title: Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Vascular and Endovascular Therapy, University of Florida College of Medicine, Gainsville, Fl, USA. leewa@surgery.ufl.edu
authors.forename: W Anthony
authors.initials: WA
authors.lastname: Lee
authors.forename: Scott A
authors.initials: SA
authors.lastname: Berceli
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Huber
authors.forename: C Keith
authors.initials: CK
authors.lastname: Ozaki
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Flynn
authors.forename: James M
authors.initials: JM
authors.lastname: Seeger
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D015331:Cohort Studies; D005260:Female; D005263:Femoral Artery; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D011446:Prospective Studies; D011859:Radiography; D012187:Retroperitoneal Space; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*