背景:对于具有解剖学上适当的腹主动脉瘤(AAA)的患者,血管内主动脉修复(EVAR)是一种比生理上更有压力的开放式手术修复(OSR)侵入性更小的方法。术后早期结果与患者的生理储备和手术干预的生理应激有关。在生理储备减少的虚弱患者中,主动脉破裂的应力与手术修复的应力相结合的耐受性较差,增加并发症和死亡率的风险。这项研究旨在评估接受微创EVAR的患者的虚弱与预后之间的相关性差异,以及破裂的AAA(rAAA)的生理压力更大的OSR。
方法:我们的回顾性队列研究包括2010年至2022年在血管质量倡议中接受rAAA修复的成年人。经过验证的风险分析指数(RAI;稳健≤20,正常21-29,脆弱30-39,非常脆弱≥40)量化了虚弱。使用多变量Cox模型比较了1年死亡率与虚弱状态以及修复类型的主要结局之间的关联,该模型产生了具有95%置信区间(95CI)的校正风险比(aHR)。交互术语评估了关联的审核。
结果:我们确定了5,806例患者(年龄72±9岁;男性77%;EVAR65%;健壮6%;正常48%;虚弱36%;非常虚弱10%),在rAAA修复后观察到1年死亡率为53%。与EVAR相比,OSR[aHR=1.43(95CI1.19-1.73)]与1年死亡率增加相关。虚弱状态增加[虚弱的aHR=1.26(95CI1.00-1.59);非常虚弱的aHR=1.64(95CI1.26-2.13)]与1年死亡率增加相关。由修复类型调节(P相互作用<0.05)。OSR与正常[aHR=1.49(95CI1.20-1.87)]和虚弱[aHR=1.51(95CI1.20-1.89)]的1年死亡率增加相关,但不在健壮[aHR=0.88(95CI0.59-1.32)]和非常虚弱[aHR=1.29(95CI0.97-1.72)]的患者中。
结论:脆弱和OSR与rAAA修复后1年死亡率的调整风险增加相关。在正常和虚弱的患者中,与EVAR相比,OSR与1年死亡率的调整风险增加相关。然而,OSR和EVAR在能很好地耐受OSR应激的健壮患者和无论何种修复类型都无法耐受rAAA的手术应激的非常虚弱的患者之间没有差异.
OBJECTIVE: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs).
METHODS: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association\'s moderation.
RESULTS: We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients.
CONCLUSIONS: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.