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Contemporary outcomes of complex abdominal aortic aneurysm repair from the Vascular Study Group of New England
Virendra I. Patel, MD, MPH1, Robert T. Lancaster, MD, MPH1, Shankha Mukhopadhyay, MS1, Junaid Malek, MD1, Philip Goodney, MD2, Daniel Bertges, MD3, Mark F. Conrad, MD, MSSc1, Richard P. Cambria, MD1.
1Massachusetts General Hospital, Boston, MA, USA, 2Dartmouth Hitchcock Medical Center, Lebannon, NH, USA, 3University of Vermont Medical Center, Boston, MA, USA.
Objective: Recent commercial availability of fenestrated stent grafts is likely to result in increasing endovascular repair of complex (juxta- and supra- renal) aortic aneurysms (cAAA). Whereas most studies providing benchmarking for outcomes following cAAA repair have been from high-volume centers, we sought to evaluate practice patterns and outcomes following elective cAAA repair at a regional level.
Methods: We used the Vascular Study Group of New England (VSGNE) registry, comprising 1875 open abdominal aortic aneurysm repairs in New England (2003-2011). Data from 14 hospitals (79 surgeons) performing both AAA and cAAA repair were used to assess the impact of clinical and technical factors on outcomes of cAAA.
Results: 443 patients had elective cAAA repair with a suprarenal (N=340; 77%) or supraceliac clamp (N=103; 23%). Compared to AAA repair, cAAA patients were more likely female (24%vs.33%; P<0.01), have HTN (81%vs.86%; P=0.01), CHF (6%vs.9%; P=0.02), COPD (33%vs.41%; P<0.01), and higher baseline creatinine (1.1±0.5mg/dLvs.1.2±0.6mg/dL;P<0.01). cAAA cases were via a retroperitoneal incision in 40%, with cold renal perfusion use in 15%, mannitol use in 73%, and renal bypass in 13%. There was a wide variation across the region in the use of retroperitoneal inc. (range: 0-100% by hospital), renal perfusion (range: 0-67% by hospital), mannitol (range: 50-100%), and renal bypass (range: 0-36%) for cAAA repair. Operative mortality (3.6%) for cAAA repair in the region was comparable to that published from high volume centers. 30-day complications occurred in 37% of patients with cardiac complications in 20%, respiratory in 18%, and ESRD in 1.2%. For cAAA repair there were no independent clinical or technical predictors of mortality. Using risk-adjusted regression models for each complication, renal/visceral ischemia time was the only technical factor which independently predicted cardiac(OR1.02[95%CI:1.00–1.03];P<0.01), respiratory(OR1.03[95%CI:1.01–1.04];P<0.01), or renal complications(OR1.03[95%CI:1.02–1.05];P<0.01). Risk adjusted predictors of late mortality following cAAA included patient factors of age (HR1.08 [95%CI: 1.04–1.1]; P<0.01), and COPD (HR1.6 [95%CI: 1.06–2.5]; P<0.01). Long-term survival for cAAA patients was 91±1% at 1year and 71±3% at 5 years.
Conclusions: These data highlight excellent operative outcomes for cAAA repair across New England despite significant variation in operative conduct across hospitals. Patients tolerating cAAA repair have durable long-term survival, at least equivalent to that after routine AAA repair.
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