High incidence of type 2 endoleak and low associated adverse events in the Vascular Quality Initiative linked to Medicare claims.
High incidence of type 2 endoleak and low associated adverse events in the Vascular Quality Initiative linked to Medicare claims.
复制标题
与医疗保险索赔相关的血管质量倡议中 2 型内漏发生率高，相关不良事件发生率低。
DOI：
10.1016/j.jvs.2023.04.013
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发表时间：
2023
影响因子：
4.3
通讯作者：
Hoel,AndrewW
中科院分区：
文献类型：
--
作者：
Mansukhani,NeelA;Brown,KellieR;Zheng,Xinyan;Mao,Jialin;Goodney,PhilipP;Hoel,AndrewW
前言2型内漏(T2EL)是主动脉瘤腔内修补术(EVAR)术后监护中最常见的不良表现。T2EL对动脉瘤相关死亡率的低发生率已被证实。然而，最优的管理策略和再干预的效果仍然存在争议。这项研究使用了来自与联邦医疗保险索赔相关的血管质量倡议(VQI-Medicare)的数据来在现实世界的队列中评估T2LE。方法这项回顾VQI-Medicare中的EVAR程序的回顾包括2015至2017年间首次接受EVAR程序的患者。排除完全性血管造影术中T2EL以外的内漏和无VQI影像随访的患者。在手术时没有参加联邦医疗保险A部分或B部分的患者，或者没有1年完整的联邦医疗保险随访数据的患者也被排除在外。暴露变量为T2EL，定义为术后第一年内检测到的任何分支血管血流。感兴趣的结果是死亡率、再干预、与T2EL相关的再干预、EVAR后成像和T2EL行为，包括自发消退、动脉瘤囊消退和再干预后消退。结果在5534例患者中，1372例(24.7%)发现T2EL，4162例(75.2%)未发现T2EL。患有和不患有T2EL的患者的中位年龄分别为77岁和75岁。T2EL患者在术后3年的死亡率、影像、再干预或与T2EL相关的再干预方面没有差异。在总队列中，动脉瘤囊直径缩小4 mm(范围9~0 mm)。以肠系膜下动脉为基础的T2EL患者的动脉瘤直径减少最小(副肾动脉为基础的T2EL的中位数为1.5 mm，多供血血管为基础的T2EL为2 mm，腰动脉为4 mm)。自发消退率为73.7%(809例)。有多支供血血管的T2 ELs自发消退率最低(n=51，54.9%)，而肠系膜下动脉(n=99，60.0%)、腰动脉(n=655，77.7%)和副肾动脉(n=31，79.5%)的自发消退率较低(P<；.001)。84例患者行PBE治疗。接受PBE且EVAR后未检测到T2EL的患者在随访时囊腔回退率最高(较基线下降7 mm)。结论EVAR后T2EL与高自发消退率、低动脉瘤囊生长率相关，没有证据表明早期死亡率或再介入治疗增加。在某些情况下，PBE可与EVAR联合应用。
IntroductionType 2 endoleak (T2EL) is the most common adverse finding on postoperative surveillance after endovascular aortic aneurysm repair (EVAR). A low rate of aneurysm-related mortality with T2EL has been established. However, the optimal management strategy and the efficacy of reintervention remain controversial. This study used data from the Vascular Quality Initiative linked to Medicare claims (VQI-Medicare) to evaluate T2LE in a real-world cohort.MethodsThis retrospective review of EVAR procedures in VQI-Medicare included patients undergoing their first EVAR procedure between 2015 and 2017. Patients with an endoleak other than T2EL on completion angiogram and those without VQI imaging follow-up were excluded. Patients without Medicare part A or part B enrollment at the time of the procedure or without 1-year complete Medicare follow-up data were also excluded. The exposure variable was T2EL, defined as any branch vessel flow detected within the first postoperative year. Outcomes of interest were mortality, reintervention, T2EL-related reintervention, post-EVAR imaging, and T2EL behavior including spontaneous resolution, aneurysm sac regression, and resolution after reintervention. The association of prophylactic branch vessel embolization (PBE) with T2EL resolution and aneurysm sac regression was also evaluated.ResultsIn a final cohort of 5534 patients, 1372 (24.7%) had an identified T2EL and 4162 (75.2%) did not. The median age of patients with and without T2EL was 77 and 75 years, respectively. There were no differences in mortality, imaging, reintervention, or T2EL-related reintervention at 3 years after the procedure for patients with T2EL. The aneurysm sac diameter decreased by 4 mm (range: 9-0 mm decrease) in the total cohort. Patients with inferior mesenteric artery-based T2EL had the smallest decrease in aneurysm diameter (median 1 mm decrease compared with 1.5 mm for accessory renal artery-based T2EL, 2 mm for multiple feeding vessel-based T2EL, and 4 mm for lumbar artery-based T2EL;P< .001). Spontaneous resolution occurred in 73.7% of patients (n = 809). T2ELs with evidence of multiple feeding vessels were associated with the lowest rate of spontaneous resolution (n = 51, 54.9%), compared with those with a single identified feeding vessel of inferior mesenteric artery (n = 99, 60.0%), lumbar artery (n = 655, 77.7%), or accessory renal artery (n = 31, 79.5%) (P< .001). PBE was performed in 84 patients. Patients who underwent PBE and were without detectable T2EL after EVAR had the greatest rate of sac regression at follow-up (7 mm decrease) compared with baseline.ConclusionsT2EL after EVAR is associated with high rates of spontaneous resolution, low rates of aneurysm sac growth, and no evidence of increased early mortality or reintervention. PBE in conjunction with EVAR may be indicated in some circumstances.