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The Impact of Concomitant Procedures during Endovascular Abdominal Aortic Aneurysm Repair on Perioperative Outcomes
Klaas H. Ultee1, Sara L. Zettervall, MD, MPH1, Peter A. Soden, MD1, Jeremy Darling1, Jeffrey J. Siracuse, MD2, Matthew J. Alef, MD3, Hence JM Verhagen, MD, PhD4, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Boston University School of Medicine, Boston, MA, USA, 3The University of Vermont Medical Center and University of Vermont College of Medicine, Burlington, VT, USA, 4Erasmus Medical Center, Rotterdam, Netherlands.
OBJECTIVES:
Concomitant procedures during endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) are performed to either facilitate endograft delivery, simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aims to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR
METHODS:
We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014, and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes.
RESULTS:
4033 patients were included in the study, with 1168 (29.0%) patients undergoing one or more additional procedure. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (OR: 4.8, 95% CI: 2.1-11.2) and renal angioplasty or stenting (3.1, 1.2-8.3). Postoperative bowel ischemia was associated with hypogastric embolization (3.8, 1.1-13.4) and iliac angioplasty or stenting (3.5, 1.3-9.6). Leg ischemia was associated with graft extension (2.3, 1.02-5.0), other artery reconstruction (5.2, 1.8-15.1), thrombo-embolectomy (5.2, 1.3-20.8), and repair of arterial injury (4.6, 1.2-18.3). Risk factors for deterioration of renal function were ilio-femoral bypass (3.9, 1.3-12.2), other artery reconstruction (2.7, 1.3-5.8), renal angioplasty or stenting (2.5, 1.3-4.6), and repair of arterial injury (4.5, 1.6-12.2). Myocardial infarction was associated with femoro-femoral bypass (3.9, 1.7-8.7), other artery reconstruction (3.9, 1.6-9.2) and repair of arterial injury (6.1, 1.8-21.0). Wound complications were predicted by femoro-femoral bypass (13.4, 5.8-31.1).
CONCLUSIONS:
Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thrombo-embolic events where possible.
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