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OBJECTIVE
The incidence of abdominal aortic aneurysm (AAA) has continued to rise over last 4 decades. With a growing aging patient population and increasing high comorbidities in this group of patients, risk assessment is increasingly important in achieving optimal clinical outcome. Dependent functional status has been demonstrated to lead to higher postoperative mortality in multiple studies of other surgical disease treatments; however the outcome in the AAA population is not well established. Our goal is to further delineate the impact of preoperative functional status on the 30 day outcome in patients undergoing AAA repair.
METHODS:
Using the ACS-NSQIP (define) database, Patients who underwent elective infrarenal AAA repair from year 2005-2011 were identified utilizing CPT codes. Patients were grouped based on preoperative functional status: independent (IND) or dependent (DEP). Clinical risk factors and short term outcomes between groups were compared. Multiple logistic regression analysis was used to identify independent factors related to increase 30-day mortality.
RESULTS:
A total of 19,441 patients underwent AAA repair (18754 [96.5%] IND and 687 [3.5%]) DEP). DEP patients were older (76.2 ± 8.8 vs 73.2 ± 8.6 years; p <0.001) and had higher comorbidities. DEP patients had significantly higher incidence of death (6.0% vs 1.5%) and major postoperative complications (32% vs 16.1%). More patients in DEP required second operation (9.5% vs 4.8%) and had longer total hospital stay (10 ± 13 vs 4.5 ± 6.8 days) [p<0.01 for all]. DEP was an independent predictor of increased mortality (OR 2.23; 95% CI: 1.54 - 3.22;p< 0.001). Both DEP and IND patients who underwent endovascular AAA repair (EVAR) had significantly lower postoperative complications compared to open AAA repair (OAAA). In addition, their total OR time, hospital length of stay and the 30-day mortality were reduced with EVAR compared to OAAA.
CONCLUSION:
Preoperative dependent functional status is related to adverse 30-day outcome after AAA repair. Comparing to OAAA, EVAR is associated with lower incidence of postoperative complications, and shorter hospitalization in DEP patients. DEP patients with AAA disease should be preferentially considered for EVAR over OAAA.
Table: Perioperative outcome after EVAR and Open AAA repair in Dependent functional status patients

	EVAR N= 509	Open N = 178	P- value
SSI	10 (2.0%)	4 (2.2%)	0.764
Pneumonia	26 (5.1%)	25 (14%)	<0.001
Unplanned intubation	24 (4.7%)	18 (10.1%)	0.017
Failure to wean	28 (5.5%)	32 (18.0)	<0.001
Progressive renal failure	5 (1.0%)	4 (2.2%)	0.248
Acute renal failure	13 (2.6%)	9 (5.1%)	0.135
UTI	18 (3.5%)	18 (10.1%)	0.001
CVA/Stroke	8 (1.6%)	1 (0.6%)	0.459
Cardiac arrest	6 (1.2%)	5 (2.8%)	0.164
MI	11 (2.2%)	4 (2.2%)	1
Bleeding requiring transfusion	64 (12.6%)	30 (16.9%)	0.089
DVT	8 (1.6%)	3 (1.7%)	0.986
Septic shock	13 (2.6%)	19 (10.7%)	<0.001
Return to OR	41 (8.1%)	24 (13.5%)	0.038
Duration of anesthesia (min)	228 ± 146	315 ±315	<0.001
Total operation time (min)	185 ± 96	230 ± 91	<0.001
Length of total hospital stay (days)	81.6 ± 12.4	15.6 ± 14.7	<0.001
Major Morbidity	133 (26.1%)	87 (48.9%)	<0.001
Mortality	25 (4.9%)	16 (9.0%)	0.064