P < .0001]; EVAR, 0.3% vs 0.8% [P < .0001]). When single-center findings were applied to the VQI dataset, an estimated 10,064 repairs were performed nationally for acceptable indications other than size criteria. Conversely, there may have been 6993 repairs (with an associated 35 deaths) performed without documented indication.
Repairs for AAA below the recommended diameter guidelines account for approximately one-third of all elective AAA procedures in both the VQI and our single-center experience. Assuming our practice is typical, nearly 60% of repairs below size recommendations meet the criteria for other clear reasons. The remaining 40% lack a documented reason, meaning that 13% of all elective AAA repairs were done for aneurysms below size recommendations without an acceptable indication. As awareness of overuse and underuse is heightened, these data help to estimate the expected proportion of repairs for less common pathologies. They also provide a potential baseline data point for efforts at decreasing overuse.