Long-Term Outcomes of Open Repair and Fenestrated Endografting for Pararenal Aortic Aneurysms in a Concurrent Propensity Adjusted Comparison

Abstract

Introduction - The choice of the best treatment in case of para-renal aortic aneurysms(p-AAA) is under investigation. Open surgical repair (OSR) still represents the gold standard for treatment, but it is associated to high surgical stress for the patient. Complex endovascular reconstructions with fenestrated endografts (fEVAR) require dedicated materials and specific expertise and are usually reserved to high risk patients. The difference in baseline characteristics of the populations treated with endovascular and open repair might influence short and long-term results. Methods - We performed a multicenter retrospective analysis on p-AAA electively treated with OSR or with fEVAR at three tertiary institutions. Endpoints of the study were the evaluation of perioperative (<30 days) significant morbidity, perioperative and late mortality, early and late reinterventions. Statistical analysis was conducted on the entire population and on a propensity score matched population. Propensity score was constructed on the basis of age, sex, medical history of coronary artery disease and chronic renal failure. Results - Mean age at time of surgery was 73 ± 7 years. Patients in the fEVAR group resulted significantly older than the patients in the OSR group and had more frequently a medical history positive for coronary artery disease and previous stroke. The groups did not significantly differ for any of the other preoperative characteristics. The baseline differences were corrected applying the propensity score method. Patients undergoing OSR resulted at higher risk to develop a perioperative systemic complication (p=.03); specifically, respiratory failure resulted more frequent in the OSR group (p=.02). Early reinterventions were more frequent in the fEVAR group, but the difference did not reach statistical significance. These findings were confirmed in the Propensity adjusted analysis, where also cardiac complications resulted higher in the OSR (p=.02). No difference in terms of peri-operative mortality was confirmed. Long term results showed higher survival and low reintervention rates in the OSR group in the unmatched population, with a small but significant difference in the risk of late visceral artery occlusion-stenosis after fEVAR. After adjustment with the propensity analysis, no differences in terms of late survival were found between the two groups. Conclusion - In selected patients with iuxta- and para-renal aneurysms, endovascular treatment and open repair may afford similar early and 5-year survival. Higher risks of peri-operative systemic complications after open surgery are counter-balanced by higher risks of late visceral vessel patency issues and need of reintervention after fenestrated endografting. Both procedures are safe and effective in the long-term in experienced centers, where single patient evaluation should drive the treatment strategy.