The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative
The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative
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DOI：
10.1016/j.jvs.2018.11.021
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发表时间：
2019-08-01
影响因子：
4.3
通讯作者：
Schermerhorn, Marc L.
中科院分区：
文献类型：
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作者：
O'Donnell, Thomas F. X.;Patel, Virendra I.;Schermerhorn, Marc L.
背景：复杂腹主动脉瘤的血管内修复已经越来越普遍，但报道大多局限于单一中心和单一装置。方法：我们研究了2014年至2018年血管质量倡议中所有复杂腹主动脉瘤（6区或尾端）的血管内修复。这包括所有市售的开窗血管内动脉瘤修复（FEVAR）、烟囱/通气管修复和医生改良的血管内移植物（pmeg），不包括研究设备豁免和临床试验设备。我们使用逆概率加权多水平logistic回归来比较围手术期结局的发生率，包括死亡、急性肾损伤（AKI）和主要心脏不良事件（mace；死亡/中风/心肌梗死的组合），并对长期死亡率进行Cox回归。结果：在研究期间，外科医生进行了1396例复杂的血管内修复：1308例（94%）为选择性修复，63例（4.5%）为症状性动脉瘤修复，25例（1.8%）为破裂修复。进行复杂血管内修复的中心数量从2014年的39家稳步增加到2017年的81家。其中FEVAR 880例（63%），PMEG 256例（18%），烟囱/通气管修复260例（19%）。在选择性病例中，3214条内脏血管合并并血运重建；120例（9%）涉及一艘船，481例（38%）涉及两艘船，560例（44%）涉及三艘船，113例（9%）涉及四艘船。合并动脉的平均数目为2.5 +/- 0.8，其中PMEG涉及的动脉最多（PMEG为3.3 +/- 0.8，FEVAR为2.5 +/- 0.6，烟囱/通气管为1.9 +/- 0.9;P < 0.001）。pmeg用于治疗更广泛的动脉瘤，更多地合并腹腔和肠系膜上动脉。动脉瘤的范围没有变化，但近端封闭的长度随着时间的推移而延长。烟囱/通气管病例采用更多的手臂或颈部通道，手术时间更长，使用更多的造影剂。围手术期死亡率（FEVAR组3.4% vs PMEG组2.7% vs烟囱/通气管组6.1%;P = 0.13）和AKI （17% vs 18% vs 19%; P = 0.42）相似，但烟囱/通气管与较高的卒中发生率（0.8% vs 0.9% vs 3.3%; P = 0.03）和mace （6.1% vs 5.4% vs 11.7%; P = 0.02）相关。调整后，围手术期死亡率、AKI和总并发症的发生率保持相似，但烟囱/通气管与卒中（比值比[OR]， 7.3 [1.5-36.4]; P = 0.015）、心肌梗死（OR, 18.7 [2.6-136.8]; P = 0.004）和mace （OR, 11.1 [2.1-58.9]; P = 0.005）的发生率显著升高相关。选择性修复后1年和3年的总生存率分别为91%和88%，在粗糙和调整后的分析中，修复类型之间没有差异。结论：血管质量倡议为研究复杂血管内动脉瘤修复的实际应用和结果提供了一个独特的机会。烟囱/通气管修复后围手术期的发病率似乎更高，但需要进一步的研究来证实这些发现并确定这些新技术的耐久性。
Background: Endovascular repair of complex abdominal aortic aneurysms has become increasingly common, but reports have mostly been limited to single centers and single devices.Methods: We studied all endovascular repairs of complex abdominal aortic aneurysms (zone 6 or caudal) from 2014 to 2018 in the Vascular Quality Initiative. This included all commercially available fenestrated endovascular aneurysm repair (FEVAR), chimney/snorkel repairs, and physician-modified endografts (PMEGs), exclusive of investigational device exemptions and clinical trial devices. We used inverse probability-weighted multilevel logistic regression to compare rates of perioperative outcomes including death, acute kidney injury (AKI), and major adverse cardiac events (MACEs; the composite of death/stroke/myocardial infarction) and Cox regression for long-term mortality.Results: During the study period, surgeons performed 1396 complex endovascular repairs: 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. The number of centers performing complex endovascular repairs expanded steadily from 39 in 2014 to 81 in 2017. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized; 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. The mean number of arteries incorporated was 2.5 +/- 0.8, with PMEGs involving the most arteries (3.3 +/- 0.8 for PMEG vs 2.5 +/- 0.6 for FEVAR and 1.9 +/- 0.9 for chimney/snorkel; P < .001). PMEGs were used to treat more extensive aneurysms, and more incorporated the celiac and superior mesenteric arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast material. Rates of perioperative death (3.4% for FEVAR vs 2.7% for PMEG vs 6.1% for chimney/snorkel; P = .13) and AKI (17% vs 18% vs 19%; P = .42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%; P = .03) and MACEs (6.1% vs 5.4% vs 11.7%; P = .02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (odds ratio [OR], 7.3 [1.5-36.4]; P = .015), myocardial infarction (OR, 18.7 [2.6-136.8]; P = .004), and MACEs (OR, 11.1 [2.1-58.9]; P = .005). Overall survival after elective repair was 91% at 1 year and 88% at 3 years, with no difference between repair types in crude or adjusted analysis.Conclusions: The Vascular Quality Initiative provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher after chimney/snorkel repair, but further study is needed to confirm these findings and to establish the durability of these novel technologies.