Open Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms in the Elderly Is Not Associated With Increased 30-Day Mortality Compared With Fenestrated Endovascular Grafting

Abstract

Endovascular repair of juxtarenal abdominal aortic aneurysm (JAAA) with fenestrated grafts has been shown to decrease operative mortality and morbidity compared with open surgical repair (OSR). Although fenestrated endovascular aneurysm repair (FEVAR) is now often chosen as the first-line therapy for high-risk patients such as the elderly, not all patients have anatomy favorable for FEVAR. At present, there is a paucity of literature examining the operative outcomes of OSR in elderly patients for JAAA relative to FEVAR. For this reason, we chose to perform a propensity score-matched comparison of OSR and FEVAR for JAAA repair in patients aged ≥70 years. Patients ≥70 years old undergoing elective nonruptured JAAA repairs in 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program targeted endovascular aneurysm repair and abdominal aortic aneurysm databases. FEVAR patients were identified in the targeted endovascular aneurysm repair database as those receiving the Cook Zenith fenestrated (Cook Medical, Bloomington, Ind) endograft. OSR patients were excluded if supraceliac clamping was required or concomitant renal or visceral revascularizations were performed. A 1:1 propensity score match algorithm matched OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm anatomy. Thirty-day outcomes of OSR including mortality, major adverse cardiovascular events, and pulmonary and renal complications were compared with a propensity score-matched group of FEVAR patients. There were 588 patients meeting study inclusion criteria (FEVAR, 182; OSR, 406). After propensity score matching, 136 OSR patients were compared with 136 FEVAR patients. There were no significant differences in preoperative clinical and demographic characteristics, operative indications, or aneurysm anatomy between propensity score-matched groups (Table I). There was no significant difference in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between OSR and FEVAR (Table II). There was a trend of higher major adverse cardiovascular events in OSR compared with FEVAR; however, the difference was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, patients undergoing OSR did have significantly higher rates of pulmonary (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040) complications. Although FEVAR should remain as the first-line therapy for JAAA in elderly patients, OSR does not have prohibitive perioperative mortality and remains a feasible option for those with unfavorable anatomy for FEVAR. However, caution should be exercised with selection of patients, given the significantly higher morbidity profile.Table IPreoperative clinical, demographic and operative characteristics of 1:1 propensity matched samplesOpen (n = 136)FEVAR (n = 136)Univariate analysis, P valueAge77.6 ± 4.877.4 ± 4.5.807Sex (Female)31 (22.8)33 (24.3).775Race.941 White105 (77.2)103 (75.7) AA/Black4 (2.9)5 (3.7) Other Race-- Unknown27 (19.9)28 (20.6)BMI27.3 ± 4.428.0 ± 5.0.497>10% Weight Loss---Albumin <3.5 g/dL9 (6.6)6 (4.4).426Diabetes18 (13.2)18 (13.2).999Hypertension115 (84.6)113 (83.1).742History of CHF2 (1.5)1 (0.7).562Smoker43 (31.6)43 (31.6).999Dyspnea23 (16.9)23 (16.9).999History of COPD34 (25.0)25 (25.7).889eGFR < 60 mL/min68 (50.0)60 (44.1).331Pre-op Dialysis---Anemia53 (39.0)59 (43.4).460Pre-op Transfusion2 (1.5)1 (0.7).562Dependent Functional Status2 (1.5)2 (1.5).999ASA >346 (33.8)49 (36.0).703Indication.906 Diameter117 (86.0)118 (86.8) Dissection-- Non-ruptured symptomatic3 (2.2)4 (2.9) Embolization/Thrombosis/Other-1 (0.7) Prior endovascular intervention with unsatisfactory result12 (8.8)9 (6.6) Prior open intervention with unsatisfactory result3 (2.2)2 (1.5) Not documented1 (0.7)2 (1.5)Aneurysm size (cm)5.7 (5.5, 6.5)5.7 (5.2, 6.2).131Prior open abdominal surgery42 (30.9)36 (26.5).679Proximal extent of aneurysm.446 Infrarenal50 (36.8)56 (41.2) Juxtarenal86 (63.2)80 (58.8)Distal extent of aneurysm.995 Aortic69 (50.7)69 (50.7) Common iliac43 (31.6)44 (32.4) External iliac3 (2.2)3 (2.2) Internal iliac3 (2.2)2 (1.5) Not documented18 (13.2)18 (13.2)AA, African American; Anemia, hematocrit <41% males, <36% females; ASA, American Society of Anesthesiologist Physical Classification System; BMI, body mass index; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; FEVAR, fenestrated endovascular aneurysm repair.Data are entered as mean +/- standard deviation, median (IQR), or n (percent). Open table in a new tab Table IIThirty-day operative outcomes of 1:1 propensity matched samplesOpen (n = 136)FEVAR (n = 136)Open vs FEVAROR (95% CI)PMortality6 (4.4)5 (3.7)1.21 (0.36-4.06).759MACE11 (8.1)5 (3.7)2.31 (0.78-6.82).131 Cardiac10 (7.4)5 (3.7)2.08 (0.69-6.25).193 Stroke1 (0.7)-NE-Pulmonary26 (19.1)5 (3.7)6.19 (2.30-16.67)<.001 Pneumonia14 (10.3)3 (2.2)5.09 (1.43-18.13).012 Prolonged intubation12 (8.8)2 (1.5)6.48 (1.42-29.55).016 Unplanned reintubation15 (11.0)3 (2.2)5.50 (1.55-19.45).008Renal11 (8.1)3 (2.2)3.90 (1.06-14.31).040 Progressive Renal Insufficiency4 (2.9)2 (1.5)2.03 (0.37-11.27).418 Acute Renal Failure7 (5.2)1 (0.7)7.33 (0.89-60.36).064FEVAR, Fenestrated endovascular aneurysm repair; MACE, major adverse cardiovascular/cerebrovascular events; OR, odds ratio; Prolonged intubation, >48 hours intubation.Data are entered as n (percent). Open table in a new tab