Comparable mortality with open repair of complex and infrarenal aortic aneurysm.

A consequence of endovascular aneurysm repair (EVAR) of anatomically straightforward infrarenal abdominal aortic aneurysm repair cohort (AAA) is that open aneurysm repair is more commonly performed for complex anatomy. Complex aneurysm repair with visceral vessel involvement (CAA) or combined aneurysm repair and visceral vessel reconstruction (VVR) has traditionally been considered to increase morbidity and mortality compared with repair of infrarenal AAA. This study evaluated contemporary outcomes of open abdominal aneurysm surgery, including AAA, CAA, and VVR using the National Surgical Quality Improvement Program (NSQIP) database. The NSQIP Participant Use File was queried by CPT code to identify patients undergoing AAA, CAA, and VVR (2005-2008). Comparative analysis of clinical features, technical details and 30-day outcomes was performed using univariate methods. Logistic regression analysis was used to identify predictors of morbidity and mortality. A total of 2820 patients underwent AAA and 592 CAA. Renal insufficiency (ie, creatinine >1.4 mg/dL) rates were similar in AAA and CAA patients, however, more frequent in patients with VVR (51% vs 31% [no bypass]; P < .01). CAA was less likely to be performed urgently (6.3% vs 9.1%; P < .05) and was associated with increased operative time (254 ± 100 vs 224 ± 93; P < .01) compared with AAA. Univariate analysis showed that CAA did not increase mortality (5.7% vs 5.1%; P = .5). CAA slightly increased overall complications (32% vs 27%; P = .01) compared with AAA. 73 (2.5%) AAA and 84 (12%) CAA patients had simultaneous VVR and these patients exhibited a trend toward increased mortality (8.9% vs 5.2%; P = .07). VVR increased complications (43% (VVR) vs 26% [no bypass]; P < .01), including ventilation >48 hours (21% [VVR] vs 12% [no bypass]; P < .01), renal failure (7.6% [VVR] vs 4.1% [no bypass]; P = .04), and sepsis (13% [VVR] vs 6.3% ([no bypass]; P < .01). Multivariate analysis demonstrated that CAA (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.6]; P = .01) and VVR (OR, 2.2 [95% CI, 1.8-3.6]; P < .01) increased the odds of any complication. Independent predictors of mortality included dependent functional status (OR, 3.6 [95% CI, 2.3-5.4]; P < .01), elevated pre-op creatinine (OR, 2.9 [95% CI, 2.2-4.0]; P < .01), type II diabetes (OR, 1.6 [95% CI, 1.05-2.4]; P = .03), and age (OR, 1.06 [95% CI, 1.03-1.08]; P < .01). Neither CAA (OR, 1.2 [95% CI, 0.84-1.8]; P = .3) nor VVR (OR, 1.6 [95% CI, 0.89-2.9]; P = .11) were associated with increased mortality compared with AAA. In contemporary practice the migration of open repair to increasingly complex cases has been achieved with 30-day mortality essentially equivalent to open repair of infrarenal AAA. Patients who require VVR do sustain increased complications, in particular renal failure. These data also emphasize the importance of baseline renal insufficiency in clinical decision making. CAA and VVR are associated with increased morbidity in comparison to AAA repair; however, both procedures can be safely performed in patients without increased risk of operative mortality.

Patel VI ，Lancaster RT ，Conrad MF ，Lamuraglia GM ，Kwolek CJ ，Brewster DC ，Cambria RP ... -  《-》

Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): an analysis using the ACS NSQIP dataset.

Abedi NN ，Davenport DL ，Xenos E ，Sorial E ，Minion DJ ，Endean ED ... -  《-》

Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms.

The mortality of ruptured abdominal aortic aneurysm (rAAA) has decreased 3.5% per decade in the last 50 years to a current rate of 40%-50%. Reports have indicated that endovascular repair (EVAR) is feasible for rAAA and may offer potential benefits over open repair. We examined the National Surgical Quality Improvement Program (NSQIP) database to compare 30-day multicenter outcomes for EVAR vs open rAAA repair. Patients that underwent rAAA repair in the NSQIP database from 2005 to 2007 were identified through a combination of Current Procedural Terminology (CPT) codes and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses. Preoperative comorbidities, operative duration and transfusion, and 30 day outcomes were evaluated using t tests or Chi-squared tests depending on the variable. A separate multivariable regression was performed for each outcome adjusting for all independently predictive preoperative and intraoperative risk factors. A total of 427 patients were identified and 76.8% of patients underwent open repair. The open repair groups exhibited lower albumin levels and higher percentage of patients with preoperative hematocrit (Hct) <38% and need for preoperative ventilation. The requirement for preoperative blood transfusion was similar. Patients undergoing open repair had much higher intraoperative transfusion requirements (11.8 +/- 8.9 vs 4.2 +/- 6.0 red blood cell units, P < .001). After adjustment for preoperative mortality risk factors, the mortality risk was higher for open repair versus EVAR (odds ratio 1.67, 95% confidence interval [CI] 0.91-3.05, P = .096) but did not reach significance. After similar adjustment the composite morbidity odds ratio for open repair versus EVAR was 1.82 (95% CI 1.11-2.99, P = .018) and the pulmonary adverse events odds ratio was 1.99 (95% CI 1.22-3.25, P = .006). Risks for the other outcomes were not significant. Composite 30-day morbidity risk is lower after EVAR vs open repair of rAAA. Open repair is associated with increased transfusion requirements. Performance of EVAR in rAAA patients with favorable anatomy could potentially result in improved outcome as compared with open repair.

Davenport DL ，O'Keeffe SD ，Minion DJ ，Sorial EE ，Endean ED ，Xenos ES ... -  《-》

Suprarenal aortic cross-clamp position: a reappraisal of its effects on outcomes for open abdominal aortic aneurysm repair.

Chong T ，Nguyen L ，Owens CD ，Conte MS ，Belkin M ... -  《-》

Risk factors and outcomes of postoperative ischemic colitis in contemporary open and endovascular abdominal aortic aneurysm repair.

Postoperative ischemic colitis (IC) can be a serious complication following infrarenal abdominal aortic aneurysm (AAA) repair. We sought to identify risk factors and outcomes in patients developing IC after open AAA repair and endovascular aneurysm repair (EVAR). The American College of Surgeons National Surgical Quality Improvement Program database was used to examine clinical data of patients undergoing AAA repair from 2011 to 2012 who developed postoperative IC. Multivariate regression analysis was performed to identify risk factors and outcomes. We evaluated a cohort of 3486 patients who underwent AAA repair (11.6% open repair and 88.4% EVAR). The incidence of postoperative IC was 2.2% (5.2% for open repair and 1.8% for EVAR). Surgical treatment was needed in 49.3% of patients who developed IC. The mortality of patients with IC was higher than that of patients without IC (adjusted odds ratio [AOR], 4.23; 95% confidence interval [CI], 2.26-7.92; P < .01). The need for surgical treatment (AOR, 7.77; 95% CI, 2.08-28.98; P < .01) and age (AOR, 1.11; 95% CI, 1.01-1.22; P = .01) were mortality predictors of IC patients. Predictive factors of IC included need for intraoperative or postoperative transfusion (AOR, 6; 95% CI, 3.08-11.72; P < .01), rupture of the aneurysm before surgery (AOR, 4.07; 95% CI, 1.78-9.31; P < .01), renal failure requiring dialysis (AOR, 3.86; 95% CI, 1.18-12.62; P = .02), proximal extension of the aneurysm (AOR, 2.19; 95% CI, 1.04-4.59; P = .03), diabetes (AOR, 1.87; 95% CI, 1.01-3.46; P = .04), and female gender (AOR, 1.75; 95% CI, 1.01-3.02; P = .04). Although open AAA repair had three times higher rate of postoperative IC compared with endovascular repair, in multivariate analysis we did not find any statistically significant difference between open repair and EVAR in the development of IC (5.2% vs 1.8%; AOR, 1.25; 95% CI, 0.70-2.25; P = .43). Postoperative IC has a rate of 2.2% after AAA repair. However, it is associated with 38.7% mortality rate. Rupture of the aneurysm before surgery, need for transfusion, proximal extension of the aneurysm, renal failure requiring dialysis, diabetes, and female gender were significant predictors of postoperative IC. AAA patients who develop IC have four times higher mortality compared with those without IC. Surgical treatment is needed in nearly 50% of IC patients and is a predictor of higher mortality.

Moghadamyeghaneh Z ，Sgroi MD ，Chen SL ，Kabutey NK ，Stamos MJ ，Fujitani RM ... -  《-》