Operative times and outcomes of complex endovascular repairs of thoracoabdominal aneurysms.

IF 3.9 2区 医学 Q1 PERIPHERAL VASCULAR DISEASE Journal of Vascular Surgery Pub Date : 2024-10-22 DOI:10.1016/j.jvs.2024.10.021
Ariela Zenilman, Tomaz Mesar, Virendra I Patel, Kirsten D Dansey, Marc Schermerhorn, Sara L Zettervall, Adam W Beck, Karan L Garg, Hiroo Takayama, Thomas F X O'Donnell
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Abstract

Background: Owing to the significant morbidity and mortality of open thoracoabdominal aortic aneurysm surgery, complex endovascular repairs have become increasingly common, but still carry substantial risk. These repairs require large-bore access, with resultant pelvic and lower extremity ischemia. We, therefore, hypothesized that operative timing would be associated with outcomes, because efficient surgery would limit the ischemic time as well as anesthesia time.

Methods: We studied all thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs (Crawford types 1, 2, 3, and 5) incorporating at least one branch vessel from 2014 to 2021 in the Vascular Quality Initiative and categorized them into quartiles of total operating time. To account for variations in case complexity and intraoperative events, we performed a subanalysis stratifying each surgeon by their median operating time. Multilevel logistic regression was used to compare perioperative outcomes including mortality, thoracoabdominal life-altering events (a composite of perioperative death, stroke, permanent paralysis and/or dialysis), spinal cord ischemia (SCI), acute kidney injury, major adverse cardiac events, myocardial infarction, and dialysis.

Results: There were 2925 thoracoabdominal aortic aneurysm surgery with complex endovascular repairs during the study period. Procedure times ranged from <204 minutes in the first quartile to >365 minutes in the fourth. Longer cases more commonly involved older patients who were more often female and higher rates of prior stroke and preoperative anemia. They involved larger, more extensive aneurysms, with higher rates of prior aortic surgery, and more commonly used physician-modified endografts or parallel grafting to incorporate more branch vessels. In addition, they were less often staged procedures, and used more spinal drains, femoral cutdowns, and upper extremity access. Operating time decreased as experience increased. In adjusted analyses, the odds of mortality and every morbidity studied increased stepwise with operating time, with 4- to 13-fold higher odds in the highest quartiles. SCI had the strongest association with procedure times, with seven-fold higher odds (odds ratio, 7.2; 95% confidence interval, 2.9-17.9; P < .001) of any SCI in the highest quartile compared to the lowest, and 13-fold higher odds of permanent SCI (OR, 13.1; 95% confidence interval, 3.9-44.7; P < .001). These results were consistent when surgeons were grouped into quartiles by their median operating times. Medium-term mortality was also higher in the upper quartile of operating time (hazard ratio, 2.7; 95% confidence interval, 1.4-5.1; P = .002).

Conclusions: Longer operating times for complex thoracoabdominal aortic aneurysm surgerywith complex endovascular repairs were associated with markedly higher rates of morbidity and mortality, especially SCI. These results emphasize the importance of expeditious repairs by experienced teams.

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复杂的胸腹动脉瘤血管内修复术的手术时间和效果。
导言:由于开胸腹主动脉瘤手术的发病率和死亡率较高,复杂的血管内修复术(eTAAA)变得越来越普遍,但仍有很大风险。这些修复手术需要大口径入路,会导致骨盆和下肢缺血。因此,我们假设手术时机与手术效果有关,因为高效的手术将限制缺血时间和麻醉时间:我们研究了血管质量倡议(Vascular Quality Initiative)从 2014 年到 2021 年所有至少包含一条分支血管的 eTAAA 修复术(克劳福德 1-3 型和 5 型),并将其归入总手术时间的四分位数。为了考虑病例复杂性和术中事件的差异,我们对每位外科医生的手术时间中位数进行了分层分析。采用多层次逻辑回归比较围手术期结果,包括死亡率、胸腹部生命改变事件(TALE:围手术期死亡、中风、永久性瘫痪和/或透析的复合结果)、脊髓缺血(SCI)、急性肾损伤(AKI)、主要心脏不良事件(MACE)、心肌梗死和透析:研究期间共进行了 2,925 例 eTAAA 修复。第四次手术时间为 365 分钟。手术时间较长的病例通常涉及年龄较大的患者,这些患者多为女性,曾患中风和术前贫血的比例较高。这些病例涉及的动脉瘤更大、范围更广,之前接受过主动脉手术的比例更高,而且更常采用 PMEG 或平行移植术来合并更多分支血管。此外,这些手术较少分期进行,使用更多椎管引流、股骨切开和上肢入路。手术时间随着经验的增加而缩短。在调整后的分析中,随着手术时间的延长,死亡率和各种发病率的几率都在逐步上升,最高的四分位数的几率要高出4到13倍。脊髓缺血与手术时间的关系最为密切,几率高出7倍(OR 7.2 [2.9-17.9],PC结论:复杂 eTAAA 修复手术的手术时间越长,发病率和死亡率就越高,尤其是脊髓缺血。这些结果强调了由经验丰富的团队进行快速修复的重要性。
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来源期刊
CiteScore
7.70
自引率
18.60%
发文量
1469
审稿时长
54 days
期刊介绍: Journal of Vascular Surgery ® aims to be the premier international journal of medical, endovascular and surgical care of vascular diseases. It is dedicated to the science and art of vascular surgery and aims to improve the management of patients with vascular diseases by publishing relevant papers that report important medical advances, test new hypotheses, and address current controversies. To acheive this goal, the Journal will publish original clinical and laboratory studies, and reports and papers that comment on the social, economic, ethical, legal, and political factors, which relate to these aims. As the official publication of The Society for Vascular Surgery, the Journal will publish, after peer review, selected papers presented at the annual meeting of this organization and affiliated vascular societies, as well as original articles from members and non-members.
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