Background

Complex abdominal aortic aneurysms (AAAs) have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. Hospital procedural volume to outcome relationship for OSR of complex AAAs has been well established, but the impact of procedural volume on FEVAR outcomes remains undefined. This study investigated the outcomes of OSR and FEVAR for the treatment of complex AAAs and examined the hospital volume-outcome relationship for these procedures.

Methods

A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012 and 2018 who underwent elective repair of a juxtarenal/pararenal AAA with FEVAR or OSR. The primary outcomes were 30-day mortality, myocardial infarction, and new dialysis. Secondary end points included postoperative pneumonia, renal dysfunction (creatine concentration increase of >2 mg/dL from preoperative baseline), major bleeding, early procedural complications, length of stay, and need for reintervention. To evaluate procedural volume-outcomes relationship, hospitals were stratified into low- and high-volume aortic centers based on a FEVAR annual procedural volume. To account for baseline differences, we calculated propensity scores and employed inverse probability of treatment weighting in comparing outcomes between treatment groups.

Results

A total of 589 patients underwent FEVAR (n = 186) or OSR (n = 403) for a complex AAA. After adjustment, OSR was associated with higher rates of 30-day mortality (10.7% vs 2.9%; P < .001) and need for dialysis (11.3% vs 1.8; P < .001). Postoperative pneumonia (6.8% vs 0.3%; P < .001) and need for transfusion (39.4% vs 10.4%; P < .001) were also significantly higher in the OSR cohort. The median length of stay for OSR and FEVAR was 9 days and 3 days, respectively. For those who underwent FEVAR, endoleaks were present in 12.1% of patients at 30 days and 6.1% of patients at 1 year, with the majority being type II. With a median follow-up period of 331 days (229-378 days), 1% of FEVAR patients required a secondary procedure, and there were no FEVAR conversions to an open aortic repair. Hospitals were divided into low- and high-volume aortic centers based on their annual FEVAR volume of complex AAAs. After adjustment, hospital FEVAR procedural volume was not associated with 30-day mortality or myocardial infarction.

Conclusions

FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Procedural FEVAR volume outcome analysis suggests limited differences in 30-day morbidity, although long-term durability warrants further research.

中文翻译：

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有孔修补术可改善围手术期结果，但与复杂腹主动脉瘤的医院容量缺乏相关性。

背景

复杂的腹主动脉瘤 (AAA) 传统上采用开放式手术修复 (OSR) 进行治疗。在过去十年中，有孔血管内动脉瘤修复术 (FEVAR) 已成为一种可行的选择。复杂 AAA 的 OSR 的医院手术量与结果的关系已经确立，但手术量对 FEVAR 结果的影响仍未确定。本研究调查了 OSR 和 FEVAR 治疗复杂 AAA 的结果，并检查了这些手术的医院容量-结果关系。

方法

对 2012 年至 2018 年间接受 FEVAR 或 OSR 肾旁/肾旁 AAA 选择性修复的所有患者进行了对全州血管外科登记处的回顾性审查。主要结果是 30 天死亡率、心肌梗塞和新透析。次要终点包括术后肺炎、肾功能不全（肌酸浓度比术前基线增加 > 2 mg/dL）、大出血、早期手术并发症、住院时间和再次干预的需要。为了评估手术量-结果的关系，根据 FEVAR 年度手术量将医院分为低容量和高容量主动脉中心。为了解释基线差异，我们计算了倾向评分，并在比较治疗组之间的结果时采用了治疗加权的逆概率。

结果

共有 589 名患者因复杂的 AAA 接受了 FEVAR（n = 186）或 OSR（n = 403）。调整后，OSR 与更高的 30 天死亡率（10.7% 对 2.9%；P  < .001）和透析需求（11.3% 对 1.8；P  < .001）相关。术后肺炎（6.8% 对 0.3%；P  < .001）和需要输血（39.4% 对 10.4%；P < .001) 在 OSR 队列中也显着更高。OSR 和 FEVAR 的中位住院时间分别为 9 天和 3 天。对于那些接受 FEVAR 的患者，30 天时 12.1% 的患者和 1 年时 6.1% 的患者存在内漏，其中大多数为 II 型。中位随访时间为 331 天（229-378 天），1% 的 FEVAR 患者需要二次手术，并且没有 FEVAR 转换为开放主动脉修复术。医院根据复杂 AAA 的年度 FEVAR 量分为低容量和高容量主动脉中心。调整后，医院 FEVAR 手术量与 30 天死亡率或心肌梗死无关。

结论

与 OSR 相比，FEVAR 与较低的围手术期发病率和死亡率相关，用于管理复杂的 AAA。程序 FEVAR 容量结果分析表明 30 天发病率的差异有限，但长期耐久性值得进一步研究。