Contemporary Indications for Open Abdominal Aortic Aneurysm Repair in the Endovascular Era

Abstract

Despite the emergence of endovascular abdominal aortic aneurysm repair (EVAR) as the most common approach to repair, open aneurysm repair (OAR) remains a critical option. We sought to define the indications for OAR in the EVAR era and how these indications affect the outcomes. We performed a retrospective review of all OAR cases at a single institution from 2004 to 2020. Preoperative computed tomography scans and operative records were assessed to determine the indications for OAR. These reasons were categorized into anatomic contraindications, systemic factors (ie, connective tissue disorders, contraindication to contrast dye), and patient and/or surgeon preference (candidates for both EVAR and OAR). The perioperative and long-term outcomes were compared. A total 370 patients were included in the analysis. Of the 370 patients, 265 (71.6%) had at least one anatomic contraindication to EVAR (36% had two or more contraindications). The most common anatomic contraindications were a short aortic neck length (51.6%), an inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1%, and the 30-day mortality was 3.6%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) had undergone OAR by patient and/or surgeon preference. These patients were younger, had a lower incidence of coronary artery disease and chronic obstructive pulmonary disease, and were less likely to require suprarenal cross-clamping than were the patients who had had anatomic and/or systemic contraindications to EVAR. The patient/surgeon preference group had a lower incidence of perioperative major complications (8.2% vs 20.1%; P = .034), a shorter length of stay (6 vs 8 days; P < .001), and no 30-day mortality. The multivariable adjusted risk for 15-year mortality was lower for the patient/surgeon preference group (19.7% vs 39.5%; adjusted hazard ratio, 0.44; 95% confidence interval, 0.24-0.80; P = .007) than for the anatomic/systemic contraindications group (Table). Within a population of patients who did not meet the instructions for use criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes after OAR. Patients who were candidates for both aortic repair approaches but who had elected to undergo OAR had 30-day mortality of 0% and superior perioperative morbidity and long-term survival rates.TableShort- and long-term outcomes stratified by OAR indicationVariableSurgeon/patient preference (n = 61)Anatomical/systemic contraindication (n = 309)P valueEstimated blood loss, mL1177 ± 9531656 ± 1653.060ICU LOS, days2 (1-2)2 (1-4).14Hospital LOS, days6 (6-9)8 (6-11)<.00130-day mortality0 (0)11 (3.6).22Long-term outcomes, adjusted 15-Year death12 (19.7)122 (39.5).007ICU, Intensive care unit; LOS, length of stay; OAR, open aneurysm repair.Data presented as mean ± standard deviation, median (interquartile range), or number (%). Open table in a new tab