Clinical Research
Endovascular Repair With Fenestrated-Branched Stent Grafts Improves 30-Day Outcomes for Complex Aortic Aneurysms Compared With Open Repair

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Background

Endovascular repair is associated with better 30-day outcomes than open surgical repair for patients with infrarenal aortic aneurysms. In patients with complex aortic aneurysms (CAAs) requiring suprarenal or supravisceral aortic cross-clamping during open repair, few data exist directly comparing the real-world outcomes of open repair versus endovascular repair with fenestrated-branched stent grafts (FEVAR).

Methods

Outcomes for patients who underwent elective CAA repair using open repair and FEVAR between 2005 and 2010 were analyzed using the American College of Surgeons National Surgical Quality Improvement Program database. CAA was defined as aneurysm of the aorta involving the visceral and/or renal arteries.

Results

This study compared 1091 patients who underwent open repair (group A: male, 71.5%; age, 71 ± 9 years) with 264 patients treated with FEVAR (group B: male, 82.2%; age, 74 ± 9 years). The 2 groups did not significantly differ with respect to American Society of Anesthesiologists (ASA) classification (ASA III/IV: A, 93%; B, 95%, P = 0.6), severe chronic obstructive pulmonary disease (A: 21%; B: 22%; P = 0.7), prior cardiac surgery (A: 24%; B: 20%; P = 0.19), or preoperative renal function (glomerular filtration rate: A: 69 ± 2; B: 70 ± 27; P = 0.535). Group A had significantly higher risk of any complication (A: 42%; B: 19%; P < 0.001), nonsurgical complications (A: 30%; B: 8%; P < 0.001), pulmonary complications (A: 21%; B: 2%; P < 0.001), renal complications (A: 10%; B: 1.5%; P = 0.001), and any cardiovascular complication (A: 8%; B: 2%; P < 0.001). The composite end point of surgical site infections/graft failure/bleeding transfusions were also higher in group A (A: 22%; B: 15%; P = 0.014). Thirty-day mortality was significantly lower for FEVAR (A: 5.4%; B: 0.8%; P = 0.001), as was total length of hospital stay (A: 11 ± 10 days; B: 4 ± 5 days; P < 0.001).

Conclusions

This nationwide real-world database suggests that in similar patient populations, repair of CAAs with FEVAR is associated with reduced 30-day morbidity and mortality compared with open repair. Although long-term comparative studies are needed, FEVAR may represent a preferred treatment alternative to open repair for patients with CAAs.

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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