O-011 - RETROPERITONEAL VERSUS TRANSPERITONEAL APPROACH FOR OPEN REPAIR OF COMPLEX ABDOMINAL AORTIC ANEURYSMS

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Rastogi V. (Beth Israel Deaconess Medical Center ~ Boston ~ United States of America) , Kim N. (Beth Israel Deaconess Medical Center ~ Boston ~ United States of America) , Marcaccio C. (Beth Israel Deaconess Medical Center ~ Boston ~ United States of America) , Patel P. (Beth Israel Deaconess Medical Center ~ Boston ~ United States of America) , Varkesvisser R. (Beth Israel Deaconess Medical Center ~ Boston ~ United States of America) , De Bruin J. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Verhagen H. (Erasmus University Medical Center ~ Rotterdam ~ Netherlands) , Schermerhorn M. (Beth Israel Deaconess Medical Center ~ Boston ~ United States of America)
Introduction:
There have been inconsistent results in the surgical literature regarding the optimal operative approach (transperitoneal [TP] or retroperitoneal [RP]) to open abdominal aortic aneurysm (AAA) repair(1,2). Several comparative studies have demonstrated advantages of the RP approach over the TP approach for infrarenal AAA repair, including lower rates of complications and long-term reinterventions(3-5). However, the RP approach is used less frequently for infrarenal AAA and more frequently for open repair of complex AAA (cAAA), which involve the renal and visceral segment(6). However, little is currently known regarding the impact of these approaches on outcomes for cAAA, which include juxtarenal aneurysms, supra-renal aneurysms, and type-IV thoracoabdominal aneurysms. Therefore, we examined peri-operative outcomes in patients undergoing open cAAA repair via a TP versus an RP approach and evaluated trends in approach usage over time.
Methods:
Patients undergoing open repair for intact cAAA (juxtarenal, suprarenal, or type-IV thoracoabdominal aortic aneurysms) between 2011-2019 were identified in the National Surgical Quality Improvement Program (NSQIP). The primary outcome was perioperative death. Secondary outcomes included perioperative complications and approach usage over time. We performed multivariable adjustment by creating propensity scores and using inverse probability-weighted logistic regression.
Results:
Among 1,195 patients identified, 729 (61%) underwent cAAA repair via a TP approach and 466 (39%) underwent repair via an RP approach. Compared with a TP approach, RP patients more frequently had a supracoeliac clamp position (32% vs. 20%, p<.001) and concomitant renal revascularization (30% vs. 18%, p<.001). After adjustment, an RP approach was associated with lower odds of perioperative mortality (4.0% vs. 7.2%; OR: 0.54; 95%CI: 0.32-0.91; p=.022). (Table) Furthermore, an RP approach was associated with lower odds of any major complication (24% vs. 30%; OR: 0.73; 95%CI: 0.56-0.94), cardiac complications (4.9% vs. 8.2%; OR: 0.60; 95%CI: 0.37-0.96), wound complications (2.1% vs. 6.0%; OR: 0.34; 95%CI: 0.17-0.64), and postoperative sepsis (0.8% vs. 2.4%; OR: 0.37; 95%CI: 0.12-0.99). There were no differences in hospitalization between groups (length of stay >10 days: 31% vs. 31%, p=.88) The proportion of repairs using an RP approach decreased from 2011-2015 to 2016-2019 (42% vs. 35%, p=.020), particularly for supra-renal and type-IV thoracoabdominal aneurysms (49% vs 37%, p=.023). (Figure) There were no differences in proportion of RP usage within juxtarenal AAA (38% vs. 35%, p=.32) and repairs with concomitant renal revascularization (56% vs. 47%, p=.19)
Conclusion:
In open cAAA repair, the RP approach may be associated with lower perioperative mortality and morbidity compared with the TP approach. However, we found that the relative usage of the RP approach is decreasing over time, even in suprarenal/type-IV TAAA's, and repairs utilizing a supracoeliac clamping site. These data demonstrate the current necessity of a randomized clinical trial on this subject to provide a higher level of evidence on the topic, and potentially persuade surgeons to use the RP approach in open cAAA repair.
References:
1. Cambria RP, Brewster DC, Abbott WM, Freehan M, Megerman J, Lamuraglia G, Wilson R, Wilson D, Teplick R, Kenneth Davison J. Transperitoneal versus retroperitoneal approach for aortic reconstruction: A randomized prospective study. J Vasc Surg (1990) 11:314-325. doi:10.1016/0741-5214(90)90275-F 2. Sicard GA, Reilly JM, Rubin BG, Thompson RW, Allen BT, Flye MW, Schechtman KB, Young-Beyer P, Weiss C, Anderson CB. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: Report of a prospective randomized trial. J Vasc Surg (1995) 21:174-183. doi:10.1016/S0741-5214(95)70260-1 3. Deery SE, Zettervall SL, O'Donnell TFX, Goodney PP, Weaver FA, Teixeira PG, Patel VI, Schermerhorn ML. Transabdominal open abdominal aortic aneurysm repair is associated with higher rates of late reintervention and readmission compared with the retroperitoneal approach. J Vasc Surg (2020) 71:39-45.e1. doi:10.1016/j.jvs.2019.03.045 4. Twine CP, Humphreys AK, Williams IM. Systematic review and meta-analysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta. Eur J Vasc Endovasc Surg (2013) 46:36-47. doi:10.1016/j.ejvs.2013.03.018 5. Teixeira PGR, Woo K, Abou-Zamzam AM, Zettervall SL, Schermerhorn ML, Weaver FA. The impact of exposure technique on perioperative complications in patients undergoing elective open abdominal aortic aneurysm repair. J Vasc Surg (2016) 63:1141-1146. doi:10.1016/j.jvs.2015.12.025 6. Buck DB, Ultee KHJ, Zettervall SL, Soden PA, Darling J, Wyers M, van Herwaarden JA, Schermerhorn ML. Transperitoneal versus retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular National Surgical Quality Improvement Program. J Vasc Surg (2016) 64:585-591. doi:10.1016/j.jvs.2016.01.055
ATTACHMENTS: