Aortic Aneurysmorrhaphy: Establishing Concurrent Results for Comparison with Endoluminal Therapies

Abstract

The authors began to evaluate endoluminal vascular prostheses in 1991. Since then, market-driven changes in health care delivery have led to shortened hospital stays and intensive care unit (ICU) stays for elective aortic aneurysmorrhapy without increasing morbidity and mortality. They reviewed concurrent results of their open surgery program during this time period to establish a baseline for mortality, morbidity, and overall outcome. Prospective follow-up identified 90 consecutive elective aortic aneurysms repaired by two fellowship-trained vascular surgeons between August 1, 1991, and August 1, 1997. All patients with aortic aneurysms 50 mm or larger presenting to the authors' clinics were offered elective aneurysmorrhaphy with no patients refused operation owing to excessive operative risk. All procedures were performed with resident participation. Mean patient age was 69.7 years (range 49-83). Risk factors included a significant smoking history in 97%, hypertension in 83%, cardiac insufficiency in 74%, pulmonary insufficiency in 42%, and renal insufficiency in 18% of the patients. There were three juxtarenal and 87 infrarenal aneurysms with a mean diameter of 58 mm (range 45-90 mm). Iliac and femoral artery aneurysmal or occlusive disease was frequent with 72 bifurcated grafts used for repair, and 18 tube grafts. There were 29 concomitant procedures: eight renal artery reimplantations, six renal artery bypasses, three infrainguinal bypasses, five distal artery aneurysm exclusions, three inferior mesenteric artery reimplantations, two nephrectomies, and two renal artery endarterectomies. There were no perioperative deaths. Survival was 97.3% at 6 years by life-table analysis, with a mean follow-up of 25.3 months (range 0.13-70.5 months). Major morbidity prolonging hospitalization occurred in 17.7%; all patients were discharged from the hospital and returned to independent living. No patient required permanent dialysis and all patients were extubated without extraordinary measures. Mean blood loss was 908.7 mL (range 250-5,000 mL). Mean hospital stay was 15.6 days (range 3-55 days) and mean ICU stay was 3.7 days (range 1-18 days). In the last 1.5 years of the study procedures were performed with reduced utilization of resources; mean blood loss 735 mL (range 250-2,500 mL), mean hospital stay 10.96 (range 3-55) days, and mean ICU stay 2.65 (range 1-14) days. Overall primary graft patency at 6 years was 99.2% by life-table analysis. Elective open aortic aneurysmorrhaphy can be safely performed in high-risk patients in their seventh, eighth, and ninth decades of life. Improved perioperative management of elective aneurysmorrhaphy procedures has led to decreased hospital and ICU stays while maintaining acceptable morbidity and low mortality rates. Direct comparison of evolving endoluminal aneurysmorrhaphy techniques with open aneurysmorrhaphy techniques must utilize concurrent morbidity and mortality data in preference to historic control data.