Clinical ResearchEndovascular Repair With Fenestrated-Branched Stent Grafts Improves 30-Day Outcomes for Complex Aortic Aneurysms Compared With Open Repair
Introduction
Complex aortic aneurysms (CAAs) are defined as those involving the renal or visceral branches, and include juxtarenal and pararenal aneurysms and type IV thoracoabdominal aortic aneurysms (TAAAs). CAAs differ from infrarenal aneurysms with respect to the surgical approach because they require aortic cross-clamping above the renal arteries, superior mesenteric artery, or celiac trunk, or even at the level of the descending thoracic aorta for type IV TAAAs. Although suprarenal aortic clamping can be reasonably tolerated by patients with low and medium risk profile as defined by their comorbidities,1, 2 it is associated with significantly higher morbidity and mortality in those at high risk profile, and therefore many surgeons deny open surgery to patients with significant comorbidities because the benefits do not outweigh the risks. In an attempt to treat high-risk patients with CAA, alternative techniques to open surgery have been developed and include debranching of the visceral aorta followed by placement of aortic endografts (the so-called hybrid procedure),3 parallel grafts alongside the aortic endograft (“chimney,” “snorkel,” or “periscope” grafts),4, 5 and fenestrated-branched stent grafts.6 Fenestrated-branched stent grafts represent an anatomically appropriate option for treating CAAs and have been reported to be implanted with low mortality and morbidity rates in studies from high-volume centers with extensive experience with these devices.7, 8, 9, 10 However, few data exist directly comparing open repair versus endovascular repair with fenestrated-branched stent grafts (FEVAR). The objective of this study was to compare the real-world operative and perioperative outcomes of endovascular repair of CAA using FEVAR versus open surgical repair through analyzing data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
Section snippets
Data Source
The NSQIP is a quality improvement program that began in 1994 and was extended into the private sector in 1999. Currently, the NSQIP is commercially available to eligible high-volume hospitals across the United States, with more than 390 different sites enrolled. The ACS-NSQIP collects data on a variety of clinical variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures
Results
The authors identified 1091 patients who underwent elective OR (group A: male, 71.5%; age, 71 ± 9 years) for CAAs involving the renal and/or visceral arteries between 2005 and 2010. During the same period, 264 patients with CAAs were treated with elective FEVAR (group B: male, 82.2%; age, 74 ± 9 years).
Discussion
The multi-institutional, nationwide, real-world data presented in this article demonstrate for the first time comparative results between open repair and FEVAR for elective repair of CAA in a large cohort of patients. FEVAR was associated with significantly lower morbidity and mortality in patients with similar comorbidities. Both groups had similar ASA classification, with most patients being ASA class III (A: 65.7%; B: 68.6%) and approximately one-quarter of the patients in ASA class IV. In
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