Klaas H J Ultee1, Sara L Zettervall2, Peter A Soden2, Jeremy Darling2, Hence J M Verhagen3, Marc L Schermerhorn4. 1. Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. 2. Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass. 3. Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. 4. Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu.
Abstract
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. METHODS: We identified all patients undergoing nonruptured complex EVAR, complex open repair, and infrarenal EVAR in the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular Module. Aneurysms were considered complex if the proximal extent was juxtarenal or suprarenal or when the Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind) was used. Independent risks were established using multivariable logistic regression analysis. RESULTS: Included were 4584 patients, with 411 (9.0%) undergoing complex EVAR, 395 (8.6%) undergoing complex open repair, and 3778 (82.4%) undergoing infrarenal EVAR. Perioperative mortality was 3.4% after complex EVAR, 6.6% after open repair (P = .038), and 1.5% after infrarenal EVAR (P = .005). Postoperative acute kidney injuries occurred in 2.3% of complex EVAR patients, in 9.5% of those undergoing complex open repair (P < .001), and in 0.9% of infrarenal EVAR patients (P = .007). Compared with complex EVAR, complex open repair was an independent predictor of 30-day mortality (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.4), renal function deterioration (OR, 4.8; 95% CI, 2.2-10.5), and any complication (OR, 3.7; 95% CI, 2.5-5.5). When complex vs infrarenal EVAR were compared, infrarenal EVAR was associated with favorable 30-day mortality (OR, 0.5; 95% CI, 0.2-0.9), and renal outcome (OR, 0.4; 95% CI, 0.2-0.9). CONCLUSIONS: In this study assessing the perioperative outcomes of patients undergoing repair for anatomically complex AAAs, complex EVAR had fewer complications than complex open repair but carried a higher risk of adverse outcomes than infrarenal EVAR. Further research is warranted to determine whether the benefits of EVAR compared with open repair for complex AAA treatment are maintained during long-term follow-up.
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. METHODS: We identified all patients undergoing nonruptured complex EVAR, complex open repair, and infrarenal EVAR in the American College of Surgeons National Surgical Quality Improvement Program Targeted Vascular Module. Aneurysms were considered complex if the proximal extent was juxtarenal or suprarenal or when the Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind) was used. Independent risks were established using multivariable logistic regression analysis. RESULTS: Included were 4584 patients, with 411 (9.0%) undergoing complex EVAR, 395 (8.6%) undergoing complex open repair, and 3778 (82.4%) undergoing infrarenal EVAR. Perioperative mortality was 3.4% after complex EVAR, 6.6% after open repair (P = .038), and 1.5% after infrarenal EVAR (P = .005). Postoperative acute kidney injuries occurred in 2.3% of complex EVAR patients, in 9.5% of those undergoing complex open repair (P < .001), and in 0.9% of infrarenal EVAR patients (P = .007). Compared with complex EVAR, complex open repair was an independent predictor of 30-day mortality (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.4), renal function deterioration (OR, 4.8; 95% CI, 2.2-10.5), and any complication (OR, 3.7; 95% CI, 2.5-5.5). When complex vs infrarenal EVAR were compared, infrarenal EVAR was associated with favorable 30-day mortality (OR, 0.5; 95% CI, 0.2-0.9), and renal outcome (OR, 0.4; 95% CI, 0.2-0.9). CONCLUSIONS: In this study assessing the perioperative outcomes of patients undergoing repair for anatomically complex AAAs, complex EVAR had fewer complications than complex open repair but carried a higher risk of adverse outcomes than infrarenal EVAR. Further research is warranted to determine whether the benefits of EVAR compared with open repair for complex AAA treatment are maintained during long-term follow-up.
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