Angela M R Ferrante1, Umberto Moscato2, Elda C Colacchio3, Francesco Snider3. 1. Vascular Surgery Unit, "A. Gemelli" University Hospital, Catholic University of Sacred Heart School of Medicine, Rome, Italy. Electronic address: aferrante@rm.unicatt.it. 2. Public Health Institute-Hygiene Section, Catholic University of Sacred Heart School of Medicine, Rome, Italy. 3. Vascular Surgery Unit, "A. Gemelli" University Hospital, Catholic University of Sacred Heart School of Medicine, Rome, Italy.
Abstract
OBJECTIVE: This study presents a retrospective analysis of long-term outcomes and factors influencing early and late results of a 20-year experience with open repair of atherosclerotic pararenal abdominal aortic aneurysms (PAAAs). METHODS: Records of consecutive patients who underwent open repair of PAAA between 1990 and 2010 at a tertiary referral care center were analyzed for demographics, comorbidities, operative variables, complications, and 30-day mortality. Long-term results were also assessed through a local electronic medical database and direct follow-up. Variables influencing early and late results were evaluated by univariate and multivariate logistic regression analyses, stepwise backward elimination, and Cox proportional hazard regression. RESULTS: The study included 200 patients (94% men; mean age, 69.5 years) who were monitored for a mean of 107.3 months. The aneurysm was juxtarenal in 78% of patients, suprarenal in 19.5%, and type IV thoracoabdominal in 2.5%. Mortality at 30 days was 2.5%. At least one major complication occurred in 51.5%. Postoperative acute renal failure (pARF) occurred in 11% of the patients, 3% had temporary hemodialysis, but only 0.5% required chronic hemodialysis. pARF was significantly related to preoperative renal function (P = .009), visceral ischemia >30 minutes (P = .05), and supraceliac or supramesenteric clamp site (P = .005). Respiratory complications (13.8%) were associated with an increasing stage of chronic obstructive pulmonary disease (P = .020), proximal clamp site (P = .047), and intraoperatively infused crystalloids (P = .014). Cardiac complications (12.8%) were related to previous myocardial infarction (P = .031) and proximal clamp site (P = .003). Late deaths were observed in 21.5%. Mean survival was 50 months, with Kaplan-Meier survival estimates of 78% at 5 years and 60.5% at 10 years. Variables influencing long-term survival included age (hazard ratio [HR], 2.67; P = .01), chronic obstructive pulmonary disease stage 2 (HR, 5.14; P = .01) and stage 3 (HR, 4.54; P = .03), postoperative cardiac complication (HR, 3.93; P ≤ .00), previous myocardial infarction (HR, 1.47; P = .02), peripheral artery disease (HR, 1.97; P = .03), and smoking (HR, 1.17; P = .02). Survival and late-onset renal insufficiency were unaffected by preoperative renal function. Late renal failure was observed in 6.2% of the patients but did not predict mortality. CONCLUSIONS: Conventional surgical repair of PAAAs can be performed with acceptable short-term and long-term mortality. Although pARF is frequent, chronic hemodialysis at discharge is rare. Cardiac and respiratory complications are also common and associated with worse survival. Our data represent a potentially useful benchmark for complex endovascular repairs of this type of aneurysm.
OBJECTIVE: This study presents a retrospective analysis of long-term outcomes and factors influencing early and late results of a 20-year experience with open repair of atherosclerotic pararenal abdominal aortic aneurysms (PAAAs). METHODS: Records of consecutive patients who underwent open repair of PAAA between 1990 and 2010 at a tertiary referral care center were analyzed for demographics, comorbidities, operative variables, complications, and 30-day mortality. Long-term results were also assessed through a local electronic medical database and direct follow-up. Variables influencing early and late results were evaluated by univariate and multivariate logistic regression analyses, stepwise backward elimination, and Cox proportional hazard regression. RESULTS: The study included 200 patients (94% men; mean age, 69.5 years) who were monitored for a mean of 107.3 months. The aneurysm was juxtarenal in 78% of patients, suprarenal in 19.5%, and type IV thoracoabdominal in 2.5%. Mortality at 30 days was 2.5%. At least one major complication occurred in 51.5%. Postoperative acute renal failure (pARF) occurred in 11% of the patients, 3% had temporary hemodialysis, but only 0.5% required chronic hemodialysis. pARF was significantly related to preoperative renal function (P = .009), visceral ischemia >30 minutes (P = .05), and supraceliac or supramesenteric clamp site (P = .005). Respiratory complications (13.8%) were associated with an increasing stage of chronic obstructive pulmonary disease (P = .020), proximal clamp site (P = .047), and intraoperatively infused crystalloids (P = .014). Cardiac complications (12.8%) were related to previous myocardial infarction (P = .031) and proximal clamp site (P = .003). Late deaths were observed in 21.5%. Mean survival was 50 months, with Kaplan-Meier survival estimates of 78% at 5 years and 60.5% at 10 years. Variables influencing long-term survival included age (hazard ratio [HR], 2.67; P = .01), chronic obstructive pulmonary disease stage 2 (HR, 5.14; P = .01) and stage 3 (HR, 4.54; P = .03), postoperative cardiac complication (HR, 3.93; P ≤ .00), previous myocardial infarction (HR, 1.47; P = .02), peripheral artery disease (HR, 1.97; P = .03), and smoking (HR, 1.17; P = .02). Survival and late-onset renal insufficiency were unaffected by preoperative renal function. Late renal failure was observed in 6.2% of the patients but did not predict mortality. CONCLUSIONS: Conventional surgical repair of PAAAs can be performed with acceptable short-term and long-term mortality. Although pARF is frequent, chronic hemodialysis at discharge is rare. Cardiac and respiratory complications are also common and associated with worse survival. Our data represent a potentially useful benchmark for complex endovascular repairs of this type of aneurysm.
Authors: Christopher A Latz; Laura Boitano; Samuel Schwartz; Nicholas Swerdlow; Kirsten Dansey; Rens R B Varkevisser; Virendra Patel; Marc L Schermerhorn Journal: Eur J Vasc Endovasc Surg Date: 2020-10-09 Impact factor: 7.069