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英美两国腹主动脉瘤修复术阈值差异的比较
Thresholds for Abdominal Aortic Aneurysm Repair in England and the United States


Alan Karthikesalingam ... 心脑血管疾病 • 2016.11.24

英美腹主动脉瘤手术指征的比较研究述评


李伟†,孔炜‡*

† 北京大学人民医院血管外科;‡ 北京大学医学部生理与病理生理系

* 通讯作者

 

腹主动脉系统是人体大血管系统的重要部分,供应运输腹盆腔主要脏器和下肢的血液和营养。腹主动脉的异常病理性扩张被称为“瘤”样变(abdominal aortic aneurysm,AAA)。尽管AAA是有别于恶性肿瘤的良性病变,但却同样具有发病隐匿和破裂致死等临床特征。遗憾的是,AAA的危害在很长一段时间里一直为公众所忽视,多数AAA直到破裂才会被发现。据统计,动脉瘤破裂造成的死亡率占1.3%~3.8%1,24.3%~33.3%的静态AAA最终会因破裂而危及生命2。20世纪90年代,AAA已成为美国第13位、加拿大第10位的致死性疾病3,4。一系列证据表明,过去20余年里AAA的发病率和破裂率正呈逐年上升趋势。澳大利亚对本国65~85岁人群10年的AAA调研发现其发病率从4.0%升至7.2%5。在英国,20年中,女性和男性AAA患病率分别升高了12.1%和8.2%,女性人群的恶化趋势较男性更为显著6。瑞典学者在比较1971—1986年和2000—2004年本国破裂性AAA发病率的时候,发现后5年较前16年显著增加了2倍(5.6/10万人年对10.5/10万人年),其中>60岁男性人群增速甚至高达3倍之多7

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摘要


背景

在不同国家间,腹主动脉瘤修复术的阈值差异相当大。

 

方法

我们调查了英国与美国在动脉瘤修复术频率、手术时动脉瘤平均直径、动脉瘤破裂率以及动脉瘤相关死亡率之间的差异。2005—2012年完整(未破裂)腹主动脉瘤修复术频率、已接受动脉瘤修复术的患者院内死亡率以及动脉瘤破裂率的数据取自英国医院发病统计数据库(Hospital Episode Statistics database in England)和美国全国住院患者样本库(U.S. Nationwide Inpatient Sample)。行修复术时动脉瘤直径数据取自英国全国血管病登记数据库(U.K. National Vascular Registry;2014年数据)及美国国家外科质量改进计划(U.S. National Surgical Quality Improvement Program;2013年数据)。2005—2012年的动脉瘤相关死亡率由从美国疾病控制和预防中心(Centers for Disease Control and Prevention,CDC)及英国国家统计局(U.K. Office of National Statistics)获得的数据确定。通过运用直接标准化或条件化逻辑回归,针对英美两国间关于人口年龄及性别的差异对数据进行了校正。

 

结果

2005—2012年,共有29,300名英国患者及278,921名美国患者接受了完整腹主动脉瘤修复术。与在美国相比,动脉瘤修复术在英国较少见(比值比为0.49;95%可信区间[CI]为0.48~0.49;P<0.001),而动脉瘤相关死亡在英国较普遍(比值比为3.60;95% CI为3.55~3.64;P<0.001)。在英国,由动脉瘤破裂引起的住院较为频繁(比值比为2.23;95% CI为2.19~2.27;P<0.001),行修复术时动脉瘤平均直径也较大(63.7 mm对58.3 mm,P<0.001)。

 

结论

我们发现,在英国进行的腹主动脉瘤修复率比在美国低,手术时动脉瘤平均直径比在美国高。而在美国,动脉瘤破裂率及动脉瘤相关死亡率都比在英国低(本研究由血液循环基金会[Circulation Foundation]等资助)。





作者信息

Alan Karthikesalingam, Ph.D., M.R.C.S., Alberto Vidal-Diez, Ph.D., Peter J. Holt, Ph.D., F.R.C.S., Ian M. Loftus, M.D.(Res.), F.R.C.S., Marc L. Schermerhorn, M.D., Peter A. Soden, M.D., Bruce E. Landon, M.D., and Matthew M. Thompson, M.D.(Res.), F.R.C.S.
From St. George’s Vascular Institute, St. George’s University of London, London (A.K., A.V.-D., P.J.H., I.M.L., M.M.T.); and the Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School (M.L.S., P.A.S.), and the Department of Health Care Policy, Harvard Medical School (B.E.L.) — both in Boston. Address reprint requests to Dr. Karthikesalingam at St. George’s Vascular Institute, Rm. 0.231, St. George’s University of London, Cranmer Ter., London SW17 0RE, United Kingdom, or at alankarthi@gmail.com.

 

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