Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair.
Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair.
复制标题
择期胸主动脉瘤腔内修复术后 1 年内死亡率的术前预测。
DOI：
10.1016/j.jvs.2012.04.018
复制
发表时间：
2012
影响因子：
4.3
通讯作者：
Beck,AdamW
中科院分区：
文献类型：
--
作者：
Scali,SalvatoreT;Chang,CatherineK;Feezor,RobertJ;HessJr,PhilipJ;Beaver,ThomasM;Martin,TomasD;Huber,ThomasS;Beck,AdamW
目的胸主动脉腔内修复术(TEVAR)比开放修复术更有利于患者的生存，已成为治疗的主要手段。由于TEVAR术后1年内死亡可能表明治疗无效，我们使用术前设置中的可用因素创建了1年内死亡的预测模型。对2000年9月至2010年11月在佛罗里达大学进行的526例TEVAR的MEHODSA登记进行了查询，以了解以退行性降胸动脉瘤为主要病理的患者。有紧急或紧急适应症的手术被排除在外。记录术前可用变量，如基线合并症、解剖和特定程序的计划细节。对影响TEVAR后30天内死亡(30天内死亡)和1年内死亡(1年内死亡)的单变量死亡预测因素进行多因素Cox比例风险分析。结果共对224例患者进行了识别和评估。30d死亡率为3%(n=7)，1年死亡率为15%(n=33)。1年死亡率的多变量预测因素(危险比[95%可信区间])包括：年龄和年龄；70岁(5.8[2.1-16.0]；P=.001)，术中辅助性操作(例如，头臂支架或内脏支架，或两者兼而有之，伴随弓形分支剥离)；4.5[1.9-10.8]；P=.001)，外周动脉疾病(3.0[1.4-6.7]；P=.006)，冠状动脉疾病(2.4[1.1-4.9]；P=0.02)和慢性阻塞性肺疾病(1.9[1.0-3.9]；P=0.06)。高脂血症的诊断是保护性的(0.4[0.2-0.7]；P=0.006)。当患者被分成具有一个、两个、三个或四个或更多危险因素的患者时，预测的1年死亡率分别为1%、3%、10%、27%和54%。结论在术前环境中，可以使用预测TEVAR后1年内死亡的指标，并可以指导临床对修复时机的决策。有多个危险因素的患者，如年龄≥70岁、冠状动脉疾病、慢性阻塞性肺疾病以及需要进行广泛的辅助治疗的手术，1年内的死亡率很高，最好是等待更大的动脉瘤大小来证明介入治疗的风险。
OBJECTIVEThoracic endovascular aortic repair (TEVAR) is known to have a survival benefit over open repair in patients with descending thoracic aneurysms and has become a mainstay of therapy. Because death before 1 year after TEVAR likely indicates an ineffective therapy, we have created a predictive model for death within 1 year using factors available in the preoperative setting.METHODSA registry of 526 TEVARs performed at the University of Florida between September 2000 and November 2010 was queried for patients with degenerative descending thoracic aneurysm as their primary pathology. Procedures with emergent or urgent indications were excluded. Preoperatively available variables, such as baseline comorbidities, anatomic-, and procedure-specific planning details, were recorded. Univariate predictors of death were analyzed with multivariable Cox proportional hazards to identify independent predictors of 30-day (death within 30 days) and 1-year mortality (death within 1 year) after TEVAR.RESULTSA total of 224 patients were identified and evaluated. The 30-day mortality rate was 3% (n = 7) and the 1-year mortality rate was 15% (n = 33). Multivariable predictors of 1-year mortality (hazard ratios [95% confidence interval]) included: age >70 years (5.8 [2.1-16.0]; P = .001), adjunctive intraoperative procedures (eg, brachiocephalic or visceral stents, or both, concomitant arch debranching procedures; 4.5 [1.9-10.8]; P = .001), peripheral arterial disease (3.0 [1.4-6.7]; P = .006), coronary artery disease (2.4 [1.1-4.9]; P = .02), and chronic obstructive pulmonary disease (1.9 [1.0-3.9]; P = .06). A diagnosis of hyperlipidemia was protective (0.4 [0.2-0.7]; P = .006). When patients were grouped into those with one, two, three, or four or more of these risk factors, the predicted 1-year mortality was 1%, 3%, 10%, 27%, and 54%, respectively.CONCLUSIONSFactors are available in the preoperative setting that are predictive of death within 1 year after TEVAR and can guide clinical decision making regarding the timing of repair. Patients with multiple risk factors, such as age ≥70 years, coronary artery disease, chronic obstructive pulmonary disease, and a need for an extensive procedure involving adjunctive therapies, have a high predicted mortality within 1 year and may be best served by waiting for a larger aneurysm size to justify the risk of intervention.