title: Fenestrated and chimney endovascular aneurysm repair versus open surgery for complex abdominal aortic aneurysms.
abstract: BACKGROUND
  Many patients with complex abdominal aortic aneurysms are unfit for open repair. New endovascular technologies and bailout techniques are being used for managing these complex anatomies. The purpose of this study is to compare the results obtained with advanced endovascular aneurysm repair (a-EVAR) techniques (fenestrated and chimney endografts) to those obtained with open repair for the treatment of complex abdominal aortic aneurysms not anatomically suitable for standard endovascular exclusion (infrarenal neck <10 mm, juxtarenal, suprarenal and Crawford's type IV thoracoabdominal aneurysms).
  
  
  METHODS
  All patients that underwent open surgery (OS cohort; historical, January 1994-December 2015) or a-EVAR (a-EVAR cohort; prospective, January 2006-December 2015) at our institution for complex abdominal aortic aneurysms that meet the anatomical criteria described above on the preoperatory contrast-enhanced computed tomography scan were included. Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (V-POSSUM) was employed for risk-assessment.
  
  
  RESULTS
  A total of 108 patients were included, all of them male: 56 in the OS cohort and 52 in the a-EVAR cohort (mean age: 67.5±6.7 vs. 72.65±6.4 years, respectively; P=0.000). V-POSSUM predicted 4 deaths for the OS cohort and 3 deaths for the a-EVAR cohorts within the postoperative period and morbidity rates of 57% and a 44.4%, respectively. All-cause 30-day mortality rates were 9 patients (16%) for the OS cohort and 2 patients (3.8%) for the a-EVAR cohort (P=0.038). Thirty-day morbidity rates were 59% for the OS cohort and 44% for the a-EVAR cohort (P=0.09). Mean cost of treatment was € 15,707 per patient for the OS cohort (median: € 11,516; inter-quartilic range [IQR]: € 7901; min-max: € 5069-11,0052) and € 33,457 per patient for the a-EVAR cohort (median: € 29,663; IQR: € 5979; min-max: € 13,865-19,3536), P=0.000.
  
  
  CONCLUSIONS
  A-EVAR is a feasible alternative to open surgery for complex abdominal aortic aneurysms at our institution, with lower 30-day mortality rates, yet increasing double the amount the total cost of the therapy.
authors.affiliation: Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain - sala_and@gva.es.
authors.forename: Vicente A
authors.initials: VA
authors.lastname: Sala-Almonacil
authors.affiliation: Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain.
authors.forename: José M
authors.initials: JM
authors.lastname: Zaragozá-García
authors.affiliation: Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain.
authors.forename: Mauricio
authors.initials: M
authors.lastname: Ramírez-Montoya
authors.affiliation: Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain.
authors.forename: Vicente
authors.initials: V
authors.lastname: Molina-Nácher
authors.affiliation: Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain.
authors.forename: Inmaculada
authors.initials: I
authors.lastname: Martínez-Perelló
authors.affiliation: Department of Vascular and Endovascular Surgery, Doctor Peset University Hospital, Valencia, Spain.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Gómez-Palonés
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000191:economics / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000401:mortality; D000072226:Computed Tomography Angiography; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D017048:Health Care Costs; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D011474:Prosthesis Design; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome