BMJ:腹主动脉瘤破裂患者血管内修复与开胸修复的临床疗效和成本效益比较!

2017-11-15 xing.T MedSci原创

在三年期间,与开胸手术相比,可疑腹主动脉瘤破裂采用血管内修复治疗与生存延长、增加QALYs、类似的再次介入水平以及降低成本相关,这种治疗策略是具有成本效益的。这些发现支持越来越多地使用血管内修复治疗策略,更广泛地进行急诊血管内修复。

近日,顶级杂志BMJ上发表了一篇研究文章,研究人员旨在评估可疑破裂腹主动脉瘤患者进行血管内修复治疗(如果主动脉形态适合,不合适进行开胸修补)和开胸修复治疗的三年临床结局和成本效益。

该研究为2009年-2016年期间在30个血管中心(1个在加拿大,29个在英国)进行的随机对照试验。参与者为613名符合条件临床诊断为动脉瘤破裂的患者(480名男性),其中502人接受急诊修补术。该研究中有316例患者随机分为进行血管内修复(275例确诊为破裂)和297例进行开胸修补(261例确诊为破裂)。主要观察指标为死亡率、动脉瘤修复术后再干预、生活质量,三年来住院费用为次要指标。

发生死亡最长的随访时间为7.1年,随访3年后每组有2例患者失访。90天的死亡率相似,在中期(三个月至三年)血管内修复治疗组发生死亡的人数比开胸手术组少(风险比为0.57,95%可信区间为0.36-0.90),导致三年的死亡率较低(48% vs. 56%),但七年死亡率每组约为60%(风险比为0.92,0.75-1.13)。502例进行修复治疗的患者结果更为明显:血管内修复治疗组的三年死亡率较低(42% vs. 54%,比值比为0.62,0.43-0.88),但七年后组间无明显差异(风险比为0.86,0.68-1.08)。三年再次手术率在随机组之间无统计学差异(风险比为1.02,0.79-1.32)。研究人员发现血管内修复治疗组早期的平均生活质量高于开胸手术组,再加上较低的三年死亡率,导致其平均质量调整生命年(QALY)有所增加,在三年时为0.17(95%可信区间为0-0.33)。血管内修复治疗组住院天数和平均成本较低,其中平均成本为−£2605(95%可信区间为−£5966至£702)(约€2813至€3439美元)。对于所有愿意为增加QALY而开销的患者,血管内修复治疗具有成本效益的概率>90%。

在三年期间,与开胸手术相比,可疑腹主动脉瘤破裂采用血管内修复治疗与生存延长、增加QALYs、类似的再次介入水平以及降低成本相关,这种治疗策略是具有成本效益的。这些发现支持越来越多地使用血管内修复治疗策略,更广泛地进行急诊血管内修复。

原始出处:


J T Powell, et al. Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial.BMJ 2017; https://doi.org/10.1136/bmj.j4859

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