症状性孤立性肠系膜上动脉夹层保守治疗与腔内治疗的疗效与成本-效益对比分析

Efficacy and cost-effectiveness comparison of conservative and endovascular treatment of symptomaticisolated superior mesentericartery dissection

目的比较症状性孤立性肠系膜上动脉夹层(SISMAD)保守治疗和腔内治疗的临床结局及成本-效益差异。方法本研究为回顾性队列研究。回顾性分析2009年10月至2022年10月就诊于中南大学湘雅医院血管外科的71例接受保守治疗或腔内治疗的SISMAD患者的临床和影像学资料,电话随访治疗结局并收集复诊的影像学资料。疗效评价采用《欧洲五维健康量表(EQ-5D)中文版》。根据治疗方式,分为保守治疗组(54例)和腔内治疗组(17例)。运用倾向性评分匹配(PSM)对两组患者基线资料进行1:1匹配,以获得组间协变量均衡的样本。比较两组的一般资料、随访结果和成本-效益差异,分析保守治疗影响SISMAD真腔重塑的相关因素。结果腔内治疗组腹痛持续时间长于保守治疗组,差异有统计学意义[7.0(4.5,20.0)d比4.0(1.4,8.5)d,Z=-2.371,P=0.022],余临床特征均无统计学差异(均P>0.05)。PSM后,两组患者腹痛时间差异无统计学意义[6.15(3.6,9.3)d比9.0(2.8,17.5)d,t=0.568,P=0.443];71例患者均完成电话随访,保守治疗组与腔内治疗组中位随访时间分别为36.0(13.5,57.0)与42.0(12.0,78.0)个月。保守治疗组和腔内治疗组患者的症状缓解率[88.8%(48/54)比94.1%(16/17),χ^(2)=0.877,P=0.315]和腹痛复发率[7.4%(4/54)比5.8%(1/17),χ^(2)=0.579,P=1.000]相当,差异均无统计学意义。41例患者获得影像学随访,其中保守治疗组33例,中位随访时间为6.0(3.0,36.0)个月;腔内治疗组8例,中位随访时间为16.5(2.0,55.5)个月。腔内治疗组肠系膜上动脉(SMA)真腔重塑率高于保守治疗组[87.5%(7/17)比39.4%(13/54),χ^(2)=1.211,P=0.020]。保守治疗患者中,SMA真腔重塑与真腔狭窄(>70%)、夹层长度、SMA起始处至夹层破口的距离、有无夹层动脉瘤、SMA与腹主动脉夹角、是否存在龛影、Sakamoto和Yun分型无相关性(均P>0.05)。71例患者中,共收回46份EQ-5D量表;其中保守治疗组36份,腔内治疗组10份。相较于腔内治疗组,保守治疗组患者住院时间更短[(12.3±4.8)d比(8.0±4.5)d,t=-1.363,P<0.001],住院费用更少[(57961.0±25885.6)元比(14891.0±11592.0)元,t=-4.946,P<0.001],且每个质量调整生命年的成本效益比更小(15836.34元比5047.80元,t=-3.537,P<0.001),差异有统计学意义。PSM后,每获得一个质量调整生命年,腔内治疗需要多支付12830.23元。结论两种治疗方式对SISMAD的症状缓解率相似,但腔内治疗可提高患者SMA真腔重塑率,而保守治疗具有住院时间短,住院费用低的优势;两种治疗方式均有较好的长期疗效。

Objective To evaluate the clinical outcomes of patients with symptomatic isolated superior mesenteric artery dissection(SISMAD)who underwent conservative or endovascular treatment.Meanwhile,to compare the cost-effectiveness difference between the two treatments of SISMAD.Methods This was a retrospective cohort study.Clinical data and imaging data of 71 patients with SISMAD who received conservative treatment or endovascular treatment in Department of Vascular Surgery,Xiangya Hospital of Central South University from October 2009 to October 2022 were retrospectively analyzed.The treatment outcomes were followed up by telephone and imaging data from follow-up visits were collected.The efficacy was evaluated based on the Chinese version of EuroQol Five Dimensions Questionnaire(EQ-5D).All 71 patients were divided into conservative treatment group(n=54)and endovascular treatment group(n=17).Propensity score matching(PSM)was applied to match one-to-one the baseline information of the two groups in order to obtain a covariate-balanced sample between the groups.The general data,follow-up results and cost-effectiveness were compared between the two groups,and the related factors affecting SISMAD true cavity remodeling after conservative treatment were analyzed.Results The duration of abdominal pain in the endovascular treatment group was longer than that in the conservative treatment group,and the difference was statistically significant[7.0(4.5,20.0)d vs.4.0(1.4,8.5)d,Z=-2.372,P=0.022],while there was no statistically significant difference in other clinical symptoms(all P>0.05).The differences of the remission rate and the recurrent abdominal pain rate between two groups were not statistically significant(all P>0.05).After PSM,there was no statistically significant difference in the duration of abdominal pain between the two groups[9.0(2.8,17.5)d vs.6.5(3.6,9.3)d,t=0.568,P=0.443].Imaging follow-up was performed in 41 patients,including 33 patients in the conservative treatment group and 8 patients in the endovascular treatment group.The median follow-up time was 6.0(3.0,36.0)months and 16.5(2.0,55.5)months,respectively.Endovascular treatment group had a higher rate of true lumen remodeling of the superior mesenteric artery(SMA)compared to the conservative treatment group[87.5%(7/170)vs.39.4%(13/54),χ^(2)=1.211,P=0.020].For conservative tredtment group,there was no significant correlation between SMA true lumen remodeling and items,including true lumen stenosis(>70%),dissection length,distance from SMA opening to dissection beginning,dissection aneurysm,angle between SMA and abdominal aorta,presence of niche shadow,Sakamoto and Yun classification(all P>0.05).A total of 46 EQ-5D forms were recovered from 71 patients,including 36 in the conservative treatment group and 10 in the endovascular treatment group.Patients in the conservative treatment group had a shorter hospital stay[(8.0±4.5)d vs.(12.3±4.8)d,t=-1.36,P<0.001]and accordingly less hospitalization cost[(14891.0±11592.0)yuan vs.(57961.0±25885.6)yuan,t=-4.95,P<0.001].In one quality-adjusted life year,the cost-efficacy ratio of conservative treatment was significantly lower than that of endovascular treatment group[(5047.80 yuan vs.15836.34 yuan,t=-3.50,P<0.01)],and the difference was statistically significant.After PSM,to gain one quality-adjusted life year,the endovascular treatment needed an additional 12830.23 yuan.Conclusion Both two treatment methods have similar symptom relief for SISMAD,but endovascular therapy can improve the patient's true lumen remodeling rate of SMA.By contrast,conservative treatment has the advantages of shorter hospital stay and lower hospital costs.Both two treatments have a good long-term effect.