Contemporary outcomes of open complex abdominal aortic aneurysm repair.
OBJECTIVE
The recent commercial availability of fenestrated stent grafts is likely to result in increasing endovascular repair of complex (juxtarenal and suprarenal) abdominal aortic aneurysms (cAAAs). Whereas most studies providing benchmarking for outcomes after open repair have been from high-volume centers, we sought to evaluate outcomes after elective open cAAA repair vs infrarenal AAA repair at a regional level.


METHODS
We used the Vascular Study Group of New England registry, which recorded 1875 open AAA repairs in New England from 2003 to 2011. Data from 14 hospitals performing both AAA and cAAA repair were used to assess the impact of clinical and technical factors on outcomes of cAAA repair.


RESULTS
There were 443 patients who had elective cAAA repair as defined by use of a suprarenal (n = 340; 77%) or supraceliac (n = 103; 23%) clamp, with median survival follow-up of 35 months (interquartile range, 47 months). Compared with AAA repair, patients undergoing cAAA repair were more likely to be female; to have hypertension, congestive heart failure, or chronic obstructive pulmonary disease; and to have a higher baseline creatinine concentration. cAAA cases were repaired through a retroperitoneal incision in 40% of cases, with hypothermic renal perfusion use in 15%, mannitol in 73%, and renal bypass in 13%, with wide variability in the application of these adjuncts. Complex aneurysm repair vs routine AAA repair was associated with a higher independent risk of 30-day mortality (3.6% vs 1.2%; P = .002), respiratory complications (19% vs 10%; P < .001), and renal complications (21% vs 8.7%; P < .001). Among all patients, the only independent clinical or technical predictors of 30-day mortality were preoperative coronary artery disease (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.1-5.4; P = .02) and amount of intraoperative blood transfusion (OR, 2.8; 95% CI, 1.3-6.2; P = .01). In the subgroup undergoing cAAA repair, there were no predictors of operative mortality. Renal or visceral ischemia time was the only technical factor during cAAA repair that independently predicted cardiac (OR, 1.01; 95% CI, 1.00-1.03; P = .04), respiratory (OR, 1.03; 95% CI, 1.01-1.04; P < .001), and renal (OR, 1.03; 95% CI, 1.02-1.05; P < .001) complications. Long-term survival for cAAA patients was 91% ± 1% at 1 year and 71% ± 3% at 5 years and not different from that of patients undergoing infrarenal AAA repair. Risk-adjusted predictors of late mortality after cAAA repair included age (hazard ratio [HR], 1.08; 95% CI, 1.04-1.11; P < .001), chronic obstructive pulmonary disease (HR, 1.9; 95% CI, 1.2-3.0; P = .008), and preoperative creatinine concentration (per mg/dL; HR, 1.8; 95% CI, 1.05-2.9; P = .03).


CONCLUSIONS
These data highlight excellent operative outcomes for open cAAA repair across the New England region despite significant variation in operative conduct across hospitals. Patients tolerating cAAA repair have durable long-term survival.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Sarah E
SE
Deery
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Robert T
RT
Lancaster
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Donald T
DT
Baril
Section of Vascular Surgery, Yale Medical Center, New Haven, Conn.
Jeffrey E
JE
Indes
Division of Vascular Surgery, University of Vermont College of Medicine, Burlington, Vt.
Daniel J
DJ
Bertges
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Mark F
MF
Conrad
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Richard P
RP
Cambria
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address: vpatel4@partners.org.
Virendra I
VI
Patel
D000367:Age Factors; D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D015897:Comorbidity; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D054625:Healthcare Disparities; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009511:New England; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome