Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm
Rae S. Rokosh, Benjamin W. Starnes, andElliot L. Chaikof1. 腹主動(dòng)脈瘤（AAA）的最佳干預(yù)時(shí)間點(diǎn)依據(jù)臨床表現(xiàn)和動(dòng)脈瘤狀態(tài)：2. AAA擇期手術(shù)究竟腔內(nèi)治療還是開放手術(shù)應(yīng)充分考慮以下幾點(diǎn)后個(gè)體化選擇：解剖學(xué)是否適合行EVAR手術(shù) 合并癥和一般情況 預(yù)期壽命 對(duì)術(shù)后隨訪的依從性 患者個(gè)人傾向
3. 如果解剖學(xué)適合，破裂AAA的治療首選EVAR（1C級(jí)證據(jù)），建議從急診入院至干預(yù)（door-to-intervention）的時(shí)間不超過90分鐘[1]。4. 當(dāng)主動(dòng)脈的解剖超出現(xiàn)有的商品化EVAR器械IFU時(shí)，或者預(yù)期壽命高于10-15年時(shí)，應(yīng)當(dāng)考慮開放手術(shù)[2]。5. 觀察性研究顯示相比開放手術(shù)，破裂AAA患者接受EVAR手術(shù)的早中期生存獲益更明顯，但是需要當(dāng)心這是相關(guān)性而非因果關(guān)系[3]。6. 破裂AAA患者腔內(nèi)治療的圍手術(shù)期生存獲益尚未被RCT證實(shí)。7. 相比開放手術(shù)，AAA擇期EVAR手術(shù)能夠降低死亡率和并發(fā)癥發(fā)生率，更快地康復(fù)。但是，遠(yuǎn)期再干預(yù)的發(fā)生率更高，且遠(yuǎn)期生存獲益無明顯差異[4]。8. 破裂AAA急救處理流程的有效實(shí)施能夠降低30天死亡率，具體策略見下圖[5]：9. 醫(yī)療衛(wèi)生系統(tǒng)應(yīng)當(dāng)考慮建立一個(gè)破裂AAA急診治療的結(jié)構(gòu)化、多學(xué)科、分級(jí)診療制度，如果沒有轉(zhuǎn)運(yùn)禁忌癥，應(yīng)當(dāng)快速轉(zhuǎn)運(yùn)至一個(gè)可行EVAR手術(shù)的醫(yī)療機(jī)構(gòu)。
10. 目前，已有幾個(gè)評(píng)分系統(tǒng)聲稱能夠準(zhǔn)確地預(yù)測(cè)破裂AAA的30天死亡率[6]。VSGNNE（VascularStudy Group of Northern New England）風(fēng)險(xiǎn)評(píng)估表在預(yù)測(cè)AAA擇期EVAR術(shù)后院內(nèi)死亡方面已經(jīng)得到了外部驗(yàn)證。未來，VSGNNE風(fēng)險(xiǎn)評(píng)估表應(yīng)作為術(shù)前常規(guī)，以促進(jìn)病人為中心的溝通和共同決策，尤其是那些計(jì)算下來高死亡風(fēng)險(xiǎn)并且預(yù)期壽命較短的患者[7]。備注：本指南是SVS制定，適用于美國(guó)臨床實(shí)踐的操作指南，僅供參考，在具體臨床工作中，仍需根據(jù)國(guó)內(nèi)各家醫(yī)院自身的情況，患者病情制定個(gè)體化的治療方案。
1. Chaikof EL, Dalman RL, Eskandari MK,Jackson BM, Lee WA, Mansour MA, et al. The Society for Vascular Surgerypractice guidelines on the care of patients with an abdominal aortic aneurysm.J Vasc Surg 2018;67:2-77.e72.2. Patel R, Sweeting MJ, Powell JT,Greenhalgh RM; EVAR trial investigators. Endovascular versus open repair ofabdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysmrepair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet2016;388:2366-74.3. Wang LJ, Locham S, Al-Nouri O, EagletonMJ, Clouse WD, Malas MB. Endovascular repair of ruptured abdominal aortic aneurysmis superior to open repair: propensity-matched analysis in the Vascular QualityInitiative. J Vasc Surg 2020;72: 498-507.4. Paravastu SC, Jayarajasingam R, CottamR, Palfreyman SJ, Michaels JA, Thomas SM. Endovascular repair of abdominal aorticaneurysm. Cochrane Database Syst Rev 2014: CD004178.5. Starnes BW, Quiroga E, Hutter C, TranNT, Hatsukami T, Meissner M, et al. Management of ruptured abdominal aortic aneurysmin the endovascular era. J Vasc Surg 2010;51:9-17.6. Hansen SK, Danaher PJ, Starnes BW,Hollis HW Jr, Garland BT. Accuracy evaluations of three ruptured abdominalaortic aneurysm mortality risk scores using an independent dataset. J Vasc Surg2019;70:67-73.7. Eslami MH, Rybin DV, Doros G, SiracuseJJ, Farber A. External validation of Vascular Study Group of New England riskpredictive model of mortality after elective abdominal aorta aneurysm repair inthe Vascular Quality Initiative and comparison against establishedmodels. JVasc Surg 2018;67:143-50.
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