胸腔血管内动脉瘤修补术长期经验的综合学习曲线分析。

IF 1.7 2区 医学 Q3 PERIPHERAL VASCULAR DISEASE
Journal of Endovascular Therapy Pub Date : 2024-10-01 Epub Date: 2023-03-24 DOI:10.1177/15266028231161489
Stefano Gennai, Nicola Leone, Luigi Am Bartolotti, Francesco Andreoli, Mattia Migliari, Roberto Silingardi
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引用次数: 0

摘要

目的:分析单个中心 25 年来胸腔内血管主动脉修复术(TEVAR)的学习曲线:一项回顾性、观察性、单中心研究共纳入了 1996 年至 2021 年间进行的 390 例连续标准 TEVAR 手术。对整个中心的经验(主要结果)以及第一位和第二位植入医生的经验进行了累积总图表分析。手术变量(造影剂用量、手术和透视时间)、30 天主要不良事件(MAE)和临床成功率、内漏率和再介入率等数据为次要结果,并细分为 4 个经验四分位数(Q1-Q4)或前 2 个四分位数与后 2 个四分位数(Q1-Q2 vs Q3-Q4):平均随访时间为 4.3±4.0 年。该中心的学习曲线是在 75 例手术后形成的,与第一位植入医生的学习曲线相似。之后的外科医生学习曲线明显较短(10 例 TEVAR)。将 Q1-Q2 与 Q3-Q4 相比,30 天 MAEs(16.1% vs 11.3%,p=0.164)、30 天死亡率(11.4% vs 3.6%,p=0.003)和术中额外操作(21.5% vs 13.3%,p=0.033)均有所减少,临床成功率也有所提高(85.9% vs 90.3%,p=0.190)。从第一季度到第四季度,手术时间(139.8±65.5 分钟到 76.7±43.7 分钟,P=0.001)、透视时间(15.1±8.8 分钟到 7.1±5.1 分钟,P=0.001)、学习曲线(139.8±65.5 分钟到 76.7±43.7 分钟,P=0.001)和临床成功率(85.9% vs 90.3%,P=0.190)均有所提高:随着时间的推移,学习曲线明显缩短,临床结果改善不可忽略,这表明要成为一名有效的 TEVAR 执行者,必须接受专门的血管内培训:临床影响:文献首次对一个血管外科中心25年来的标准TEVAR学习曲线进行了评估。该中心和历史上第一位开展 TEVAR 的医生的学习曲线是在治疗第 75 位患者时达到的。此后,外科医生的学习曲线明显缩短(10 例)。这四分之一个世纪表明,术中学习相关变量与长期临床结果有关,而且随着时间的推移,所有变量都有所改善。首次开展 TEVAR 的中心和培训计划提供者可以利用这些数据,争取提供更好的临床效果。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Comprehensive Learning Curve Analysis of a Long-Term Experience With Thoracic Endovascular Aneurysm Repair.

Purpose: To analyze the learning curve for thoracic endovascular aortic repair (TEVAR) in a single center over a period of 25 years.

Materials and methods: In total, 390 consecutive standard TEVAR procedures undertaken between 1996 and 2021 were included in a retrospective, observational, single-center study. Cumulative sum charts were elaborated for the entire center experience (primary outcome) as well as for the first and second implanting physicians. Data on procedural variables (contrast volume, operative and fluoroscopy time), 30-day major adverse events (MAEs) and clinical success, and endoleak and reintervention rates were secondary outcomes and subdivided into 4 quartiles of experience (Q1-Q4) or presented as first 2 versus latest 2 quartiles (Q1-Q2 vs Q3-Q4).

Results: The mean follow-up was 4.3±4.0 years. The center's learning curve was achieved after 75 procedures, and it was similar for the first implanting physician. The surgeon coming thereafter had a significantly shorter curve (10 TEVARs). Comparing Q1-Q2 with Q3-Q4, 30-day MAEs (16.1 vs 11.3%, p=0.164), 30-day mortality (11.4% vs 3.6%, p=0.003), and intraoperative additional maneuvers (21.5% vs 13.3%, p=0.033) were reduced along with an improvement in clinical success (85.9% vs 90.3%, p=0.190). From Q1 to Q4, operative time (139.8±65.5 to 76.7±43.7 min, p=0.001), fluoroscopy time (15.1±8.8 to 7.1±5.1 min, p<0.001), and contrast volume (244.0±112.1 to 104.3±46.1 mL, p<0.001) showed a considerable reduction. Late endoleak and aortic-related mortality declined significantly from Q1-Q2 to Q3-Q4 (24.1% to 15.5%, p=0.033 and 18.6% vs 8.2%, p=0.006, respectively). Operative time (p=0.021), contrast volume (p=0.016), and fluoroscopy time (p=0.004) were independent risk factors for endoleak, causing a 1.3-fold risk increase for both each 60 minutes of additional operative time (p=0.021) and every 100 mL of additional contrast medium (p=0.016). Each 10-minute increase in fluoroscopy time determined a 1.4-fold risk increment (p=0.004).

Conclusion: The learning curve shortened significantly over time with non-negligible clinical outcome improvements, suggesting that specific endovascular training is mandatory to become an effective TEVAR performer.

Clinical impact: For the first time in literature, the standard TEVAR's learning curve has been evaluated at a single vascular surgery center over a period of 25 years. The learning curve for the center and the first physician historically undertaking TEVAR was achieved at the 75th treated patient. The learning curve of the surgeons coming thereafter was significantly shorter (10 cases). This quarter-century demonstrated that intraoperative learning-related variables were associated with long-term clinical outcomes and all have improved over time. Centers approaching TEVAR for the first time and training program providers could use these data to aim to offer better clinical outcomes.

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来源期刊
CiteScore
5.30
自引率
15.40%
发文量
203
审稿时长
6-12 weeks
期刊介绍: The Journal of Endovascular Therapy (formerly the Journal of Endovascular Surgery) was established in 1994 as a forum for all physicians, scientists, and allied healthcare professionals who are engaged or interested in peripheral endovascular techniques and technology. An official publication of the International Society of Endovascular Specialists (ISEVS), the Journal of Endovascular Therapy publishes peer-reviewed articles of interest to clinicians and researchers in the field of peripheral endovascular interventions.
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