title: Transperitoneal versus retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular National Surgical Quality Improvement Program.
abstract: OBJECTIVE
  We sought to compare current practices in patient selection and 30-day outcomes for transperitoneal and retroperitoneal abdominal aortic aneurysm (AAA) repairs.
  
  
  METHODS
  All patients undergoing elective transperitoneal or retroperitoneal surgical repair for AAA between January 2011 and December 2013 were identified in the Targeted Vascular National Surgical Quality Improvement Program database. Emergency cases were excluded. Baseline characteristics, anatomic details, and intraoperative and postoperative outcomes were evaluated among those with infrarenal or juxtarenal AAA only.
  
  
  RESULTS
  We identified 1135 patients: 788 transperitoneal (69%) and 347 retroperitoneal (31%). When only infrarenal and juxtarenal AAAs were evaluated, the retroperitoneal patients were less likely to have an infrarenal clamp location (43% vs 68%) and had more renal revascularizations (15% vs 6%; P < .001), more visceral revascularizations (5.6% vs 2.4%; P = .014), and more lower extremity revascularizations (11% vs 7%; P = .021) compared with the transperitoneal approach. Postoperative mortality and return to the operating room were similar. Transperitoneal patients had a higher rate of wound dehiscence (2.4% vs 0.4%; P = .045), and retroperitoneal patients had higher incidence of pneumonia (9% vs 5%; P = .034), transfusion (77% vs 71%; P = .037), and reintubation (11% vs 7%; P = .034), and a longer median length of stay (8 vs 7 days; P = .048). After exclusion of all concomitant procedures, only transfusions remained more common in the retroperitoneal approach (78% vs 70%; P = .036). Multivariable analyses showed only higher rates of reintubation in the retroperitoneal group (odds ratio, 1.7; 95% confidence interval, 1.0-3.0; P = .047).
  
  
  CONCLUSIONS
  The retroperitoneal approach is more commonly used for more proximal aneurysms and was associated with higher rates of pneumonia, reintubation, and transfusion, and a longer length of stay on univariate analyses. However, multivariable analysis demonstrated similar results between groups. The long-term benefits and frequency of reinterventions remain to be proven.
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Dominique B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Klaas H J
authors.initials: KH
authors.lastname: Ultee
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Sara L
authors.initials: SL
authors.lastname: Zettervall
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Pete A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Darling
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Mark
authors.initials: M
authors.lastname: Wyers
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Joost A
authors.initials: JA
authors.lastname: van Herwaarden
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherme@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D017558:Elective Surgical Procedures; D005260:Female; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D010537:Peritoneum / Q000601:surgery*; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012187:Retroperitoneal Space / Q000601:surgery*; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D055815:Young Adult