Endovascular Repair of Abdominal Aortic Aneurysm
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《新英格兰医药杂志》
To the Editor: The long-term prognosis after successful repair of an abdominal aortic aneurysm is related to the presence and extent of underlying coronary artery disease.1 Blankensteijn et al. (June 9 issue)2 showed that the favorable response to endovascular repair, as compared with open surgery, at 30 days dissipated after one year.
We analyzed 396 patients with an abdominal aortic aneurysm (57 who had undergone endovascular repair and 339 who had undergone open repair) for long-term prognosis with regard to the presence or absence and the extent of coronary artery disease (Figure 1), as assessed by the number of stress-induced ischemic wall-motion abnormalities determined with the use of a 16-segment model during dobutamine echocardiography. During a median follow-up of 2.8 years, 74 deaths from cardiac causes and 109 myocardial infarctions occurred. Multivariate Cox regression analysis, correcting for the type of surgery and cardiac risk factors (age and the presence or absence of angina, myocardial infarction, diabetes, heart failure, and stroke) showed that prognosis was related to the presence of ischemic wall-motion abnormalities (hazard ratio, 2.54; 95 percent confidence interval, 1.70 to 3.79) and to the increasing extent of such abnormalities (hazard ratio, 3.37; 95 percent confidence interval, 2.11 to 5.40), whereas the type of aneurysm repair was not related to long-term survival (hazard ratio, 0.82; 95 percent confidence interval, 0.45 to 1.50).
Figure 1. Long-Term Prognosis after Repair of Abdominal Aortic Aneurysm, According to the Presence or Absence of Coronary Artery Disease.
Among 396 patients with an abdominal aortic aneurysm, the preoperative presence of stress-induced myocardial ischemia during dobutamine echocardiography was associated with a worse long-term prognosis (P<0.001).
Since the long-term outcome after successful repair of an abdominal aortic aneurysm is related to underlying coronary artery disease, aggressive treatment is of critical importance.3
Olaf Schouten, M.D.
Erasmus Medical Center Rotterdam
3015 GD Rotterdam, the Netherlands
Jeroen J. Bax, M.D., Ph.D.
Leiden University Medical Center
2300 RC Leiden, the Netherlands
Don Poldermans, M.D., Ph.D.
Erasmus Medical Center Rotterdam
3015 GD Rotterdam, the Netherlands
d.poldermans@erasmusmc.nl
References
The United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002;346:1445-1452.
Blankensteijn JD, de Jong SECA, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005;352:2398-2405.
Kertai MD, Boersma E, Westerhout CM, et al. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004;116:96-103.
The authors reply: Dr. Schouten and colleagues present results from an observational study that, at first glance, appears to support our findings. We agree that the prognosis of patients undergoing either method of surgical repair of an abdominal aortic aneurysm is materially affected by their preexisting cardiac risk. However, the findings presented by Dr. Schouten and colleagues do not explain the differential death rates we observed in our randomized trial after the first postoperative month among patients who had undergone either open or endovascular repair. The inference that the method of surgery had no effect on outcome is problematic in nonrandomized comparisons, since the results may suffer from selection bias caused by the outcome of, for example, preoperative dobutamine echocardiography. More extensive ischemic wall-motion abnormalities may have led to the preferential use of endovascular repair. In our study, all patients were suitable for both treatments. Multivariate analysis cannot fully correct for all potential confounders. However, we do agree with Dr. Schouten and colleagues that treatment of coronary artery disease and aggressive management of risk factors are of the utmost importance in the attempt to maintain a potential small survival benefit of less invasive surgery.
Jan D. Blankensteijn, M.D.
Radboud University Nijmegen Medical Center
6500 HB Nijmegen, the Netherlands
j.blankensteijn@chir.umcn.nl
Diederick E. Grobbee, M.D.
University Medical Center, Utrecht
3508 GA Utrecht, the Netherlands
We analyzed 396 patients with an abdominal aortic aneurysm (57 who had undergone endovascular repair and 339 who had undergone open repair) for long-term prognosis with regard to the presence or absence and the extent of coronary artery disease (Figure 1), as assessed by the number of stress-induced ischemic wall-motion abnormalities determined with the use of a 16-segment model during dobutamine echocardiography. During a median follow-up of 2.8 years, 74 deaths from cardiac causes and 109 myocardial infarctions occurred. Multivariate Cox regression analysis, correcting for the type of surgery and cardiac risk factors (age and the presence or absence of angina, myocardial infarction, diabetes, heart failure, and stroke) showed that prognosis was related to the presence of ischemic wall-motion abnormalities (hazard ratio, 2.54; 95 percent confidence interval, 1.70 to 3.79) and to the increasing extent of such abnormalities (hazard ratio, 3.37; 95 percent confidence interval, 2.11 to 5.40), whereas the type of aneurysm repair was not related to long-term survival (hazard ratio, 0.82; 95 percent confidence interval, 0.45 to 1.50).
Figure 1. Long-Term Prognosis after Repair of Abdominal Aortic Aneurysm, According to the Presence or Absence of Coronary Artery Disease.
Among 396 patients with an abdominal aortic aneurysm, the preoperative presence of stress-induced myocardial ischemia during dobutamine echocardiography was associated with a worse long-term prognosis (P<0.001).
Since the long-term outcome after successful repair of an abdominal aortic aneurysm is related to underlying coronary artery disease, aggressive treatment is of critical importance.3
Olaf Schouten, M.D.
Erasmus Medical Center Rotterdam
3015 GD Rotterdam, the Netherlands
Jeroen J. Bax, M.D., Ph.D.
Leiden University Medical Center
2300 RC Leiden, the Netherlands
Don Poldermans, M.D., Ph.D.
Erasmus Medical Center Rotterdam
3015 GD Rotterdam, the Netherlands
d.poldermans@erasmusmc.nl
References
The United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002;346:1445-1452.
Blankensteijn JD, de Jong SECA, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005;352:2398-2405.
Kertai MD, Boersma E, Westerhout CM, et al. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004;116:96-103.
The authors reply: Dr. Schouten and colleagues present results from an observational study that, at first glance, appears to support our findings. We agree that the prognosis of patients undergoing either method of surgical repair of an abdominal aortic aneurysm is materially affected by their preexisting cardiac risk. However, the findings presented by Dr. Schouten and colleagues do not explain the differential death rates we observed in our randomized trial after the first postoperative month among patients who had undergone either open or endovascular repair. The inference that the method of surgery had no effect on outcome is problematic in nonrandomized comparisons, since the results may suffer from selection bias caused by the outcome of, for example, preoperative dobutamine echocardiography. More extensive ischemic wall-motion abnormalities may have led to the preferential use of endovascular repair. In our study, all patients were suitable for both treatments. Multivariate analysis cannot fully correct for all potential confounders. However, we do agree with Dr. Schouten and colleagues that treatment of coronary artery disease and aggressive management of risk factors are of the utmost importance in the attempt to maintain a potential small survival benefit of less invasive surgery.
Jan D. Blankensteijn, M.D.
Radboud University Nijmegen Medical Center
6500 HB Nijmegen, the Netherlands
j.blankensteijn@chir.umcn.nl
Diederick E. Grobbee, M.D.
University Medical Center, Utrecht
3508 GA Utrecht, the Netherlands