腔内修复完全替代开放手术救治破裂腹主动脉瘤:单中心7年经验总结

摘要

Objective To evaluate the safety and effectiveness of endovascular aortic repair (EVAR) used in ruptured abdominal aortic aneurysm ( AAA ) , and to discuss the possibility for replacement of the traditional open surgery with EVAR in this disease. Methods Cases of EVAR on noninfected ruptured AAA over recent 7-year period were reviewed, in which the treatment strategies evolved from "EVAR/OPEN"approach (2009.1～2014.3) to "EVAR-PRIMARY" approach (2014.4～2016.7) were compared. Results Over this 7 years, 80 patients with truly-ruptured AAA were admitted in the emergency room of Zhongshan hospital from March 2009 to July 2016, among which 27 (33.8％) died preoperatively. Twenty six cases ( 15 EVARs and 11 OPENs ) were treated during "EVAR/OPEN" period , and thereafter during the "EVAR-PRIMARY" period all the 27 cases were treated by EVAR. The 30-day mortality rate was 26.9％ ( 26 . 7％for EVAR and 27 . 3％ for OPEN ) for the "EVAR/OPEN" period and 25 . 9％ for the "EVAR-PRIMARY" period (P=0.93). For all patients , preoperative hemodynamic stability (OR=0.22,95％CI 0.06～0.85,P=0.03) w as found associated with lower mortality rate. As for EVAR patients, local anesthesia (OR=0.18,95％CI 0.04～0.82,P=0.03) were found associated with lower mortality rate, comparing with general anesthesia. However, any association between hemodynamic status and the prognosis in both procedures were not found. Conclusions The "EVAR-PRIMARY" approach has allowed EVAR to be used in nearly all the ruptured AAA with similar mortality comparing with "EVAR/OPEN"approach.%目的 分析腹主动脉腔内修复术(EVAR)在破裂腹主动脉瘤中应用的安全性和有效性,探讨其是否可以有效替代传统开放手术进行破裂腹主动脉瘤的救治.方法 回顾性分析复旦大学附属中山医院血管外科2009年1月至2016年7月手术治疗的真性破裂腹主动脉瘤的临床资料,对比分析"选择性EVAR"时期(2009年1月至2014年3月)与"EVAR首选"时期(2014年4月至2016年7月)两种治疗策略的术后30 d死亡率情况.结果 排除症状性或先兆破裂性腹主动脉瘤、 肾上型腹主动脉瘤、CrawfordⅠ～Ⅳ型胸腹主动脉瘤破裂、EVAR术后破裂患者,本研究入组80例真性破裂腹主动脉瘤病例,其中27例(33.8％)在术前死亡.在"选择性EVAR"时期,26例(15例EVAR和11例开放手术)接受手术;而在"EVAR首选"时期,27例全部使用EVAR进行治疗."选择性EVAR"时期,开放手术及EVAR后30 d死亡率分别为27.3％(3/11)和26.7％(4/15)(P=0.94);"EVAR首选"时期术后30 d死亡率为25.9％(7/27),两个时期的术后30 d死亡率比较,差异无统计学意义(P=0.93).术前血流动力学稳定(OR=0.22,95％CI 0.06～0.85,P=0.03)及使用局部麻醉(OR=0.18,95％CI 0.04～0.82,P=0.03)采用EVAR治疗的患者的死亡率更低,然而不同术式在不同术前血流动力学状态患者中对死亡率的影响无统计学意义.结论 基于所在中心平诊手术经验的"EVAR首选"策略可以有效地用于几乎所有破裂腹主动脉瘤的急诊救治,并获得与"选择性EVAR"策略一致的疗效.