title: Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Vascular Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, New York, New York 10467, USA.
authors.forename: Palma M
authors.initials: PM
authors.lastname: Shaw
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Veith
authors.forename: Evan C
authors.initials: EC
authors.lastname: Lipsitz
authors.forename: Takao
authors.initials: T
authors.lastname: Ohki
authors.forename: William D
authors.initials: WD
authors.lastname: Suggs
authors.forename: Manish
authors.initials: M
authors.lastname: Mehta
authors.forename: Katherine
authors.initials: K
authors.lastname: Freeman
authors.forename: Jamie
authors.initials: J
authors.lastname: McKay
authors.forename: George L
authors.initials: GL
authors.lastname: Berdejo
authors.forename: Reese A
authors.initials: RA
authors.lastname: Wain
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Gargiulo Iii
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D011379:Prognosis; D011446:Prospective Studies; D012187:Retroperitoneal Space; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods* / Q000401:mortality