Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping

Background

Juxtarenal abdominal aortic aneurysm (AAA) comprises 15–20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs.

Methods

Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40 years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included.

Results

All patients had fusiform-type AAAs and were divided into infrarenal (N = 98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4 months (95% CI: 48.6–54.2). Mean survival time was 51.4 months (95% CI: 48.6–54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P > .999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P > .999). Old age (HR: 1.084; 95% CI: 1.025–1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225–4.553; P = .010) were substantially associated with in-hospital complications.

Conclusions

Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

     

Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms

Background

As endovascular aneurysm repair (EVAR) continues to advance, eligibility of patients with anatomically complex abdominal aortic aneurysms (AAAs) for EVAR is increasing. However, whether complex EVAR is associated with favorable outcome over conventional open repair and how outcomes compare with infrarenal EVAR remains unclear. This study examined perioperative outcomes of patients undergoing complex EVAR, focusing on differences with complex open repair and standard infrarenal EVAR.

Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998

PURPOSE: The purpose of this study was to determine the safety and durability of traditional surgical treatment for asymptomatic infrarenal abdominal aortic aneurysms (AAAs) in a large series of patients who underwent open operations during the decade preceding the commercial availability of stent graft devices for endovascular AAA repair. METHODS: From 1989 to 1998, 1135 consecutive patients (985 men [87%], 150 women; mean age, 70 +/- 7 years) underwent elective graft replacement of infrarenal AAA. Computerized perioperative data have been supplemented with a retrospective review of hospital charts/outpatient records and a telephone canvass to calculate survival rates and the incidence rate of subsequent graft-related complications. Seventy-four patients (6.5%) were lost during a median follow-up period of 57 months for the entire series. RESULTS: The 30-day mortality rate was 1.2%. The hospital course was completely uneventful for 939 patients (83%), and the median length of stay for all patients was 8 days. A total of 196 patients had single (n = 150; 13%) or multiple (n = 46; 4%) postoperative complications, which were more likely to occur in men (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.1 to 5.2) and in patients with a history of congestive heart failure (OR, 3.7; 95% CI, 1.7 to 7.8), chronic pulmonary disease (OR, 1.9; 95% CI, 1.2 to 2.9), or renal insufficiency (OR, 2.5; 95% CI, 1.3 to 4.7). Kaplan-Meier method survival rate estimates were 75% at 5 years and 49% at 10 years. As was the case with early complications, the long-term mortality rate primarily was influenced by age of more than 75 years (risk ratio [RR], 2.2; 95% CI, 1.7 to 2.8) or previous history of congestive heart failure (RR, 2.1; 95% CI, 1.3 to 3.4), chronic pulmonary disease (RR, 1.5; 95% CI, 1.2 to 2.0), or renal insufficiency (RR, 3.2; 95% CI, 2.2 to 4.6). Of the 1047 patients who survived their operations and remained available for follow-up study, only four (0.4%) have had late complications that were related to their aortic replacement grafts. CONCLUSION: These results reconfirm the exemplary success of open infrarenal AAA repair. The future of endovascular AAA repair is exceedingly bright, but until the long-term outcome of the current generation of stent grafts is adequately documented, their use should be justified by the presence of serious surgical risk factors.     

Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification.

OBJECTIVE: to propose an anatomical classification of juxtarenal aortic aneurysm (JRA) that relates to their epidemiology and the result of surgical repair. MATERIAL AND METHODS: retrospective study of 53 JRA and 376 infrarenal aortic aneurysm (AAA) operated between January 1989 and August 1999. RESULTS: perioperative mortality after JRA repair was 19% for type A (interrenal), 13% for type B (aneurysm of one or two renal origins) and 4% for type C (no infrarenal neck). These differences were not significant. The overall perioperative mortality after JRA repair (11%) was significantly higher than mortality of AAA (3%p<0.01). Postoperative morbidity after JRA repair was 62% for type A, 75% for type B and 33% for type C. Postoperative morbidity after type B repair was significantly more frequent than after type C (p<0.001). The overall postoperative morbidity (51%) was significantly more frequent than after AAA repair (26%p<0.01). Preoperative ischaemic heart disease, aortic clamping above the coeliac axis and aortic proximal clamping longer than 30 min were significant risk factors for death after JRA repair. Survival by life-table analysis at five years after JRA repair and AAA repair were respectively 73%+/-7% and 76%+/-3%. CONCLUSION: there is a less favourable outcome after JRA repair as compared to AAA repair. The complexity of the surgical procedure requires accurate preoperative morphological assessment. The proposed classification of juxtarenal aneurysms may be helpful in guiding surgical access.     

Critical Analysis of Outcome Determinants Affecting Repair of Intact Aneurysms Involving the Visceral Aorta

Visceral (mesenteric and/or renal) ischemia/reperfusion phenomena likely contribute to the greater operative risk associated with pararenal and lower thoracoabdominal aortic aneurysm (TAA) repair. To differentiate the relative adverse effects of aortic clamp level, visceral ischemic duration, and various pre- and perioperative factors shared with infrarenal aneurysm patients, a comparative analysis of early and late outcomes after open repair of intact infrarenal and visceral aortic aneurysms was undertaken. A retrospective review of our university experience from 1993-1999/2002 revealed 549 patients (mean age 70 ± 8 years, 11% female) undergoing open repair of intact, degenerative aneurysms of the infrarenal (n = 391, 71%), juxtarenal (n = 78, 14%), suprarenal (n = 35, 7%), and type IV (n = 40, 7%) and type III (n = 5, 1%) TAA segments. All pararenal aneurysms required suprarenal (SR) or supravisceral (SV, above celiac or superior mesenteric artery) clamp placement. Concomitant renal reconstruction was done in 30% of visceral aortic and 3% of open infrarenal aneurysm repairs. Thirty-day adverse outcomes [death, renal failure (creatinine 2 × baseline or new dialysis), visceral (bowel, hepatic, renal, spinal cord, multiple organ dysfunction), and nonvisceral (cardiac, pulmonary, procedural) complications] were analyzed relative to patient and operative factors using univariate comparisons and multivariate stepwise logistic regression. Perioperative mortality rates varied significantly between aneurysm locations (infrarenal 2.1%, juxtarenal 2.6%, suprarenal 11.4%, TAA 13.3%; p < 0.01) and for clamp locations (infrarenal 2.1%, SR 3.0%, SV 10.8 %; p < 0.01) but were not different between juxtarenal (1.8% vs. 4.4 %) and SR (9.1% vs. 12.5%) aneurysms requiring SR or SV clamping, respectively. Visceral ischemic time (VIT) during SR or SV clamping, and not clamp location, was the only independent predictor of operative mortality [odds ratio (OR) = 10.8, 95% confidence interval (CI) 4-29]. Sensitivity analyses revealed VIT > 32 min to be the strongest predictor of early death. Visceral complication or renal failure affected 34% and 23% of visceral aortic (5% dialysis) and 7% and 5% (1% dialysis) of infrarenal repairs, respectively. VIT > 32 min, SV clamp placement, diabetes, and inflammatory aneurysm repair were each predictive of visceral complications and/or renal failure. Five-year survival rate was similar after visceral aortic (70%) and infrarenal (75%) repairs but negatively impacted only in patients with prior infrarenal abdominal aortic aneurysm repair and recurrent aneurysms (OR = 2.8, 95% CI 1.2-6.9). The high incidence of early adverse outcomes following repair of pararenal and lower thoracoabdominal aneurysms is primarily associated with excessive periods of renal and/or gut ischemia during visceral aortic clamp placement. However, nearly equivalent early and late survival was seen for visceral aortic and infrarenal repairs when VIT < 32 min was achieved.Presented at the Twenty-eighth Annual Meeting of the Southern Association for Vascular Surgery, Rio Grande, Puerto Rico, January 14-17, 2004.     

Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms

ObjectiveThe Zenith Fenestrated Endovascular Graft (ZFEN; Cook Medical, Bloomington, Ind) has expanded the anatomic eligibility of endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysms (AAAs). Current data on ZFEN mainly consist of single-institution experiences and show conflicting results. Therefore, we compared perioperative outcomes after repair using ZFEN with open complex AAA repair and infrarenal EVAR in a nationwide multicenter registry.MethodsWe identified all patients undergoing elective AAA repair using ZFEN, open complex AAA repair, and standard infrarenal EVAR between 2012 and 2016 within the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Open complex AAA repairs were defined as those with a juxtarenal or suprarenal proximal AAA extent in combination with an aortic cross-clamping position that was above at least one renal artery. The primary outcome was perioperative mortality, defined as death within 30 days or within the index hospitalization. Secondary outcomes included postoperative renal dysfunction (creatinine concentration increase of >2 mg/dL from preoperative value or new dialysis), occurrence of any complication, procedure times, blood transfusion rates, and length of stay. To account for baseline differences, we calculated propensity scores and employed inverse probability-weighted logistic regression.ResultsWe identified 6825 AAA repairs—220 ZFENs, 181 open complex AAA repairs, and 6424 infrarenal EVARs. Univariate analysis of ZFEN compared with open complex AAA repair demonstrated lower rates of perioperative mortality (1.8% vs 8.8%; P = .001), postoperative renal dysfunction (1.4% vs 7.7%; P = .002), and overall complications (11% vs 33%; P < .001). In addition, fewer patients undergoing ZFEN received blood transfusions (22% vs 73%; P < .001), and median length of stay was shorter (2 vs 7 days; P < .001). After adjustment, open complex AAA repair was associated with higher odds of perioperative mortality (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4-18), postoperative renal dysfunction (OR, 13; 95% CI, 3.6-49), and overall complication rates (OR, 4.2; 95% CI, 2.3-7.5) compared with ZFEN. Compared with infrarenal EVAR, ZFEN presented comparable rates of perioperative mortality (1.8% vs 0.8%; P = .084), renal dysfunction (1.4% vs 0.7%; P = .19), and any complication (11% vs 7.7%; P = .09). Furthermore, after adjustment, there was no significant difference between the odds of perioperative mortality, postoperative renal dysfunction, or any complication between infrarenal EVAR and ZFEN.ConclusionsZFEN is associated with lower perioperative morbidity and mortality compared with open complex AAA repair, and outcomes are comparable to those of infrarenal EVAR. Long-term durability of ZFEN compared with open complex AAA repair warrants future research.     

Perioperative complications and early outcome after endovascular and open surgical repair of abdominal aortic aneurysms

BACKGROUND: Open repair (OR) of abdominal aortic aneurysms (AAAs) is a major surgical procedure with elevated morbidity and a low but definite mortality. Advocates of endovascular repair (EVAR) claim decreased complication rates and outcome equal to OR. METHODS: Data of all patients with infrarenal AAA that was treated electively, both with OR and EVAR, at Mayo Clinic Rochester between December 1, 1999 and December 1, 2001 were retrospectively reviewed. Thirty-day morbidity and mortality and early clinical outcomes were assessed and compared. RESULTS: Three hundred fifty-five patients underwent treatment: 261 patients, including 229 males and 32 females (mean age: 73 years; range: 52 to 90 years) underwent OR, and 94 patients including 85 males and 9 females (mean age: 77 years; range: 61 to 98 years) underwent EVAR (AneuRx: 53, Ancure: 38, Endologix: 3). Median AAA size was 57 mm in both groups. There were more high-risk patients in the EVAR group (27% vs 14%, P =.007). Thirty-day mortality rates were 1.1 % (3/261) for OR and 0 for EVAR (P = NS). Cardiac and pulmonary complications were less frequent after EVAR (11% vs 22%, P =.02, and 3% vs 16%, P =.001, respectively), but graft-related complications were more frequent (13% vs 4%, P =.002). The association between type of repair and cardiac, pulmonary, and graft complications remained statistically significant after adjusting for age, gender, and high-risk status. The multivariate odds ratios (EVAR vs OR) for cardiac, pulmonary, and graft complications were 0.35 (95% confidence interval [CI]: 0.17 to 0.74), 0.14 (95% CI: 0.04 to 0.47), and 3.81 (95% CI: 1.51 to 9.58), respectively. Primary and secondary patency and freedom-from-reintervention rates at 1 year were lower after EVAR (83% vs 98%, P <.001; 96% vs 99%, P =.02; 65% vs 93%, P <.001, respectively). CONCLUSIONS: Both elective OR and EVAR can be performed with low mortality, but cardiac and pulmonary complications are less frequent and less severe after EVAR. The tradeoff of EVAR is a higher rate of graft-related complications, with more reinterventions and a lower graft patency rate at 1 year. These results should be considered before EVAR is offered to patients with AAA.     

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.     

Preservation of renal function with surgical revascularization in patients with atherosclerotic renovascular disease

OBJECTIVE: Clinical and anatomic factors predictive of a favorable response to renal revascularization performed for renal function salvage remain poorly defined. To clarify decision making in such patients we reviewed a contemporary experience of surgical renal artery revascularization (RAR) performed primarily for preservation of renal function. METHODS: Between June 1990 and March 2001 (ensuring 1 year minimum follow-up), 96 patients with renal insufficiency (serum creatinine [Cr] concentration >or=1.5 mg/dL) and hypertension underwent RAR for preservation of renal function. Study end points included early and late renal function response, progression to dialysis dependence, and long-term survival. Variables potentially associated with these end points were assessed with univariate analysis, Cox regression analysis, and logistic regression analysis, and survival was assessed with the Kaplan-Meier method. RESULTS: Perioperative failure of RAR occurred in 3 patients (3%), with perioperative mortality in 4 patients (4.1%); thus 92 patients were available for long-term follow-up (mean, 39 months). Mean patient age was 70 +/- 9 years with a mean baseline Cr of 2.6 mg/dL (range, 1.5-7.8 mg/dL). Operative management consisted of aortorenal bypass in 38% of patients, extraanatomic bypass in 38% of patients, and endarterectomy in 24% of patients; 32% of patients required combined aortic revascularization and RAR, and 27% underwent bilateral RAR. At hospital discharge renal function had improved (20% decrement in Cr) in 41 (43%) patients, including 7 patients who were removed from dialysis; remained unchanged in 40 (41%) patients; and declined (20% increase in Cr) in 15 (16%) patients. At last follow-up renal function was either improved or unchanged in 72% of patients. Predictors of a favorable response to RAR at last follow-up included stable Cr at hospital discharge (odds ratio [OR], 7.1; 95% confidence interval [CI], 2.5-21.8; P =.0004) and decreased Cr at hospital discharge (OR, 16; 95% CI, 1.6-307.8; P <.0001); bilateral renal artery repair (OR, 3.1; 95% CI, 0.9-10.6; P =.07) approached clinical significance. Predictors of worsened excretory function at last follow-up included decline of renal function at hospital discharge (OR, 28.9; 95% CI, 5.0-165.4; P =.0002), intervention to treat unilateral renal artery stenosis (OR, 3.8; 95% CI, 0.8-16.6; P =.05), and level of baseline Cr (OR, 3.0; 95% CI, 1.0-4.0; P =.04). Progression to dialysis occurred in 16 (17%) patients. Dialysis-free survival at 5 years was 50%, and overall actuarial survival at 5 years was 59%. Predictors of progression to dialysis during follow-up included treatment of complete renal artery occlusion (OR, 6.2; 95% CI, 1.3-29.5; P =.02), early failure of RAR (OR, 3.1; 95% CI, 0.7-14.2; P =.04) and baseline Cr (OR, 2.9; 95% CI, 1.3-6.1; P =.006). CONCLUSION: Long-term clinical success in the preservation of renal function, noted in 70% of patients, can be predicted by the initial response to RAR and by anatomic factors, in particular, bilateral repair. While extreme (mean Cr >or=3.2 mg/dL) renal dysfunction generally is predictive of poor long-term outcome, a subset of patients will experience favorable results, even to the extent of rescue from dialysis. These results may facilitate clinical decision making in the application of RAR for renal function salvage.     

Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience

PURPOSE: We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. METHODS: From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 +/- 3 degrees C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T(9) to L(1) region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. RESULTS: The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35. 3; 95% CI, 5.3 to 233; P <.001) and renal failure (OR, 32.2; 95% CI, 6.6 to 157; P <.001) were the only independent predictors of postoperative death. SCI of any severity occurred in 7% of cases (type I/II, 10 of 83 [12%]; all other types, 2 of 87 [2.3%]), versus a predicted (Acher model) incidence of 18.5% for this cohort (P =. 003). Half the deficits were minor, with good functional recovery, and devastating paraplegia occurred in three patients (2.0%). Independent correlates of SCI included types I and II TAA (OR, 8.0; 95% CI, 1.4 to 46.3; P =.021), nonelective operation (OR, 8.3, 95% CI, 1.8 to 37.7; P =.006), oversewn T(9) to L(2) intercostal vessels (OR, 6.1; 95% CI, 1.3 to 28.8; P =.023), and postoperative renal failure (OR, 23.6; 95% CI, 4.4 to 126; P <.001). These same clinical variables of nonelective operations (OR, 7.7; 95% CI, 1.4 to 41.4; P =.017), oversewn T(9) to L(2) intercostal arteries (OR, 9.7; 95% CI, 1.5 to 61.2; P =.016), and postoperative renal failure (OR, 20.8; 95% CI, 3.0 to 142.1; P =.002) were independent predictors of SCI in the subgroup analysis of high-risk patients, ie, patients with type I/II TAA. CONCLUSION: EC has been effective in reducing immediate, devastating, total paraplegia after TAA repair. A strategy that combines the neuroprotective effect of regional cord hypothermia, avoiding the sacrifice of potential spinal cord blood supply, and postoperative adjuncts (eg, avoidance of hypotension, CSF drainage) appears necessary to minimize SCI after TAA repair.     

Existence of abdominal aortic aneurysms in patients with thoracic aortic dissections

OBJECTIVE: The objective of this study was to determine the coexistence or later development of pararenal and infrarenal abdominal aortic aneurysms (AAAs) in patients with thoracic aortic dissections. METHODS: One hundred forty-five patients (95 men, 50 women) encountered from 1992 to 2001 with thoracic aortic dissections-excluding those associated with trauma, those with Marfan's syndrome, and those with thoracoabdominal aortic aneurysms-were studied. The most common risk factors included hypertension (59%) and a history of tobacco use (52%). Type III dissections affected 86 patients (59%), and type I dissections affected the remaining 59 patients (41%). Aortic computed tomography (CT) scans were obtained annually. Data were assessed by univariate and multivariate analyses. RESULTS: Five patients (3%) had a history of AAA repair prior to their thoracic aortic dissection diagnosis-3 were type III dissections and 2 were type I dissections. Twelve patient's (8%) AAAs were diagnosed with the initial CT study of their thoracic aortic dissection. Type III dissections accounted for all but one of these (11 of 12, 92%). Ten additional AAAs (7%) developed in the 128 patients with no initial evidence of an AAA being recognized from 1 to 48 months (average 16 months) after the thoracic aortic dissection was diagnosed. Type III dissections affected 8 of these 10 patients. Among the total 27 AAAs noted in this series, 74% (20 AAAs) were not continuous with the thoracic aortic dissection. In the univariate analysis, age (P =.0002), male gender (P =.044), history of smoking (P =.01), chronic obstructive pulmonary disease (P <.001), duration of dissection (P =.05), and presence of type III dissection (P =.009) were associated with the presence of an AAA. In the multivariate analysis, both chronic obstructive pulmonary disease (odds ratio 5.4, 95% CI, 1.3 to 22.3; P =.02) and age (OR 1.06, 95% CI, 1.02 to 1.11; P =.004) were significant predictors of the development of AAAs. CONCLUSION: This study documented that patients with thoracic aortic dissections are at risk to harbor or develop a later AAA. This finding supports the tenet that abdominal CTs or ultrasound scanning should be mandatory in the follow-up of patients with known thoracic aortic dissections.     

The effect of secondary operations on mortality following abdominal aortic aneurysm repair in the United States: 1988-2001

Certain complications following open repair of abdominal aortic aneurysms (AAAs) require additional operations or invasive procedures. The purpose of this study was to determine the effect of secondary interventions on mortality rate following open repair of intact and ruptured AAAs in the United States. Clinical data on 98,193 patients treated from 1988 to 2001 with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) primary procedure code 38.44 (resection of the abdominal aorta with replacement) were analyzed. Demographic factors, types of secondary interventions, and in-hospital mortality rates were assessed by univariate and multivariate logistic regression analysis (SPSS Version 11.0, Chicago, IL). The database utilized in this study was The Nationwide Inpatient Sample (NIS). The mortality rate was 4.5% in the intact AAA group and 45.5% in the ruptured AAA group. The rate of secondary operations and procedures was much higher in the ruptured AAA group, especially related to renal failure (5.52% vs 1.49%, p <0.001); respiratory failure (3.67% vs 0.71%, p <0.001); postoperative bleeding (2.41% vs 0.81%, p <0.001); or colonic ischemia (2.38% vs 0.36%, p <0.001). Increased mortality following open repair of intact AAAs accompanied: peripheral artery angioplasty/stenting (OR, 1.25; 95% CI, 1.04-1.51; p = 0.018); coronary artery angioplasty/stenting (OR, 1.68; 95% CI, 1.05-2.70; p = 0.031); inferior vena cava (IVC) filter placement (OR, 2.02; 95% CI, 01.31-3.1; p = 0.001); vascular reconstruction or thromboembolectomy (OR, 2.05; 95% CI, 1.9-2.22; p <0.001); lower extremity amputation (OR, 4.09; 95% CI, 2.78-6.0; p <0.001); coronary artery bypass (OR, 6.71; 95% CI, 3.74-12.03; p <0.001); operations for postoperative bleeding (OR, 6.92; 95% CI, 5.71-8.4; p <0.001); initiation of hemodialysis (OR, 10.52; 95% CI, 9.22-12.01; p <0.001); tracheostomy (OR, 11.9; 95% CI, 9.86-14.37; p <0.001); and colectomy (OR, 16.22; 95% CI, 12.55-20.95; p <0.001). Increased risk of mortality following open repair of ruptured AAAs accompanied the following: operations for postoperative bleeding (OR, 1.5; 95% CI, 1.22-1.85; p <0.001); colectomy (OR, 1.63; 95% CI, 1.32-2.01; p <0.001); and initiation of hemodialysis (OR, 2.66; 95% CI, 2.30-3.08; p <0.001). The only independent variable in this group associated with decreased risk of in-hospital mortality was IVC filter placement (OR, 0.41; 95% CI, 0.27-0.64; p <0.001). This study confirms the perception that additional operations or invasive procedures following open repair of AAA entail significantly worse in-hospital mortality rates, especially when related to colonic ischemia, respiratory failure, and renal failure.     

Genetic similarity in inflammatory and degenerative abdominal aortic aneurysms: a study of human leukocyte antigen class II disease risk genes.

PURPOSE: Clinically, abdominal aortic aneurysms (AAAs) display a spectrum of inflammation that extends from apparently noninflamed (degenerative) AAAs to the classic inflammatory variant. Genes encoded in the human leukocyte antigen (HLA) region are important in the development of both variants of AAA; however, their role in progression to the inflammatory variant is unknown. The purpose of this study was to compare HLA class II genes in patients with degenerative versus classic inflammatory AAAs and to quantify their impact as disease risk factors. METHODS: Genotypes of the 12 major alleles of the HLA-DR B1 locus were determined in patients with degenerative (102) and inflammatory (40) AAAs who were compared with controls (118). Univariate and multivariate logistic regression analyses were used to determine allele distributions and to quantify disease risk. RESULTS: Distribution of the HLA-DR B1 alleles was nonrandom and similar in both degenerative and inflammatory AAA groups compared with controls. The B1*02 and B1*04 alleles were enhanced in both degenerative (39.2% vs. 25.4%, P =.03; and 35.3% vs. 24.6%, P =.08 respectively) and inflammatory (47.5% vs. 25.4%, P =.01; and 32.5% vs. 24.6%, P =.09, respectively) AAAs compared with controls. The B1*02 and B1*04 alleles were associated with risk for both degenerative (odds ratio [OR] 2.2; 95% CI, 1.2-4.0; and OR 2.0; 95% CI, 1.1-3.7, respectively) and inflammatory AAAs (OR 3.7; 95% CI, 1.8-8.6; and OR 2.5; 95% CI, 1.1-6.1). CONCLUSION: This study demonstrates that identical HLA alleles function as genetic risk factors for both inflammatory and degenerative AAAs. These results support the concept of a common, immune-mediated pathogenesis for AAAs that may be modulated by HLA-independent factors.     

Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair

Background and aims Since the introduction of endovascular aortic aneurysm repair (EVAR) for aortic aneurysms, the number of juxtarenal aortic aneurysms (JRA) has been growing steadily due to selection bias (neck morphology for EVAR). This case-match study compares the perioperative outcome and midterm results of suprarenally clamped JRA with infrarenal aortic aneurysms (AAA). Methods From 1997 to 2004, patients who received open surgery with suprarenal clamping for JRA were included in the study and compared to matched patients with infrarenal clamping (AAA). Measurements analyzed were the in-hospital mortality and morbidity. Midterm results were obtained through clinical investigation and magnetic resonance angiography imaging. Results Thirty-five patients (mean age, 68.4 years; 30 male and 5 female) received suprarenal cross-clamping for JRA. The overall in-hospital mortality for JRA and for the controls (AAA) with elective aortic repair was 4.5% (6.1% JRA; 3% AAA, p = 0.058). The morbidity of JRA was elevated according to the rate of pulmonary complications (p = 0.021) and the need for re-operation (p = 0.019). The mean follow-up time was 2.3 years (range, 8–96 months). At follow-up, 28 patients (80%) from the JRA group and 29 patients from the AAA group (82.9%) were alive. Conclusion Open aortic surgery for JRA with the need for suprarenal cross-clamping shows a slightly elevated in-hospital mortality rate without statistical significance and equal midterm mortality results in comparison with infrarenally clamped aortic aneurysms.     

Renal Artery Endarterectomy for Treatment of Renovascular Hypertension Combined with Infrarenal Aortic Reconstruction: Analysis of Surgical Results

From June 1995 to February 2000, 16 patients with renovascular hypertension had bilateral transaortic renal artery endarterectomy (RA TEA) combined with either infrarenal aortic aneurysm repair (8 patients) or infrarenal aortodistal bypass for occlusive disease (8 patients). Aortic clamp level for RA TEA was supraceliac in eight patients and suprarenal in eight patients with a mean clamp time of 19 min (range 14 to 25 min). Perioperative complications occurred in four patients. These included respiratory insufficiency with prolonged intubation (1 patient), prolonged intubation with transient renal failure requiring temporary dialysis (1 patient), acute thrombosis of right limb of aortofemoral bypass graft (1 patient) and major left hemispheric cerebrovascular accident (1 patient). Results from this contemporary patient series demonstrate acceptable perioperative morbidity and mortality when RA TEA for treatment of renovascular hypertension is combined with infrarenal aortic reconstruction. In this setting, either supraceliac or suprarenal aortic clamping for short time periods appears to be well tolerated. Clinical outcome is enhanced by salvage of renal function, decrease in medication requirement, and improvement in blood pressure control.     

Predictors of renal dysfunction after endovascular and open repair of abdominal aortic aneurysms

Objective

Renal complications after repair of abdominal aortic aneurysms (AAAs) have been associated with increased morbidity and mortality. However, limited data have assessed risk factors for renal complications in the endovascular era. This study aimed to identify predictors of renal complications after endovascular AAA repair (EVAR) and open repair.

Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular abdominal aortic repair

OBJECTIVE: To review, in the era of endovascular abdominal aortic repair (EVAR), the clinical spectrum of colonic ischemia (CI) following abdominal aortic aneurysm (AAA) repair and to assess the rate, overall mortality, and associated factors of occurrence. METHODS: Between 1995 and 2005, 1174 patients with infrarenal AAA were treated either by open surgery (n = 682) or by EVAR (n = 492). Preoperative risk factors, clinical presentation, intraoperative data, and early postoperative outcomes were prospectively assessed. Overt colonic ischemia as proven by colonoscopy and/or by operation was considered as a validating event and was correlated to collected variables. RESULTS: CI occurred in 34 patients (2.9%). Eighteen out of 34 (53%) patients died within 1 month. At 2 years, the survival rate was 35% in the CI group vs 86% in the non-CI group. Associated factors of occurrence of CI were: type of operation (open group = 27/682 [4%] vs EVAR = 7/492 [1.4%] [P = .01]), aneurysm rupture (11/88 [12.5%] vs 23/1086 [2.1%], P < .001), preoperative renal insufficiency (4/30 [13.3%] vs 29/1133 [3.1%], P = .01), preoperative respiratory insufficiency (8/157 [7%] vs 23/1005 [2%], P = .01), duration of operation (<2 hours [518] = 1.7%, between 2 to 4 hours [558] 2.9%, more than 4 hours [66] 13.6%, P = .001). Mean blood loss was greater in patients with CI (CI = 2000 ml [650-3350] than in those without CI = 1000 ml [500-1800] P = .008). Logistic regression analysis showed that rupture (OR 6.03 [interval of confidence (IC) 95% 2.68-13.5] P = .0001), duration of operation (OR 5.73 [IC 95% 2.06-15.9] P = .001) and creatinin > 200 mol/l (OR 4.67 [IC 95% 1.39-15.7] P = .028) were independent factors of CI. The mortality due to colonic ischemia was not statistically different between open surgery 14/27 (52%) and EVAR 4/7 (57%). CONCLUSION: CI remains a serious complication following AAA repair. In the univariate analysis, EVAR was associated with a lower rate of colonic ischemia. However, the logistic regression analysis showed that only rupture, long duration of operation, and prior renal disease were independently associated with CI. Within the two treatment modalities, the mortality rate remained identical.     

Age versus comorbidities as risk factors for complications after elective abdominal aortic reconstructive surgery

PURPOSE: This study estimated the association between age and in-hospital postoperative complications, controlling for known or suspected risk factors, in a series of patients undergoing elective abdominal aortic reconstructive surgery (AAR). METHODS: This retrospective cohort study of outcome data with multivariate logistic regression analysis was conducted at Emory University Hospital, a tertiary care, university-affiliated hospital. All patients undergoing elective AAR between Jan 1, 1986, and Aug 1, 1996, were included (n = 856). An estimate of the odds ratio (OR) and 95% CI for the association between patient age and in-hospital major morbidity or mortality after elective AAR was made, controlling for significant risk factors. RESULTS: Among the 856 patients, 170 had a nonfatal complication (136 with major and 34 with minor complications), and 11 patients (1.3%) died. The final logistic regression model demonstrated a mild association between increasing age and rate of major postoperative complications, including death (for each increase in age of 10 years: OR, 1.23; 95% CI, 1.00-1.52; P =.052). Other significant covariates in the final model included cardiac disease (OR, 2.84; 95% CI, 1.18-6.86; P =.020), pulmonary disease (OR, 1.96; 95% CI, 1.35-2.84; P =.0004), and renal disease (OR, 2.57; 95% CI, 1.66-3.99; P =.0001). Increasing age was associated with a moderate increase in the rate of death (for each increase in age of 10 years: OR, 2.74; 95% CI, 1.22-6.16; P =.015) in a model with cardiac disease as the only significant covariate (OR, 14.67; 95% CI, 3.46-62.16; P =.0003). CONCLUSION: For patients undergoing elective AAR, increasing patient age is associated with a small increase in risk for in-hospital morbidity or mortality. However, significant cardiac, pulmonary, or renal disease is associated with a much greater risk of postoperative complications, and, therefore, advanced age should not be the sole basis of exclusion for otherwise suitable candidates for elective AAR.     

Transperitoneal versus retroperitoneal suprarenal cross-clamping for repair of abdominal aortic aneurysm with a hostile infrarenal aortic neck

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.     

Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study.

PURPOSE: This study reviewed the long-term outcome of patients who underwent open repair of infrarenal abdominal aortic aneurysms (AAAs). METHODS: A retrospective study of 208 patients (188 men and 20 women) with a mean age of 65.6 years who survived elective or emergency open repair of an infrarenal AAA was conducted at a university referral hospital. Main outcome measures included late graft-related complications, survival free from any reintervention, survival free from any vascular reintervention, and overall survival rates. RESULTS: Late graft-related complications occurred in 32 patients (15.4%). A proximal para-anastomotic pseudoaneurysm developed in six patients (2.9%), and a distal pseudoaneurysm developed in 18 patients (8.7%); in seven of these cases (3.4%), it was bilateral or recurrent. A graft limb occlusion occurred in 11 patients (5.3%). These complications required 37 surgical or other invasive procedures in 27 patients (13.0%). Thirty-one vascular and/or endovascular reoperations were performed. The 5-year, 10-year, and 15-year survival free from any reintervention rates were 91.5%, 86.2%, and 72.0%, respectively. At the same intervals, the survival free from any vascular reintervention rates were 93.8%, 88.5%, and 73.9%, respectively, and the overall survival rates were 66.8%, 39.4%, and 18.0%, respectively. Complications associated with a ruptured femoral artery pseudoaneurysm, a ruptured aortic pseudoaneurysm, an aortoduodenal fistula, and the elective repair of a femoral pseudoaneurysm were the graft-related causes of death, which occurred in four patients (1.9%). Age (P <.0001) and chronic obstructive pulmonary disease (P =.002) were shown by means of multivariate analysis to be predictive of poor survival outcome, and chronic obstructive pulmonary disease (P =.02) and lower limb ischemia (P =.04) were shown to be associated with an increased need for vascular reinterventions to treat graft-related complications. CONCLUSION: Open repair of infrarenal AAAs can achieve satisfactory 15-year follow-up rates of survival free from reintervention for any graft-related complications, suggesting that surgery should still be considered the procedure of choice for infrarenal AAAs, at least in patients who are fit for surgery.