| Background In recent years,the surgical treatment of aortic diseases in China has developed rapidly,with the scale of operations increasing continuously.However,there exists a serious problem of imbalanced development between regions and different levels of hospitals,which is in stark contradiction to addressing the growing burden of aortic disease.Therefore,it is urgent to conduct a comprehensive analysis and evaluation of the status of aortic surgery in China,so as to improve the quality of care,and promote the development from "quantity" to "quality".Up to now,the national Hospital Quality Monitoring System(HQMS)has covered more than 2,000 tertiary hospitals national wide,basically covering all hospitals capable of carrying out aortic surgery,which is expected to become an important data source.Objective This study aimed to analyze the current scale,medical quality,and existing problems of aortic surgery in China,by using HQMS data.Methods The study included the aortic surgery records of patients over 18 years of age between January 2017 and December 2021.Among them,four representative operations were selected for the key analysis and evaluation,including thoracic endovascular aortic repair(TEVAR),abdominal endovascular aortic repair(EVAR),Bentall procedure and total aortic arch artificial vascular replacement.The study described and evaluated the status,development trend,and clinical outcomes of aortic surgery from various levels.The primary outcome indicators were in-hospital death and non-recommended discharge,and the secondary outcome indicators included length of hospital stay,hospitalization cost,and unplanned readmission within 30 days after surgery.Results From 2017 to 2021,the scale of aortic surgery in China expanded continuously with endovascular aortic repair developing most rapidly.The annual number of TEVAR increased from 14,000 to 29,000,and EVAR increased from 7,600 to 17,900.Compared with open surgery,endovascular repair was more popular.In 2021,the number of hospitals in China that can perform TEVAR and EVAR surgery were 1,078 and 1,083 respectively,and the number of hospitals that can perform total aortic arch replacement and Bentall procedure were 320 and 350 respectively.There were significant differences among different levels of hospitals in the aortic surgery.About 20%of large hospitals performed about 80%of the surgeries.There were significant differences in the quality of the medical service among provinces,which led to an obvious phenomenon of inter-provincial migration for medical care.The proportion of inter-provincial migration among patients with open aortic surgery was 18.3%,and with endovascular surgery was 9.3%.The incidence of adverse in-hospital outcomes of aortic surgery tended to decrease with the increase in hospital annual operation volume(P<0.01).Conclusion Using the HQMS database,the study comprehensively described the scale of aortic surgery,patient characteristics,and in-hospital outcomes,and evaluated the existing quality issues nationwide.In recent years,the scale of aortic surgery had continued to increase,but there still existed great differences between regions and hospitals.There were significant differences in the quality of medical care between provinces,and the phenomenon of inter-provincial migration for medical care was prominent.Hospitals with lower annual aortic surgery volume had relatively poorer medical quality.Background Aortic disease(aortic aneurysm,aortic dissection,penetrating aortic ulcer,etc.)is a type of cardiovascular disease with high mortality and high risk of surgical treatment,which seriously threatens human health.At present,the surgical treatment and intervention methods for the ascending aorta,descending aorta,and abdominal aorta are becoming more and more mature.However,due to the complexity of the anatomy,function,and pathological changes of the aortic arch,controversies of the optimal treatment strategy for arch lesions have continued currently,and the perioperative mortality and the incidence of cardiovascular and cerebrovascular adverse events after surgery are relatively high.For new surgical techniques,including complete endovascular technique and hybrid surgery,there is still a lack of multi-center,large-scale clinical studies to evaluate their safety and effectiveness for treating aortic arch lesions.Objective In this study,a multi-center,prospective,and descriptive registration study was carried out to establish a database of clinical data of patients underwent aortic arch surgery,to describe the patient clinical characteristics,to explore risk factors,and to evaluate outcomes of endovascular techniques,hybrid techniques,and conventional open surgery on aortic arch lesions.Methods This study continuously included patients who received complete thoracic endovascular aortic repair(cTEVAR),hybrid surgery,traditional total arch replacement(TAR),and patients with aortic arch disease who underwent revascularization of at least one arch branch vessel during surgery.According to the received surgical treatment,they were divided into three groups:TAR,cTEVAR,and Hybrid.The data of patient characteristics,preoperative examination,comorbidities,aortic CTA examination,records related to the operation process,and postoperative outcome were collected.The primary endpoint was 1-year treatment success,which was defined as no death within 30 days after operation,no cardiovascular and cerebrovascular adverse events,and no aortic-related reoperation during the 1-year follow-up.The secondary end point included the endoleak,arch branch occlusion or thrombosis,device-related adverse events,and other serious complications.Results A total of 533 patients with aortic arch lesions who received surgical treatment were included in the study,including 246 patients(46.1%)in the cTEVAR group,90 patients(16.9%)in the Hybrid group,and 197 patients(37.0%)in the TAR group.The mean age of patients in the three group were 58.63± 11.52,61.10±9.57 and 50.33±1 1.82,respectively.Aortic dissection was the main type of disease in all three groups.In terms of the proximal anatomical location of the lesion,the cTEVAR group was mostly located at or near the level of the left subclavian artery orifice(80.7%),while the Hybrid group(75.3%)and TAR group(90.4%)were mostly located at or near the level of the innominate artery orifice.In cTEVAR group,revascularization of branch vessels was mainly based on fenestration technique(75.2%).The average operation time of patients in this group was 107.07±44.44 minutes,the average intraoperative blood loss was 29.21±48.85 mL,and the average postoperative ICU stay was 1.51±1.93 days.In Hybrid group,type Ⅱ hybrid surgery(50.0%)was the most procedure.The average operation time of patients in this group was 336.41 ± 133.00 minutes,the average extracorporeal circulation time was 104.90±90.14 minutes,and the average intraoperative blood loss was 650.1 1±3 18.62 mL,the average length of ICU stay was 4.13±4.32 days.3.3%of patients underwent a second thoracotomy during hospitalization.In TAR group,total arch replacement was the main method of revascularization(85.6%).The average operation time of patients in this group was 353.79± 124.63 minutes,the average extracorporeal circulation time was 141.38±59.17 minutes,and the average deep hypothermic circulatory arrest time was 8.20± 13.78 minutes,the average intraoperative blood loss was 778.73±331.67 mL,the average postoperative ICU stay was 4.11±3.85 days.0.5%of the patients underwent a second thoracotomy during hospitalization.There were statistically significant differences in the average operation time,average intraoperative blood loss,and average postoperative ICU length of stay among the three groups.The incidence of the primary end point was 95.7%,94.7%and 95.3%in the cTEVAR group,Hybrid group and TAR group,respectively,and there was no statistically significant difference after statistical correction test.The incidence of secondary end point in the three groups were 21.1%,23.2%and 15.0%,respectively,with no statistical difference.Multivariate COX regression analysis showed:age(HR=1.063,95%CI:1.012-1.117,p=0.0148),second thoracotomy during hospitalization(HR=17.487,95%CI:1.736-176.158,p=0.0152)and re-transfer to ICU(HR=6.580,95%CI:1.865-23.223,p=0.0034)were risk factors for 1-year mortality after surgery.Conclusion In general,the new technique for aortic arch surgery,including cTEVAR and Hybrid,has a comparable interim outcome with TAR,with less trauma and better recovery.Considering that different surgical methods have different indications on the anatomy and pathological types of the arch lesions,an individualized comprehensive surgical strategy is conducive to improving the quality of aortic arch diseases treatment. |
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