Treatment of juxtarenal and complex neck abdominal aortic aneurysms (AAAs) is now commonly by endovascular rather than open surgical repair (OSR). Published comparisons show poor validity and scientific precision. UK-COMPASS is a comparative cohort study of endovascular treatments OSR for patients with an AAA unsuitable for standard on label endovascular aneurysm repair (EVAR). All procedures for AAA in England (November 2017 to October 2019) were identified, AAA anatomy assessed in a Corelab, peri-operative risk scores determined, and propensity scoring used to identify patients suitable for either endovascular treatment or OSR. Patients were stratified by aneurysm neck length (0 – 4 mm, 5 – 9 mm, or ≥ 10 mm) and operative risk; the highest quartile was considered high risk and the remainder standard risk. Death was the primary outcome measure. Endovascular treatments included fenestrated EVAR (FEVAR) and off label standard EVAR (± adjuncts). Among 8 994 patients, 2 757 had AAAs that were juxtarenal, short neck, or complex neck in morphology. Propensity score stratification and adjustment method comparisons included 1 916 patients. Widespread off label use of standard EVAR devices was noted (35.6% of patients). The adjusted peri-operative mortality rate was 2.9%, lower for EVAR (1.2%; = .001) and FEVAR (2.2%; = .001) than OSR (4.5%). In standard risk patients with a 0 – 4 mm neck, the mortality rate was 7.4% following OSR and 2.3% following FEVAR. Differences were smaller for patients with a neck length ≥ 5 mm: 2.1% OSR 1.0% FEVAR. At 3.5 years of follow up, the overall mortality rate was 20.7% in the whole study population, higher following FEVAR (27.6%) and EVAR (25.2%) than after OSR (14.2%). However, in the 0 – 4 mm neck subgroup, overall survival remained equivalent. The aneurysm related mortality rate was equivalent between treatments, but re-intervention was more common after EVAR and FEVAR than OSR. FEVAR proves notably safer than OSR in the peri-operative period for juxtarenal aneurysms (0 – 4 mm neck length), with comparable midterm survival. For patients with short neck (5 – 9 mm) and complex neck (≥ 10 mm) AAAs, overall survival was worse in endovascularly treated patients compared with OSR despite relative peri-operative safety. This warrants further research and a re-appraisal of the current clinical application of endovascular strategies, particularly in patients with poor general survival outlook owing to comorbidity and age.

中文翻译：

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肾旁和复杂颈主动脉瘤的开放手术和血管内技术的比较：英国复杂动脉瘤研究 (UK-COMPASS) – 围手术期和中期结果

近肾和复杂颈腹主动脉瘤 (AAA) 的治疗现在通常通过血管内治疗而不是开放手术修复 (OSR)。已发表的比较显示有效性和科学精度较差。UK-COMPASS 是一项针对不适合血管内动脉瘤修复 (EVAR) 标签标准的 AAA 患者进行血管内治疗 OSR 的比较队列研究。确定了英格兰（2017 年 11 月至 2019 年 10 月）的所有 AAA 手术，在 Corelab 中评估 AAA 解剖结构，确定围手术期风险评分，并使用倾向评分来识别适合血管内治疗或 OSR 的患者。根据动脉瘤颈长度（0 – 4 毫米、5 – 9 毫米或≥ 10 毫米）和手术风险对患者进行分层；最高的四分位被认为是高风险，其余的被认为是标准风险。死亡是主要结果指标。血管内治疗包括开窗 EVAR (FEVAR) 和标签外标准 EVAR（± 辅助）。在8 994例患者中，2 757例AAA的形态为近肾、短颈或复杂颈。倾向评分分层和调整方法比较包括1 916名患者。注意到标准 EVAR 装置的广泛标签外使用（35.6% 的患者）。调整后的围手术期死亡率为 2.9%，EVAR (1.2%; = .001) 和 FEVAR (2.2%; = .001) 低于 OSR (4.5%)。在颈部直径为 0 – 4 毫米的标准风险患者中，OSR 后的死亡率为 7.4%，FEVAR 后的死亡率为 2.3%。颈部长度 ≥ 5 mm 的患者差异较小：2.1% OSR 1.0% FEVAR。随访 3.5 年时，整个研究人群的总死亡率为 20.7%，FEVAR（27.6%）和 EVAR（25.2%）后的死亡率高于 OSR（14.2%）后的死亡率。然而，在 0 – 4 毫米颈部亚组中，总生存率保持不变。治疗之间的动脉瘤相关死亡率相当，但 EVAR 和 FEVAR 后的再次干预比 OSR 更常见。事实证明，在肾近动脉瘤（颈长 0 – 4 毫米）的围手术期，FEVAR 明显比 OSR 更安全，并且中期生存率相当。对于短颈 (5 – 9 mm) 和复杂颈 (≥ 10 mm) AAA 的患者，尽管围手术期安全性相对较高，但与 OSR 相比，血管内治疗患者的总生存期较差。这需要进一步研究和重新评估当前血管内治疗策略的临床应用，特别是对于由于合并症和年龄而总体生存前景较差的患者。