Long-Term Outcomes of Abdominal Aortic Aneurysm in the Medicare Population.
Long-Term Outcomes of Abdominal Aortic Aneurysm in the Medicare Population.
复制标题
DOI：
10.1056/nejmoa1405778
复制
发表时间：
2015-07-23
期刊：
影响因子：
--
通讯作者：
Landon BE
中科院分区：
文献类型：
--
作者：
Schermerhorn ML;Buck DB;O'Malley AJ;Curran T;McCallum JC;Darling J;Landon BE
随机试验和观察性研究表明，腹主动脉瘤腔内修复术的围手术期发病率和死亡率低于开放修复术，但生存获益并不持久。此外，人们对动脉瘤破裂的长期风险或腔内修复术后再次介入的必要性提出了担忧。我们评估了2001年至2008年期间接受修复术并随访至2009年的Medicare受益人中倾向评分匹配队列的腹主动脉瘤腔内修复术与开放修复术后的围手术期和长期生存率、再干预和并发症。我们确定了39,966对匹配的患者，他们接受了开放性修复术或腔内修复术。腔内修复术的围手术期死亡率为1.6%，而开放修复术为5.2%（P<0.001）。从2001年到2008年，接受腔内修复术患者的围手术期死亡率下降了0.8个百分点（P = 0.001），接受开放修复术患者的围手术期死亡率下降了0.6个百分点（P = 0.01）。从腔内到开放修复术的转换率从2001年的2.2%下降到2008年的0.3%（P<0.001）。在前3年随访中，腔内修复术后的生存率显著高于开放性修复术后的生存率，之后的生存率相似。通过8年的随访，与动脉瘤或其并发症的管理相关的干预在腔内修复术后更常见，而与剖腹手术相关的并发症的干预在开放修复术后更常见。在8年随访中，腔内修复术后5.4%的患者发生动脉瘤破裂，而开放修复术后1.4%的患者发生动脉瘤破裂（P<0.001）。腔内修复术后2年的总再介入率随时间推移而下降（从2001年接受手术的患者的10.4%降至2007年接受手术的患者的9.1%）。腹主动脉瘤的腔内修复术与开放修复术相比，具有显著的早期生存优势，但随着时间的推移，这种优势逐渐降低。腔内修复术后晚期破裂的发生率明显高于开放修复术后。随着时间的推移，腔内修复术的结局一直在改善。（由美国国立卫生研究院资助。
Randomized trials and observational studies have shown that perioperative morbidity and mortality are lower with endovascular repair of abdominal aortic aneurysm than with open repair, but the survival benefit is not sustained. In addition, concerns have been raised about the long-term risk of aneurysm rupture or the need for reintervention after endovascular repair. We assessed perioperative and long-term survival, reinterventions, and complications after endovascular repair as compared with open repair of abdominal aortic aneurysm in propensity-score–matched cohorts of Medicare beneficiaries who underwent repair during the period from 2001 through 2008 and were followed through 2009. We identified 39,966 matched pairs of patients who had undergone either open repair or endovascular repair. The overall perioperative mortality was 1.6% with endovascular repair versus 5.2% with open repair (P<0.001). From 2001 through 2008, perioperative mortality decreased by 0.8 percentage points among patients who underwent endovascular repair (P = 0.001) and by 0.6 percentage points among patients who underwent open repair (P = 0.01). The rate of conversion from endovascular to open repair decreased from 2.2% in 2001 to 0.3% in 2008 (P<0.001). The rate of survival was significantly higher after endovascular repair than after open repair through the first 3 years of follow-up, after which time the rates of survival were similar. Through 8 years of follow-up, interventions related to the management of the aneurysm or its complications were more common after endovascular repair, whereas interventions for complications related to laparotomy were more common after open repair. Aneurysm rupture occurred in 5.4% of patients after endovascular repair versus 1.4% of patients after open repair through 8 years of follow-up (P<0.001). The rate of total reinterventions at 2 years after endovascular repair decreased over time (from 10.4% among patients who underwent procedures in 2001 to 9.1% among patients who underwent procedures in 2007). Endovascular repair, as compared with open repair, of abdominal aortic aneurysm was associated with a substantial early survival advantage that gradually decreased over time. The rate of late rupture was significantly higher after endovascular repair than after open repair. The outcomes of endovascular repair have been improving over time. (Funded by the National Institutes of Health.)