title: Increasing complexity in the open surgical repair of abdominal aortic aneurysms.
abstract: BACKGROUND
  Patient selection and techniques for the operative management of abdominal aortic aneurysms (AAAs) continue to evolve. We sought to examine trends in open surgical repair (OSR) over a 15-year period in which endovascular aneurysm repair (EVAR) has become increasingly prevalent.
  
  
  METHODS
  Patients undergoing elective repair of infra- and pararenal AAAs were identified through our center's prospective vascular surgery registry during two time periods: 1995 to 2004 (era 1) and 2004 to 2010 (era 2). Data collected included comorbidities, demographics, and operative characteristics.
  
  
  RESULTS
  A total of 1,188 elective AAAs were repaired during the study period, including 828 (70%) OSRs and 360 (30%) EVARs. The proportion of OSRs requiring suprarenal cross-clamping increased from 14.2% during era 1 to approximately 50% by the end of era 2. Compared with era 1, increases were seen in the unadjusted mortality rates during era 2 for OSR with infrarenal clamping (from 0.62% to 1.73%) and OSR with suprarenal clamping (from 1.22% to 3.98%); after adjusting for other variables, however, no significant temporal trends were seen. Similarly, no significant change in major complication rate was seen after adjusting for other factors. The incidence of major comorbidities among the OSR group was largely unchanged between the two eras.
  
  
  CONCLUSIONS
  OSR of AAAs has become increasingly complex, with the increased utilization of EVAR. Despite this complexity, risk-adjusted outcomes may remain good in high-volume centers.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02215, USA.
authors.forename: Neal R
authors.initials: NR
authors.lastname: Barshes
authors.forename: James
authors.initials: J
authors.lastname: McPhee
authors.forename: C Keith
authors.initials: CK
authors.lastname: Ozaki
authors.forename: Louis L
authors.initials: LL
authors.lastname: Nguyen
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Menard
authors.forename: Edwin
authors.initials: E
authors.lastname: Gravereaux
authors.forename: Michael
authors.initials: M
authors.lastname: Belkin
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D057510:Endovascular Procedures / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000639:trends; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods* / Q000706:statistics & numerical data