背景:对于男性大于5.5cm,女性大于5cm的动脉瘤,建议进行腹主动脉瘤(AAA)修复。由于AAA在老年人中更常见,我们试图评估当代的择期AAA修复实践和术后2年结局.
方法:我们确定了在2012-2019年血管质量倡议中接受选择性AAA修复的八十岁老人。我们纳入了接受血管内(EVAR)和开放(OAR)主动脉修复的患者。比较了患者组之间的人口统计学和合并症。使用先前发布的方法计算脆弱。虚弱评分高于手术队列第75百分位数的患者被认为是高虚弱。主要结果是一年和两年死亡率。次要结果包括术后并发症。使用标准统计方法。Cox比例风险模型用于确定影响死亡率的因素。
结果:八十岁老人的AAA修复频率保持稳定。所有主动脉手术中有21.4%是在八十岁老人上进行的;9,735(41,712的23.3%)血管内(EVAR)和755(7,325的10.3%)OAR。在八十岁的患者中,42.0%的EVAR低于尺寸阈值:48.3%的男性≤5.5cm直径,21.5%的女性≤5.0cm直径,而18.8%的OAR:23.4%的男性和10.7%的女性。此外,25.6%的人有较高的脆弱分数。在八十岁的老人中,EVAR患者的一年和两年死亡率分别为9.3%±0.3%和14.8%±0.4%,OAR患者为15.2%±1.3%和18.9%±1.5%,分别(p<0.01)。OAR后住院死亡率更高(0.87%EVARvs7.55%OAR,p<0.01),并因虚弱而不同(EVAR,低脆弱0.2%与高脆弱1.7%;OAR,低脆弱2.3%对高脆弱15.6%)。对于EVAR,与死亡率相关的患者因素包括心力衰竭(HR=1.15[1.06-1.25],p=0.001)和透析(HR=1.71[1.13-2.59],p=0.012)。对于OAR,冠状动脉疾病(HR=1.55[0.98-2.44],p=0.062)与死亡率相关。他汀类药物的使用对所有患者的死亡率都有保护作用(EVAR;(HR=0.68[0.60-0.78],p<0.01):OAR;(HR=0.58[0.37-0.92],p=0.020))。在八十岁的老人中,高虚弱与两年死亡率独立相关(EVAR;(HR=3.36[2.62-4.31,p<0.01)和OAR;(HR=2.35[1.09-5.10],p=0.030))。
结论:在全国范围内,八十岁老人的大部分选择性AAA修复是在推荐的尺寸阈值以下进行的,其中四分之一的人很虚弱,长期两年死亡率很低。该年龄组AAA修复后的高两年死亡率超过了5-5.5cmAAA破裂的公开风险,这表明应该探索增加八十岁老人的选择性修复的大小阈值。
Abdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm in men and 5 cm in women. Because AAA is more common among the elderly, we sought to evaluate contemporary practices of elective AAA repair and 2-year postoperative outcomes in octogenarians.
We identified octogenarians undergoing elective AAA repair in the Vascular Quality Initiative from 2012 to 2019. We included patients undergoing endovascular (EVAR) and open (OAR) aortic repair. Demographics and comorbid conditions were compared between patient groups. Frailty was calculated using previously published methods. Patients with frailty scores above the 75th percentile of the operative cohort were considered high frailty. The primary outcome was 1- and 2-year mortality. Secondary outcomes included postoperative complications. Standard statistical methods were utilized. Cox proportional hazard models were used to identify factors that affect mortality.
The frequency of AAA repair in octogenarians has remained stable. Of all aortic operations, 21.4% were performed on octogenarians; 9735 (23.3% of 41,712) EVAR and 755 (10.3% of 7325) OARs. Among octogenarian patients, 42.0% of EVARs were under size thresholds: 48.3% males ≤5.5 cm diameter and 21.5% females ≤5.0 cm diameter compared with 18.8% OARs: 23.4% males and 10.7% females. Additionally, 25.6% had high frailty scores. Among octogenarians, 1- and 2-year mortality was 9.3% ± 0.3% and 14.8% ± 0.4% for EVAR and 15.2% ± 1.3% and 18.9% ± 1.5% for OAR patients, respectively (P < .01). In-hospital mortality rate was higher after OAR (0.87% EVAR vs 7.55% OAR; P < .01) and differed with frailty (EVAR, low frailty 0.2% vs high frailty 1.7%; OAR, low frailty 2.3% vs high frailty 15.6%). For EVAR, patient factors associated with mortality included heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.06-1.25; P = .001) and dialysis (HR, 1.71; 95% CI, 1.13-2.59; P = .012). For OAR, coronary artery disease (HR, 1.55; 95% CI, 0.98-2.44; P = .062) was associated with mortality. Statin use was protective of mortality for all patients (EVAR: HR, 0.68; 95% CI, 0.60-0.78; P < .01): OAR: HR, 0.58; 95% CI, 0.37-0.92; P = .020). Among octogenarians, high frailty was independently associated with 2-year mortality (EVAR: HR, 3.36; 95% CI, 2.62-4.31; P < .01 and OAR: HR, 2.35; 95% CI, 1.09-5.10; P = .030).
Nationally, a large portion of elective AAA repair in octogenarians is performed below recommended size thresholds, one-quarter of whom are frail with poor long-term 2-year mortality rates. High 2-year mortality following AAA repair in this age group exceeds the published risk of rupture for 5- to 5.5-cm AAA, suggesting that increase in the size threshold of elective repair among octogenarians should be explored.