Abdominal Aort Anevrizmalarına Yönelik Uygulanan Endovasküler Aort Tamiri Sonrası Mortalite ve Morbiditeye Etki Eden Faktörler

Amaç: Endovasküler aort tamiri (EVAT) abdominal aort anevrizmalarında artan bir oranda cerrahi seçenek olarak uygyulanmaktadır. Minimal invazif bir prosedür olan EVAT işlemi sonrası mortalite ve morbiditeye etki eden faktörleri araştırdık. Gereç ve Yöntemler: Eylül 2014 ile Ocak 2019 yılları arasında toplam 96 (91 E, 5 K) elektif EVAT uygulanmış hastalar çalışmaya dahil edildi. Ameliyat öncesi ve sonrası bilgisayarlı tomografi görüntüleri incelendi ve rutin kontroller ile takip edildi. Demografik faktörler, anevrizmanın anatomik özellikleri ve diğer risk faktörleri incelendi. Kaplan-Meier sağkalım analizi yapıldı. Cox regresyon analizi ile risk faktörlerinin mortalite ve morbiditedeki artış riski hesaplandı ve HR(hazard ratio) olarak değer belirtildi. Bulgular: Ortalama takip süresi 27,45 ± 12,99 aydı. Aort boyun morfolojisin istatistiksel anlamlı olarak mortalite üzerine etkili olduğu görüldü (p değeri:0.046). Aort boyun açısı, sigara, perifer arter hastalığı(PAH), koroner arter hastalığı, kronik obstrüktif akciğer hastalığının bulunmasıyla mortalite üzerinde zarar görme riskinin yükseldiği görüldü (HR sırasıyla: 1,39; 1,45; 3,33; 1,84; 1,87; 3,60). Artmış kreatinin seviyesi (p değeri:0.003), kronik böbrek yetmezliği(p değeri:0.013), şeker hastalığı (p değeri: 0.038)’nın morbidite üzerinde istatistiksel olarak anlamlı olumsuz etkisi olduğu görüldü. Obezite ve PAH’nın morbidite üzerine zarar verme riskinin arttığı görüldü ( HR sırasıyla: 4,58; 1,61). Sonuç: Bu çalışma bize hayatta kalımın ve morbiditenin EVAT sonrası, ameliyat öncesi ve sonrası faktörlerden etkilendiğini gösterdi. EVAT işlemi öncesi anevrizmanın anatomik özelliklerinin ayrıntılı değerlendirilmesinin işlemden en iyi oranda fayda görülmesi açısından önemlidir.

Anahtar Kelimeler:

Endovasküler aort tamiri, endovasküler anevrizma onarımı, abdominal aort anevrizması, mortalite, morbidite, EVAT

Factors Affecting Mortality and Morbidity After Endovascular Aortic Repair for Abdominal Aortic Aneurysms

Objective: Endovascular aortic repair (EVAR) has been preferred increasingly surgical repair for abdominal aortic aneurysms (AAAs). This minimally invasive procedure has favorable effects in the early period but our purpose is to reveal the anatomical and non-anatomical risk factors affecting mortality and morbidity after EVAR in the prolonged period.Materials and Methods: A total of 96 patients ( 91m, 5 f) electively EVAR operated for infrarenal AAAs between September 2014 to January 2019 is included to the study. Preoperative and postoperative computed tomography (CT) scans is controlled periodly and determined individually. Demographic factors, anatomical properties of the AAAs and non-anatomical risk factors are assessed. Kaplan-Meier survival analysis was used to determine survival rates. Cox regression and hazard ratio (HR) was used to assess the relation of these determined factors on mortality and morbidity.Results: Mean follow up time was 27,45 ± 12,99 months. We found that aortic neck morphology has an statistically significant effect on mortality (p value: 0.046 and HR: 1,73 [ 1,01-2,96]). Aortic neck angle, cigarette smoking, obesity, Peripheral artery disease(PAD), coronary artery disease, chronic obstructive pulmonary disease have an increased hazard ratio on mortality ( HR in order; 1,39; 1,45; 3,33; 1,84; 1,87; 3,60). Increased creatinine level (p value: 0.003), precence of chronic renal failure (p value: 0.013)and diabetes mellitus (p value: 0.038) have an statistically significant negative effect on morbidity. Obesity and PAD have an increased hazard ratio on morbidity(HR in order; 4,58; 1,61). Conclusion: This study showed us survival after EVAR procedure is connected with several pre and postoperative factors. Preoperative datailed evaluation for the anatomical properties of aneurysm is important to achieve prolonged benefit and postoperative follow up is crucial.

Keywords:

Endovascular aortic repair, endovascular aneurysm repair, abdominal aortic aneurysm, EVAR, mortality, morbidity,

PDF

___

1. Moll FL, PowellJT, Fraedrich G, Verzini F, Haulon S, Waltham M et al. Management of abdominal aortic aneurysms practice guidelines of the european society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41: 1-58.
2. Wang L, Djousse L, Song Y, Akinkuolie AO, Matsumoto C, Manson JE, Sesso HD. Associations of diabetes and obesity with risk of abdominal aortic aneurysm in men. Journal of Obesity 2017; 2017: 1-11 https://doi.org/10.1155/2017/3521649.
3. Stather PW, Sidloff DA, Rhema IA, Choke E, Bown MJ, Sayers RD. A review of current reporting of abdominal aortic aneurysm mortality and prevalence in the literature. Eur J Vasc Endovasc Surg 2014; 47(3): 240-242.
4. Kühnl A, Erk A, Trenner M, Salvermoser M, Schmid V, Eckstein HH. Incidence, treatment and mortality in patients with abdominal aortic aneurysms— an analysis of hospital discharge data from 2005–2014. Dtsch Arztebl Int 2017; 114: 391–8.
5. Lee YTM. Historical Development of Modern Surgery in America. Advances in Historical Studies 2016; 5(04): 168-182.
6. Turkish Statistical Institutes report of 2018-2080 population projections http://www.tuik.gov.tr/PreTablo.do?alt_id=1027.
7. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 1991; 5(6): 491-9.
8. Lederle FA, Kane RL, MacDonald R, Wilt TJ. Systematic review: repair of unruptured abdominal aortic aneurysm. Annals of Internal Medicine 2007; 146(10): 735-741.
9. Chaikof EL, Fillinger MF, Matsumura JS, Rutherford RB, White GH, Blankensteijn JD, et al. Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair. J Vasc Surg 2002; 35(5): 1061-1066.
10. Akbulut M, Aksoy E, Kara İ, Çelik EC, Rabuş MB, Çekmecelioğlu D et al. Comparison of short-and mid-term results of open surgery versus endovascular stent graft repair of abdominal aortic aneurysms. Turkish Journal of Vascular Surgery 2017; 26(1): 5-11.
11. Khasram M, Jenkins JS, Jenkins J, Kruger AJ, Boyne NS, Foster WJ et al. Long-term outcomes and factors influencing late survival following elective abdominal aortic aneurysm repair: A 24 –year experience. Vascular 2016; 24(2): 115-25.
12. Boult M, Maddern G, Barnes M, Fitridge R. Factors affecting survival after endovascular aneurysm repair: Results from a population based audit. Eur J Endovasc Surg 2007; 34: 156-162.
13. De Bruin JL, Baas AF, Heymans MW, Buimer MG, Prinssen M, Grobbee DE et al. DREAM Study Group. Statin therapy is associated with improved survival after endovascular and open aneurysm repair. J Vasc Surg 2014;59: 39-44
14. Guilherme MR, Jose OP, Armando M. Predictors of long-term mortality following elective endovascular repair of abdominal aortic aneurysms. International Angiology 2018; 37(4 ): 277-285.
15. Stackelberg O, Björck M, Sadr‐Azodi O, Larsson SC, Orsini N, Wolk A. Obesity and abdominal aortic aneurysm. British Journal of Surgery 2013;100(3), 360-366.
16. Cronin O, Walker PJ, Golledge J. The association of obesity with abdominal aortic aneurysm presence and growth. Atherosclerosis 2013; 226(2), 321-327.
17. Meijer CA, Kokje VB, van Tongeren RBM, Hamming JF, van Bockel JH, Möller GM et al. An association between chronic obstructive pulmonary disease and abdominal aortic aneurysm beyond smoking: results from a case-control study. Eur J Vasc Endovasc Surg 2012; 44:153–7.
18. Xiong J, Wu Z, Chen C, Guo W. Chronic obstructive pulmonary disease effect on the prevalence and postoperative outcome of abdominal aortic aneurysms: A meta-analysis. Sci Rep 2016; 6, 25003: 1-12, doi:10.1038/srep25003.
19. Liao KM, Chen CY. Impact of chronic obstructive pulmonary disease on patients with aortic aneurysms: a nationwide retrospective cohort study in Taiwan. BMJ Open 2017; Sep 3; 7(9) e015806. doi: 10.1136/bmjopen-2016-015806.
20. Takagi H, Umemoto T. Smoking promotes pathogenesis of aortic aneurysm through the 5-lipoxygenase pathway. Med. Hypotheses 2005; 64: 1117–1119.
21. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillence: UK Small aneurysm Trial Participants Ann Surg 1999; 230: 289-296
22. Koole D, Moll FL, Buth J, Hobo R, Zandvoort H, Pasterkamp G et al. The influence of smoking on endovascular abdominal aortic aneurysm repair. J Vasc Surg 2012; 55(6): 1581-1586.
23. De Rango P, Farchioni L, Fiorucci B, Lenti M. Diabetes and abdominal aortic aneurysms. Eur J Vasc and Endovasc Surg 2014; 47(3): 243-261.
24. Komshian S, Farber A, Patel VI, Goodney PP, Schermerhorn ML, Blazick EA et al. Patients with end-stage renal disease have poor outcomes after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2019; 69(2): 405-13.
25. Azizzadeh A, Sanchez LA, Miller CC, Marine L, Rubin BG, Safi HJ et al. Glomerular filtration rate is a predictor of mortality after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2006; 43(1): 14-18.
26. Boult M, Babidge W, Maddern G, Barnes M, Fitridge R on behalf of the Audit Reference Group Predictors of success following endovascular aneurysm repair: mid-term results. Eur J Vasc Endovasc Surg 2006; 31: 123-129.
27. Peppelenbosch N, Buth J, Harris PL, Marrenwijk Cv, Fransen G, for the EUROSTAR Collaborators Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: Does size matter ? A report from EUROSTAR. J Vasc Surg 2004; 39: 288-97.
28. Jim J, Rubin BG, Geraghty PJ, Criado FJ, Sanchez LA. Outcome of endovascular repair of small and large abdominal aortic aneurysms. Ann Vasc Surg 2011; 25: 306-14.
29. Antoniou GA, Georgiadis GS, Antoniou SA, Kuhan G, Murray D. A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy. J Vasc Surg 2013; 57(2): 527-538.
30. Leurs LJ, Kievit J, Dagnelie PC, Nelemans PJ, Buth J. Influence of infrarenal neck length on outcome of endovascular abdominal aortic aneurysm repair. Journal of Endovascular Therapy 2006; 13(5): 640-648.
31. Hobo R, Kievit J, Leurs LJ, Buth J. Influence of severe infrarenal aortic neck angulation on complications at the proximal neck following endovascular AAA repair: a EUROSTAR study. Journal of Endovascular Therapy 2007; 14(1): 1-11.
32. Albertini JN, Kalliafas S, Travis S, Yusuf SW, Macierewicz JA, Whitaker SC et al. Anatomical risk factors for proximal perigraft endoleak and graft migration following endovascular repair of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2000; 19: 308-312.