TY - JOUR
T1 - Open abdominal aortic aneurysm repair in the endovascular era
T2 - Effect of clamp site on outcomes
AU - Landry, Gregory
AU - Lau, Ignatius
AU - Liem, Timothy
AU - Mitchell, Erica
AU - Moneta, Gregory
PY - 2009/9
Y1 - 2009/9
N2 - Objective: To describe a contemporary series of open abdominal aortic aneurysm (AAA) repairs in patients not anatomically suitable for endovascular AAA repair. Methods: A prospectively maintained database including consecutive nonruptured open aneurysm repairs from March 1, 2000, through July 31, 2007, was reviewed. Patient demographic characteristics and perioperative outcomes were evaluated and stratified based on proximal aortic cross-clamp placement. Results: A total of 185 patients with AAA underwent 103 infrarenal and 82 suprarenal cross-clamp repairs. Overall, the complication rate was 37.0% with infrarenal and 61.0% with suprarenal cross-clamps (P=.001). The 30-day mortality was 2.9% with infrarenal and 6.1% with suprarenal cross-clamps (P=.18). Postoperative renal insufficiency (29.3% vs 7.8%; P<.001) and pulmonary complications (25.6% vs 12.6%; P=.03) were more frequent with suprarenal cross-clamps. Suprarenal cross-clamps were associated with greater intraoperative blood loss (2586 mL vs 1638 mL; P=.006), operative duration (391 min vs 355 min; P=.005), use of adjunctive renal and/or visceral grafts (43.9% vs 1.9%; P<.001), duration of intensive care unit stay (4.5 days vs 3.0 days; P=.006), and hospital length of stay (9 days vs 7 days; P=.04). Of patients who received a suprarenal cross-clamp, 25.6% required temporary nursing home placement vs 17.5% with an infrarenal cross-clamp (P=.14). Conclusions: Until fenestrated and branched endografts are available, open AAA repairs will become increasingly complex. Suprarenal cross-clamping is associated with increased rates of complications but similar mortality rates and need for nursing home placement. With the disappearance of straightforward open aneurysm repair, trainees in vascular surgery will have to learn AAA repair almost exclusively by operating on patients with complex AAAs. Fewer surgeons will perform these repairs, and fewer fellows will be able to complete the operation independently immediately after training.
AB - Objective: To describe a contemporary series of open abdominal aortic aneurysm (AAA) repairs in patients not anatomically suitable for endovascular AAA repair. Methods: A prospectively maintained database including consecutive nonruptured open aneurysm repairs from March 1, 2000, through July 31, 2007, was reviewed. Patient demographic characteristics and perioperative outcomes were evaluated and stratified based on proximal aortic cross-clamp placement. Results: A total of 185 patients with AAA underwent 103 infrarenal and 82 suprarenal cross-clamp repairs. Overall, the complication rate was 37.0% with infrarenal and 61.0% with suprarenal cross-clamps (P=.001). The 30-day mortality was 2.9% with infrarenal and 6.1% with suprarenal cross-clamps (P=.18). Postoperative renal insufficiency (29.3% vs 7.8%; P<.001) and pulmonary complications (25.6% vs 12.6%; P=.03) were more frequent with suprarenal cross-clamps. Suprarenal cross-clamps were associated with greater intraoperative blood loss (2586 mL vs 1638 mL; P=.006), operative duration (391 min vs 355 min; P=.005), use of adjunctive renal and/or visceral grafts (43.9% vs 1.9%; P<.001), duration of intensive care unit stay (4.5 days vs 3.0 days; P=.006), and hospital length of stay (9 days vs 7 days; P=.04). Of patients who received a suprarenal cross-clamp, 25.6% required temporary nursing home placement vs 17.5% with an infrarenal cross-clamp (P=.14). Conclusions: Until fenestrated and branched endografts are available, open AAA repairs will become increasingly complex. Suprarenal cross-clamping is associated with increased rates of complications but similar mortality rates and need for nursing home placement. With the disappearance of straightforward open aneurysm repair, trainees in vascular surgery will have to learn AAA repair almost exclusively by operating on patients with complex AAAs. Fewer surgeons will perform these repairs, and fewer fellows will be able to complete the operation independently immediately after training.
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U2 - 10.1001/archsurg.2009.157
DO - 10.1001/archsurg.2009.157
M3 - Article
C2 - 19797104
AN - SCOPUS:70349464714
SN - 0004-0010
VL - 144
SP - 811
EP - 816
JO - Archives of Surgery
JF - Archives of Surgery
IS - 9
ER -