Results of Laparoscopic Surgery for Abdominal Aortic Aneurysms in Patients With Standard Surgical Risk and Anatomic Criteria Compatible With EVAR

Abstract

The recent Anévrisme de l'aorte abdominale: Chirurgie versus Endoprothèse (ACE) study showed that open surgery of infrarenal abdominal aortic aneurysms (AAAs) provided very good results in patients with standard surgical risk, with good anatomic results for endovascular aneurysm repair (EVAR). The goal of the current study was to show that aortic laparoscopy is a minimally invasive alternative to open surgery while avoiding the complications associated with laparotomy. From February 2002 to August 2010, the authors performed 239 laparoscopic AAA repairs. A subgroup of 99 patients with standard surgical risk presented with AAAs compatible with EVAR. The evaluation criteria of surgical risk and anatomic criteria compatible with EVAR corresponded to those edicted by the Agence Française de Sécurité Sanitaire des Produits de Santé and the Haute Autorité de Santé. The patients' database was prospective and the file analysis was retrospective. Digital data were given in median and extremes. The patient age was 68 years (range, 53-79 years). The aneurysmal diameter was 51 mm (range, 45-69 mm). Surgery and clamping times were 210 min (range, 180-520 min) and 81 min (range, 35-140 min), respectively. There were 60 aortic tubes and 39 bifurcated prostheses. Five patients (5%) required conversion. No hospital mortality occurred. Three patients presented with severe systemic complications (3%): 1 perioperative cardiac arrest on atrioventricular block grade 3, 1 case of febrile hypoxic atelectasis, and 1 colonic ischemia with transient renal failure with transient dialysis. Ten patients had a moderate systemic complication (10%): 7 transitory elevations of creatinemia, 1 pneumonia, 1 prostatitis, 1 sigmoiditis, and 1 cardiac arrhythmia/atrial fibrillation (CA/AF). Intensive care stay and hospitalization durations were 24 hours (range, 12-768 hours) and 6 days (range, 4-39 days), respectively. Four local complications occurred: 1 limb thrombosis, 1 compartment syndrome, 1 spleen rupture, and 1 parietal hematoma. On multivariate analysis, the overall procedure time was a predictive factor of severe systemic complications (P=0.02). Follow-up was 42 months (range, 1-97 months). Two patients required late surgery (2%): 1 for limb thrombosis after neuroendovascular procedure and 1 for iliac thrombosis. Morphologic tests did not show any defects at the aortic prosthesis level. The only abdominal complication was a rupture at the level of a laparotomy conversion. The 6 late deaths (6%) were not related to the AAA. This study shows that AAA laparoscopic surgery is a safe, long-lasting, minimally invasive technique in patients with standard surgical risk when EVAR can be considered.