複雑な血管内大動脈瘤修復における術者数と技術的成功およびその後の転帰への影響

Although complex endovascular repairs are becoming increasingly common, complication rates are less well studied, and published rates of technical success vary widely. In addition, whether high volume surgeons are more able to rescue intra-operative complications has not been well studied.

This study analysed all complex abdominal aortic aneurysm (AAA) repairs in the Vascular Quality Initiative from 2014 to 2023. Multilevel logistic regression with inverse probability weighting was used to identify factors associated with lack of technical success (defined as successful introduction of the main graft, incorporation of all target vessels without occlusion or stenosis > 50%, and no type I/III endoleaks). Secondary analyses assessed the differential impact of type I/III endoleaks compared with graft/target vessel complications.

There were 6 556 repairs (3 246 para/juxtarenal AAAs and 3 310 thoraco-abdominal aortic aneurysms) with an overall technical success rate of 82.7%; technical failures were due to type I/III endoleak in 9.6%, target vessel complications in 5.6%, and complications with the main body in 4.0%. Technical success increased in concert with volume in crude and adjusted analyses. Technical failure was associated with a markedly higher adjusted odds of peri-operative death, thoraco-abdominal life altering events, acute kidney injury, dialysis, spinal cord ischaemia, and re-operation. Repairs with technical failure at the hands of higher volume surgeons were less likely to experience death than cases of technical failure in the hands of lower volume surgeons (p < .01 for interaction). Technical success was similarly associated with higher 5 year survival (86% vs. 65%; p < .001). Both type I/III endoleaks and branch/main body complications were associated with worse peri-operative outcomes and lower 5 year survival. Although type I/III endoleaks had less impact than branch/main body complications in elective settings, in symptomatic/ruptured settings.

Technical success had a strong association with outcomes of endovascular complex AAA repair, especially in non-elective settings. Higher volume surgeons had higher rates of technical success, and their outcomes were less negatively impacted by technical failures, suggesting a potential benefit to centralising more urgent and complex cases.