Long-Term Outcomes of Open Surgical, Endovascular Aneurysm Repair for IRAAA

Open surgical repair (OSR) had better outcomes than endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (IRAAA), according to results of a retrospective cohort study published in the Journal Vascular Brasileiro.

Patients (N=119) with asymptomatic IRAAA who underwent elective surgery with the same principal surgeon at Hospital Universitario de Salamanca in Spain between 2006 and 2015 were reviewed for outcomes. OSR (n=63) or EVAR (n=56) procedures were selected on the basis of patient age, comorbidities, hostile abdomen status, IRAAA anatomy, need for treating another serious retroperitoneal pathology during the operation, need for rapid recovery due to other diseases, and patient choice.

Contraindications for EVAR included aortic neck diameter less than 17 or greater than 32 mm, angle greater than 60°, length less than 15 mm, and thrombus and calcification greater than 50% of perimeter.

The OSR and EVAR cohorts had a mean age of 72.2±6.6 and 70.0±6.9 years; 92.1% and 92.9% were men; 79.4% and 75.0% had arterial hypertension; 66.7% and 64.3% had dyslipidemia; and 15.9% and 23.2% diabetes, respectively.

More of the EVAR cohort were active smokers (P =.025), had a history of heart disease (P =.027), chronic renal failure (P =.041), chronic obstructive pulmonary disease (P <.001), had a hostile abdomen (P <.001), and had greater American Society of Anesthesiology risk (P <.001).

During OSR, patients received the additional procedures: cholecystectomy (n=4), nephrectomy (n=3), inguinal herniorrhaphy (n=1), exeresis of malignant fibrous histiocytoma (n=1), femoral-popliteal bypass (n=1), lymphadenectomy (n=1), endoprosthesis exclusion of a thoracic aortic aneurysm (TEVAR; n=1). During EVAR, 1 patient also had TEVAR.

EVAR was associated with shorter surgical intervention (P <.001), length of stay in the hospital (P =.02) and in the intensive care unit (P =.007), and lower number of transfused red cell concentration (P <.001).

No group differences were observed for 30-day complications, reinterventions, or mortality.

The most frequent complications of OSR were bleeding (12.7%), respiratory complications (9.5%), and renal failure (6.3%); for EVAR, bleeding (8.9%), respiratory complications (8.9%), urinary infection (7.1%), and cardiologic complications (5.4%). Reoperations occurred among 2 of the OSR and 3 of the EVAR recipients. One mortality was associated with OSR.

During a median follow-up of 4.25-4.79 years, OSR associated with fewer revisions (mean, 3.13 vs 4.21; P =.007), angio-computed tomography (mean, 0.22 vs 3.23; P =.001), complications (6.4% vs 37.5%; P =.001), reinterventions (3.2% vs 23.2%; P =.001), and mortality (20.6% vs 48.2%; P =.001).

Among the EVAR cohort, aneurysm diameter greater than 6.5 cm increased risk for type II endoleak, and distal anchoring on the eternal iliac artery increased risk for prosthetic branch thromboses.

Mortality risk was associated with chronic renal disease (odds ratio [OR], 2.35; 95% CI, 1.07-5.10; P =.032), chronic obstructive pulmonary disease (OR, 2.37; 95% CI, 1.20-4.65; P =.012), and age (OR, 1.12; 95% CI, 1.06-1.18; P =.001).

This study was limited by its retrospective observational design.

These data indicated that OSR had more favorable long-term outcomes than EVAR, emphasizing the importance of pre-surgical patient stratification.

“…[O]ur study is consistent with the findings of the best prospective trials that report better perioperative clinical results with the EVAR technique but better results with OSR during follow-up due to the fewer complications, reoperations, failures and deaths associated with the latter technique,” the study authors noted. “Therefore, experienced teams that select patients appropriately for each treatment modality obtain the best overall results, because they avoid OSR in cases at high risk from the technique and avoid EVAR in those with high anatomical complexity.”

Reference

Torres Hernández JA, Sánchez-Barba M, García-Alonso J, Sancho M, González-Porras JR, Lozano Sanchez FS. Early and late results of open surgical and endovascular treatment of infrarenal abdominal aortic aneurysms, selected according to surgical risk. J Vasc Bras. 2021;20:e20200024. doi:10.1590/1677-5449.200024