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. 腹主动脉瘤（AAA）的最佳干预时间点依据临床表现和动脉瘤状态：破裂AAA需要急诊修复 有症状的未破裂AAA应尽早手术 无症状AAA可以在完善术前评估后择期手术治疗
2. AAA择期手术究竟腔内治疗还是开放手术应充分考虑以下几点后个体化选择：解剖学是否适合行EVAR手术 合并症和一般情况 预期寿命 对术后随访的依从性 患者个人倾向
3. 如果解剖学适合，破裂AAA的治疗首选EVAR（1C级证据），建议从急诊入院至干预（door-to-intervention）的时间不超过90分钟[1]。4. 当主动脉的解剖超出现有的商品化EVAR器械IFU时，或者预期寿命高于10-15年时，应当考虑开放手术[2]。5. 观察性研究显示相比开放手术，破裂AAA患者接受EVAR手术的早中期生存获益更明显，但是需要当心这是相关性而非因果关系[3]。6. 破裂AAA患者腔内治疗的围手术期生存获益尚未被RCT证实。7. 相比开放手术，AAA择期EVAR手术能够降低死亡率和并发症发生率，更快地康复。但是，远期再干预的发生率更高，且远期生存获益无明显差异[4]。8. 破裂AAA急救处理流程的有效实施能够降低30天死亡率，具体策略见下图[5]：9. 医疗卫生系统应当考虑建立一个破裂AAA急诊治疗的结构化、多学科、分级诊疗制度，如果没有转运禁忌症，应当快速转运至一个可行EVAR手术的医疗机构。
10. 目前，已有几个评分系统声称能够准确地预测破裂AAA的30天死亡率[6]。VSGNNE（VascularStudy Group of Northern New England）风险评估表在预测AAA择期EVAR术后院内死亡方面已经得到了外部验证。未来，VSGNNE风险评估表应作为术前常规，以促进病人为中心的沟通和共同决策，尤其是那些计算下来高死亡风险并且预期寿命较短的患者[7]。备注：本指南是SVS制定，适用于美国临床实践的操作指南，仅供参考，在具体临床工作中，仍需根据国内各家医院自身的情况，患者病情制定个体化的治疗方案。
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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