Identifying Patients With AAA With the Highest Risk Following Endovascular Repair

Introduction: It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair. Methods: We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression. Results: A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups. Conclusions: Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.     

Is abdominal aortic aneurysm repair appropriate in oxygen-dependent chronic obstructive pulmonary disease patients?

BACKGROUND: The life expectancy of patients with oxygen-dependent chronic obstructive pulmonary disease (COPD) is significantly reduced, but the risk of any intervention is considered prohibitive. However, severe COPD may increase the risk of abdominal aortic aneurysm (AAA) rupture. We reviewed our experience with AAA repair in oxygen-dependent patients to determine whether operative risk and expected long-term survival justify surgical intervention. METHODS: A retrospective review of 44 consecutive patients with oxygen-dependent COPD undergoing AAA repair over an 8-year period was performed. Information was recorded for survival, length of follow-up, patient age, medical comorbidities, pulmonary function tests, and operative approach. Survival data were analyzed by Kaplan-Meier curves and compared with published cohorts of oxygen-dependent patients and the natural history of untreated aneurysms. RESULTS: Twenty-four patients underwent endovascular aneurysm repair (EVAR), and 20 underwent open procedures (14 retroperitoneal and 6 transabdominal). The mean AAA diameter was 6.1 cm (range, 5-9.5 cm). The mean age was 71.4 years, and 82% of patients were male. Operative mortality was 0%. The mean length of stay was 11.2 days for open procedures and 4.3 days for EVAR (significantly longer than that for standard-risk patients). The mean survival time was 37.9 months (range, 2-91 months). Preoperative medical comorbidities, type of repair, and pulmonary function tests were not predictive of survival. Postoperative morbidity was significantly higher with open repair. Long term survival was comparable to historical series of the natural history of O2 dependent patients without AAA but better than untreated 6 cm AAA cohorts. At 42 months, almost 50% of patients in our study group were still alive, compared to 20% survival at 34 months for those with untreated 6 cm AAAs. CONCLUSIONS: It is reasonable to continue to offer AAA repair to home oxygen-dependent COPD patients who are ambulatory and medically optimized and who are without untreated coronary artery disease. Although EVAR may be the most suitable treatment for oxygen-dependent COPD patients, our results show that even open repair may be safely performed in this population, with acceptable results.     

Minimal incision aortic surgery.

PURPOSE: In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD). METHOD: Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques. RESULTS: Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs. 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs. 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (< or = 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs. CONCLUSIONS: MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair.     

Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms

OBJECTIVE: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. METHODS: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P =.04-.001) in the retroperitoneal group. All factors were correlated with outcome. RESULTS: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P >.2). CONCLUSION: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.     

Abdominal aortic aneurysm repair in octogenarians: myth or reality?

AIM: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair. METHODS: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate. RESULTS: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01). CONCLUSION: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.     

Quality of life before and after endovascular and retroperitoneal abdominal aortic aneurysm repair

PURPOSE: This study was undertaken to evaluate changes in quality of life and to compare conventional outcomes in patients undergoing endovascular and open retroperitoneal abdominal aortic aneurysm (AAA) repair. METHODS: Between October 2000 and May 2003, 129 patients underwent elective AAA repair, endovascular repair in 22 patients and open retroperitoneal repair in 107 patients. The Short-Form Health Survey, 12 items (SF-12) was administered preoperatively and at 3 weeks, 4 months, and 1 year after discharge. Quality of life, hospital and intensive care unit stay, perioperative complications, discharge disposition, readmission, and hospital cost were statistically evaluated. RESULTS: For the total group, significant differences were observed for both Physical Component Summary scores (P<.001) and Mental Component Summary scores (P=.001) between time points. There were no significant differences for either Component Summary score between open and endovascular procedures for any time period. Number of weeks required to return to baseline functional status was similar after either open or endovascular repair (7.22 vs 5.47 weeks, respectively; P=.09). Mean hospital and intensive care unit stay was 4.4 and 1 days, respectively, for open repair versus 1.9 and 0 days, respectively, for endovascular repair (P<.0001). No significant difference between groups was observed in terms of perioperative complications, discharge disposition, or hospital readmission (P> or =.54). Mean total hospital cost for endovascular repair was 1.60 times that for open repair (mean difference, $11,662; P<.0001; 95% confidence interval, $17,799-$5525). CONCLUSIONS: Hospital stay is significantly shorter after endovascular AAA repair. However, hospital cost is almost twice that for open retroperitoneal repair. Perioperative complications, discharge disposition, and hospital readmission are not statistically different between the two groups. Effect on health-related quality of life is similar after either open retroperitoneal or endovascular AAA repair.     

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair

PURPOSE: Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure. METHODS: Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality. RESULTS: Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups. CONCLUSION: Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.     

Durability of benefits of endovascular versus conventional abdominal aortic aneurysm repair

PURPOSE: Endovascular abdominal aortic aneurysm (AAA) repair is reported to result in less initial patient morbidity and a shorter hospital length of stay (LOS) when compared with conventional AAA repair. We sought to examine the durability of this result during the intermediate follow-up interval. METHODS: The records of all admissions for all patients who underwent AAA repair during a 26-month interval were reviewed. RESULTS: Three hundred thirty-seven (337) patients underwent procedures to repair AAAs (163 open and 174 endovascular). Endovascular procedures were performed with a variety of devices (Talent, 108; Ancure, 36; AneuRx, 26; Zenith, 2; and Cordis, 2) and configurations (141 bifurcated and 33 aortomonoiliac). The mean follow-up period was 10.6 months (endovascular repair) and 12.3 months (open repair). LOS did not significantly vary by device (P =.24 to P =.92) or configuration (P =.24). The initial median LOS for procedures was significantly shorter (P =.009) for endovascular repairs (5 days) than for open procedures (8 days). However, the patients who underwent endovascular repair were more likely to be readmitted during the follow-up interval when compared with patients who underwent open procedure. The readmission-free survival rate after AAA repair at 12 months was 95% for patients for open AAA repair versus 71% for patients for endovascular repair (P <.001). If the total hospital days were compared, including the initial and all subsequent AAA-related admissions, there was no significant difference for mean LOS for patients who underwent endovascular versus open AAA procedures (11 days versus 13.6 days; P =.21). The patients for endovascular AAA repair most commonly needed readmission for treatment of endoleak (n = 31), wound infection (n = 12), and graft limb thrombosis (n = 9). Although women had similar LOS to men for endovascular repair (P =.44), they had longer initial LOS for open AAA repair (15 versus 10 days; P =.03). After endovascular repair, women were more likely than men to be readmitted by 12 months (51% versus 71% readmission-free survival rate; P =.03) and they had longer LOS on readmission (13.2 versus 5.2 days; P =.006). No gender differences were identified for patients after open AAA repair regarding readmission-free survival rate (P =.09) or LOS on readmission (P =.98). CONCLUSION: Although initial LOS was shorter for the patients who underwent endovascular as compared with conventional AAA repair, this advantage was lost during the follow-up interval because of frequent readmission for the treatment of procedure-related complications, chiefly endoleak. These readmissions frequently involved the performance of additional invasive procedures. Gender differences existed regarding LOS and the likelihood of complications after open and endovascular AAA repair.     

Endovascular repair of abdominal aortic aneurysms: risk stratified outcomes

OBJECTIVE: The impact of co-morbid conditions on early and late clinical outcomes after endovascular treatment of abdominal aortic aneurysm (AAA) was assessed in concurrent cohorts of patients stratified with respect to risk for intervention. SUMMARY BACKGROUND DATA: As a minimally invasive strategy for the treatment of AAA, endovascular repair has been embraced with enthusiasm for all prospective patients who are suitable anatomical candidates because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. METHODS: From April 1994 to March 2001, endovascular AAA repair was performed in 236 patients using commercially available systems. A subset of patients considered at increased risk for intervention (n = 123) were categorized, as such, based on a preexisting history of ischemic coronary artery disease, with documentation of myocardial infarction (60%) or congestive heart failure (35%), or due to the presence of chronic obstructive disease (21%), liver disease, or malignancy. RESULTS: Perioperative mortality (30-day) was 6.5% in the increased-risk patients as compared to 1.8% among those classified as low risk (P = NS). There was no difference between groups in age (74 +/- 9 years vs. 72 +/- 6 years; mean +/- SD), surgical time (235 +/- 95 minutes vs. 219 +/- 84 minutes), blood loss (457 +/- 432 mL vs. 351 +/- 273 mL), postoperative hospital stay (4.8 +/- 3.4 days vs. 4.0 +/- 3.9 days), or days in the ICU (1.3 +/- 1.8 days vs. 0.5 +/- 1.6 days). Patients at increased risk of intervention had larger aneurysms than low-risk patients (59 +/- 13 mm vs. 51 +/- 14 mm; P <.05). Stent grafts were successfully implanted in 116 (95%) increased-risk versus 107 (95%) low-risk patients (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3% and 5%, respectively. The initial endoleak rate was 22% versus 20%, based on the first CT performed (either at discharge or 1 month; P = NS). To date, increased-risk patients have been followed for 17.4 +/- 15 months and low-risk patients for 16.3 +/- 14 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P <.05, Mantel-Cox test). Both cohorts had similar two-year primary and secondary clinical success rates of approximately 75% and 80%, respectively. CONCLUSIONS: Early and late clinical outcomes are comparable after endovascular repair of AAA, regardless of risk-stratification. Notably, 2 years after endovascular repair, at least one in five patients was classified as a clinical failure. Given the need for close life-long surveillance and the continued uncertainty associated with clinical outcome, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.     

Analysis of medical risk factors and outcomes in patients undergoing open versus endovascular abdominal aortic aneurysm repair

OBJECTIVE: The emergence of endovascular repair (ER) for infrarenal abdominal aortic aneurysm (AAA) has provided surgeons with a new technique that should ideally improve patient outcomes. To more accurately characterize the advantages of ER versus traditional/open AAA repair (TOR), we compared the preoperative medical risk factors (PMRFs) and perioperative outcomes (PO) of those patients undergoing elective treatment of infrarenal AAA with ER and TOR over a recent 18-month period at our center. METHODS: Through our institutional vascular surgery patient registry, all patients undergoing aortic aneurysm repair of any type between December 1999 and June 2001 were identified. Only those patients undergoing elective infrarenal AAA repair were analyzed. Hospital records were examined for all patients, and PMRF and PO were assessed via Society for Vascular Surgery/International Society for Cardiovascular Surgery reporting guidelines. Student t, chi(2), Fisher exact, or Wilcoxon rank sum tests were applied where appropriate to determine differences among PMRF and PO according to method of aneurysm repair. RESULTS: During the 18-month study period, a total of 199 aortic aneurysms were repaired at our institution. Ninety-nine elective infrarenal AAA repairs made up the study cohort (ER, n = 33; TOR, n = 66). When examined by method of aneurysm repair, no differences existed in demographics or AAA size. Patients undergoing ER had a significantly greater degree of preoperative pulmonary comorbidity than patients undergoing TOR (P <.001). However, no differences existed in terms of American Society of Anesthesiologists classification or cardiac (P =.52), cerebrovascular (P =.44), diabetic (P =.51), hypertensive (P =.90), hyperlipidemia (P =.91) or renal (P =.23) comorbidities between the two groups. Perioperative morbidity and mortality rates were also not significantly different by method of repair. ER was associated with shorter operative time, intensive care unit stay, and overall hospital length of stay (P <.0001). However, subsequent operative procedures related to the AAA repair were performed more frequently after ER (TOR = 1.5% versus ER = 15.2%; P = 0.015). CONCLUSION: These results suggest that ER offers improvements in hospital convalescent and operating room times but no beneficial impact on overall morbidity and mortality rates when similar PMRFs exist, especially when used at medical centers where low morbidity and mortality rates are already established for TOR. Other centers performing ER should undertake such an analysis to assess its impact on their patients.     

Outcome after Simultaneous Abdominal Aortic Aneurysm Repair and Aortocoronary Bypass

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.     

Evolving strategies for the treatment of aortoenteric fistulas

BACKGROUND: Aortoenteric fistulas (AEFs) are a rare but often fatal cause of gastrointestinal bleeding. Operative repair of AEF has been historically associated with extremely high morbidity and mortality. We reviewed our experience of open surgical and endovascular treatment of AEF to compare outcomes over a contemporaneous time period. METHODS: Over a 9-year period between January 1997 and January 2006, 16 patients (11 men and 5 women) were diagnosed with and treated for AEFs. Seven patients underwent open surgical repair, and nine, with anatomically suitable lesions, underwent endovascular repair. The outcome after treatment of these patients was investigated for survival, perioperative complications, length of hospital stay, and long-term disposition. RESULTS: Three primary and 13 secondary AEFs were treated. The mean time from the initial aortic operation until AEF diagnosis was 5.9 years (range, 0.7-12.2 years) for patients with secondary AEFs. The overall 30-day mortality rate was 18.8%. One intraoperative death and one in-hospital death secondary to multisystem organ failure occurred in patients undergoing open repair. One in-hospital death related to persistent sepsis occurred in the endovascular group. The overall perioperative complication rate was 50.0%. Complications in the open group included sepsis, renal failure, bowel obstruction, and pancreatitis. Complications in the endovascular group were related to persistent sepsis. The mean in-hospital length of stay was significantly longer for patients undergoing open repair compared with endovascular repair (44.0 vs 19.4 days; P = .04). Four (80%) of five patients who were discharged from the hospital in the open group were placed in skilled nursing facilities, and seven (87.5%) of eight patients discharged in the endovascular group returned home. The median overall survival after hospital discharge was 23.1 months. There were no late aneurysm-related deaths or late deaths related to septic complications. CONCLUSIONS: Patients with AEFs have limited overall survival. Endovascular therapy offers an alternative to open surgical repair, seems to be associated with decreased perioperative morbidity and mortality and a shorter in-hospital stay, and allows for acceptable survival given the presence of coexisting medical comorbidities. Furthermore, endovascular repair provides a therapeutic option to control bleeding and allow for continued intervention in a stabilized setting.     

Evaluation of the complexity of open abdominal aneurysm repair in the era of endovascular stent grafting

OBJECTIVE: Endovascular repair has proven to be an effective treatment for many abdominal aortic aneurysms (AAA). Aneurysms that require open repair have usually been disqualified from an endovascular approach as a result of a variety of anatomic constraints, which may also make open repair more difficult. Our purpose was to review open AAA repair and assess the complexity of the operative procedure and associated morbidity and mortality data in the era of endovascular stent grafting. METHODS: We retrospectively reviewed the records of 606 patients undergoing elective open AAA repair at a single tertiary care community hospital from January 1, 1996, to December 31, 2004. Patients with ruptured aneurysms and all endovascular repairs were excluded. Patients were grouped into two categories. Group 1 included 301 patients who underwent open repair before the initiation of an endovascular stent grafting program in November 1999. Group 2 included 305 patients who underwent open repair after the initiation of the stent graft program. Operative reports were reviewed to determine the location of the proximal aortic cross clamp, management of the renal vein, associated iliac aneurysmal or occlusive disease, and type of surgical reconstruction. Morbidity, mortality, and disposition data were compared for the two groups and subjected to chi2 analysis. RESULTS: Suprarenal aortic cross-clamp placement was required in 6% of group 1 patients and 20% of group 2 patients (P < .05). Division of the renal vein was necessary in 11% of group 1 patients and 18% of group 2 patients (P < .05). Iliac aneurysms were present in 25% of group 1 patients and 42% of group 2 patients (P < .05). The incidence of associated iliac occlusive disease was 12% in group 1 and 20% in group 2 (P < .05). The type of reconstruction required (aortoaorto, aortoiliac, aortofemoral) was not found to be statistically significant. All major sources of morbidity, including renal insufficiency, myocardial infarction, stroke, and intubation times, were similar between the two groups. The length of stay was 9.2 days in both groups, and 11.3% of group 1 patients and 26% of group 2 patients were discharged to an extended-care facility rather than directly home. The overall mortality rate was 2.0% for patients in group 1 and 3.8% for group 2 patients. This was not a statistically significant difference. CONCLUSIONS: Surgeons performing open repair of AAA in the era of endovascular stent grafting are operating on patients who require more complex repairs, including a greater frequency of suprarenal cross clamping, renal vein division, and management of associated iliac aneurysmal and occlusive disease. Despite this, morbidity and mortality rates are similar to those in patients operated on before the initiation of an endovascular stent grafting program.     

A statewide experience with endovascular abdominal aortic aneurysm repair: rapid diffusion with excellent early results

OBJECTIVE: The purpose of this study was to compare survival and outcomes of endovascular versus open repair of abdominal aortic aneurysms (AAAs) in New York State (NYS). METHODS: We used the NYS discharge dataset Statewide Planning and Research Cooperative System (SPARCS) to analyze the outcomes of elective admission for nonruptured (International Classification of Diseases-9th revision [ICD-9] 441.4) open aneurysm repair (38.44) and endovascular aneurysm repair (39.71) during the years 2000-2002. The ICD-9 code for endovascular repair was introduced in late 2000, thus capturing 3 months of empiric data for 2000. RESULTS: There has been a significant increase in the number of AAA procedures performed in NYS (comparing before and after 2000: average, 1419 vs 1701; P =.0001), temporally coinciding with the implementation of training programs after US Food and Drug Administration approval of endovascular grafts and the new payment code. From 2000 to 2002 the number of NYS hospitals performing endovascular repairs increased from 24 to 60. By 2002 there were more endovascular repairs being performed than open repairs (871 vs 783). The target population for these surgical interventions showed interesting differences. In 2002, women had a 43% chance of receiving an endograft, whereas men had a 55% probability. The use of endovascular repair over the observation period was relatively constant in patients younger than 65 years. In patients older than 65 years, and especially those older than 75 years, endovascular use increased substantially, so that by 2002 older patients were more likely to undergo endovascular repair than open repair. Patients who underwent endovascular repair had significantly more hypertension, coronary artery disease, diabetes, and hyperlipidemia than did patients who underwent open repair. Yet the mean length of stay for endovascular procedures was approximately 3.6 days, and for open procedures was about 10.3 days, across all 3 years (P = <.0001). Moreover, patients who underwent endovascular repair had statistically fewer postoperative complications and significantly lower mortality. In-hospital mortality in 2001 was 3.55% for open repair and 1.14% for endovascular repair (P =.0018), and in 2002 these rates were 4.21% versus 0.8% (P <.0001), respectively. CONCLUSION: This dataset suggests that endovascular AAA repairs are being performed in a patient population with a higher frequency of comorbidities. However, endovascular repairs still are associated with significantly lower in-hospital mortality, fewer postoperative complications, and a dramatically shorter length of stay. These results suggest that, despite the rapid diffusion of this new technique, early perioperative outcomes may be superior to those with conventional open repair. However, prospective clinical studies are needed to confirm these insights, and such studies may require the infrastructure of consortia of hospitals or society-based registries.     

Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001

OBJECTIVE: Small patient numbers, mixed data from clinical trials, and longitudinal series representing institutional learning curves have characterized previous studies of early outcomes after endovascular abdominal aortic aneurysm (AAA) repair. We compared the perioperative outcomes of endovascular and open surgical AAA repair in an unselected sample of patients in a single calendar year using a national administrative database. METHODS: The 2001 National Inpatient Sample database was retrospectively reviewed. This database represents 20% of all-payer stratified sample of non-federal US hospitals. Patients older than 49 years were identified by primary diagnostic codes (International Classification of Disease, ninth revision [ICD-9], 441.4, intact, nonruptured AAA) and procedure codes (ICD-9 38.44 for open, 39.71 for endovascular repair). Patient demographic data (age, sex), comorbid conditions (ICD-9 coded), inpatient complications (ICD-9 coded), length of stay, final discharge disposition (home vs institution vs death), and hospital charges were examined with univariate and multivariate analyses. RESULTS: In calendar year 2001, 7172 patients underwent either open (64%) or endovascular (36%) repair of intact, nonruptured AAAs. Despite comparable rates of preoperative comorbid conditions and a greater proportion of octogenarians (23% vs 16%%; P =.0001), morbidity (18% vs 29%; P =.0001) and mortality (1.3% vs 3.8%; P =.0001) were significantly lower for endovascular repair than for open repair. The median length of stay (2 vs 7 days; P =.0001) and the rate of discharge to an institutional facility versus home (6% vs 14%; P =.0001) were also much lower in the endovascular group than in the open repair group. At multivariate analysis, open AAA repair and age older than 80 years were strong independent predictors (P =.0001 for all) for death (open repair: odds ratio [OR], 3.3; 95% confidence interval [CI], 2.3-4.9; age: OR, 14.2; 95% CI, 3.5-58.1), complications (open repair: OR, 1.9; 95% CI, 1.7-2.1; age: OR, 1.9; 95% CI, 1.5-2.5), and not being discharged to home (open repair: OR, 3.4; 95% CI, 2.9-4.1; age: OR, 12.0; 95% CI, 7.0-20.4). Mean hospital charges were significantly greater (difference, $3337; P =.0009) for endovascular repair than for open repair. Extrapolated to the total number of endovascular AAA repairs performed during the single 2001 calendar year, this resulted in a staggering $50.3 million in additional hospital charges. CONCLUSIONS: Endovascular repair of intact AAAs results in a significantly lower number of complications and deaths, shorter hospital stay, and improved likelihood of discharge to home, even in older patients, when compared with open surgical repair. These impressive gains in clinical outcome, however, are achieved at similarly impressive increases in health care costs.     

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE: To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective study. MATERIAL AND METHODS: The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS: At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS: The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.     

Abdominal aortic aneurysms in "high-risk" surgical patients: comparison of open and endovascular repair

OBJECTIVE: To evaluate the early results of endovascular grafting for high-risk surgical candidates in the treatment of abdominal aortic aneurysms (AAA). SUMMARY BACKGROUND DATA: Since the approval of endoluminal grafts for treatment of AAA, endovascular repair of AAA (EVAR) has expanded to include patients originally considered too ill for open AAA repair. However, some concern has been expressed regarding technical failure and the durability of endovascular grafts. METHODS: The University of Alabama at Birmingham (UAB) Computerized Vascular Registry identified all patients who underwent abdominal aneurysm repair between January 1, 2000, and June 12, 2002. Patients were stratified by type of repair (open AAA vs. EVAR) and were classified as low risk or high risk. Patients with at least one of the following classifications were classified as high risk: age more than 80 years, chronic renal failure (creatinine > 2.0), compromised cardiac function (diminished ventricular function or severe coronary artery disease), poor pulmonary function, reoperative aortic procedure, a "hostile" abdomen, or an emergency operation. Death, systemic complications, and length of stay were tabulated for each group. RESULTS: During this 28-month period, 404 patients underwent AAA repair at UAB. Eighteen patients (4.5%) died within 30 days of their repair or during the same hospitalization. Two hundred seventeen patients (53%) were classified as high risk. Two hundred fifty-nine patients (64%) underwent EVAR repair, and 130 (50%) of these were considered high-risk patients (including four emergency procedures). One hundred forty-five patients (36%) underwent open AAA repair, including 15 emergency operations. All deaths occurred in the high-risk group: 12 (8.3%) died after open AAA repair and 6 (2.3%) died after EVAR repair. Postoperative length of stay was shorter for EVAR repair compared to open AAA. CONCLUSIONS: High-risk and low-risk patients can undergo EVAR repair with a lower rate of short-term systemic complications and a shorter length of stay compared to open AAA. Despite concern regarding the durability of EVAR, high-risk patients should be evaluated for EVAR repair before committing to open AAA repair.     

The incidence of hypomagnesaemia following abdominal aortic aneurysm surgery

IntroductionMagnesium is important for cardiac function. Hypomagnesaemia is associated with a higher incidence of arrhythmias and poorer outcomes in cardiac surgery. No studies have investigated the incidence or impact of postoperative hypomagnesaemia after abdominal aortic aneurysm (AAA) surgery. We aim to assess the incidence of hypomagnesaemia after AAA repair in our population.MethodsRetrospective analysis was performed of patients who underwent elective AAA surgery at a single vascular centre. The last 110 patients undergoing open or endovascular AAA repair were identified. The hospital pathology system was used to identify the immediate postoperative serum magnesium levels as well as patient demographics and admission details. Hypomagnesaemia was defined as serum magnesium of <0.7mmol/l.ResultsA total of 211 patients were studied and there were 3 deaths. Of the patients included, 101 underwent open elective AAA repair and 110 underwent endovascular repair. In the elective open repair group, 73 patients (73%) were hypomagnesaemic. In the endovascular repair group, 35 (32%) had hypomagnesaemia. A t-test showed a statistically significant difference in hypomagnesaemia between the open and endovascular groups (p<0.001).ConclusionsAAA surgery is associated with a high incidence of postoperative hypomagnesaemia, which is significantly greater among open repair patients. This is likely to have an effect on cardiac activity and lead to cardiac complications such as arrhythmias and poorer postoperative outcomes, especially in the open AAA repair subgroup. This stresses the importance of serum magnesium and cardiac monitoring in the postoperative phase. A prospective study is proposed to further investigate these findings, and their potential implications on perioperative morbidity and mortality.     

Predictors of Early Discharge following Open Abdominal Aortic Aneurysm Repair

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.