O-117 - SHORT- AND LONG TERM CLINICAL OUTCOMES OF ENDOVASCULAR VERSUS OPEN REPAIR FOR JUXTA- AND PARARENAL ABDOMINAL AORTIC ANEURYSMS: RESULTS FROM FIVE HIGH-VOLUME EUROPEAN ACADEMIC CENTRES

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Zlatanovic P. (Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade ~ Belgrade ~ Serbia) , Mascia D. (Vascular Surgery Unit at the San Raffaele Hospital, Milan, Italy ~ Milano ~ Italy) , Ancetti S. (Bologna University Vascular Surgery Unit, Bologna, Italy ~ Bologna ~ Italy) , Yeung K.K. (Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands ~ Amstedan ~ Netherlands) , Jaap Graumans M. (Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands ~ Amstedan ~ Netherlands) , Jongkind V. (Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands ~ Amstedan ~ Netherlands) , Herman V. (Vascular Surgery at the Helsinki University Hospital (Helsinki, Finland) ~ Helsinki ~ Finland) , Davidovic L. (Faculty of Medicine, University of Belgrade, Serbia ~ Belgrade ~ Serbia)
Introduction:
Studies comparing endovascular and open repair (OR) are sparse, especially when it concerns long-term outcomes. The latest European Society for Vascular Surgery (ESVS) Guidelines on the treatment of AAA do not have strong recommendations about the treatment of JAAA/PAAA. (1) The aim of this study was to compare short and long-term clinical outcomes for endovascular versus open repair (OR) of juxtarenal and pararenal abdominal aortic aneurysm (JAAA/PAAA) in five European academic high volume centres.
Methods:
This was a retrospective cohort study with all consecutively treated patients (845) who were prospectively followed from the five academic high volume AAA centres (more than 50 open and 50 endovascular AAA repairs per year) in Europe. This study excluded patients with symptomatic, mycotic AAA, ruptured, dissected AAA, patients with suprarenal AAA, thoracoabdominal aortic aneurysm (ThAAA), and those with connective tissue disorders. JAAA was defined as AAA where aortic neck is shorter than 1cm or as AAA than would require proximal clamp above one/both renal arteries in OR, while PAAA was defined as AAA where aneurysm involves at least one renal artery orifice without superior mesenteric artery and coeliac trunk involvement, thus excluding suprarenal AAAs and ThAAAs.2 Using propensity score matching (PSM) each patient undergoing endovascular JAAA/PAAA surgery was matched to one patient undergoing OR in 1:1 ratio (145 patients per each group). The primary endpoints were long-term all-cause mortality and the freedom from aortic-related reintervention. Secondary endpoints were hospital, 30-day mortality, and postoperative adverse events.
Results:
A total of 845 consecutive elective patients were treated for JAAA/PAAA at five academic European high-volume AAA centres, 258 patients in endovascular and 587 in the OR group. Using the PSM two comparable cohorts (145 patients per group) were identified for final analysis. After PSM, no difference was observed between two patient cohorts in mentioned characteristics between the two cohorts of patients. More than two-thirds of the patients in the OR group had proximal suprarenal clamp position (69.6%). In 30% of patients undergoing OR, bypass or reimplantation of either one or both renal arteries in the aortic graft was performed. The majority of patients in the endovascular group used fenestrated configuration for the AAA repair (88.3%). A proximal sealing zone as high as in zone 5 was necessary in more than half of the patients (53.1%). The average number of used fenestrations/branches for visceral arteries involvement was 3.4±0.8. Operating time was longer in the endovascular group (273.5±90.2 vs 185.4±67.3 min, p<.001). Regarding the postoperative complications, spinal cord ischaemia (SCI) occurred more frequently in the endovascular group (3.4% vs 0%, p=.028). Bleeding requiring surgical reintervention was more frequent in OR group (6.9% vs 1.4%, p=.03). Acute kidney injury (AKI) according to the RIFLE criteria (2) occurred more frequently in the OR group (32.4% vs 20.7%, p=.046). There was no difference in the proportion of cardiac, pulmonary, or other surgical complications, hospital and 30-day mortality. After a median follow-up of 84 months, no difference in overall survival between the two groups of patients was observed (31% for OR vs 27.6% for endovascular surgery, p=.93) (Figure 1). Patients undergoing endovascular surgery more frequently underwent aortic-related reinterventions (13.8% vs 5.5%, p=.015) (Figure 2).
Conclusion:
In patients with JAAA and PAAA there was no difference in terms of long-term survival, but there was a higher rate of aortic-related reintervention in endovascular patients. SCI occurred more frequently in the endovascular group, while AKI occurred more frequently in the OR group, however, the majority of patients did not have permanent renal damage. Both open and endovascular treatment can be performed in high-volume aortic centres with a low short-term mortality/morbidity and good long-term results.
References:
1. Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019;57(1):8-93. 2. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P;Acute Dialysis Quality Initiative workgroup. Acute renal failured definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:204-12.
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