Transabdominal open AAA repair shows higher rate of late reintervention than retroperitoneal approach

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Repair-related reinterventions and readmissions are lower after retroperitoneal compared with transabdominal open abdominal aortic aneurysm (AAA) repair, according to a large multicentre retrospective review published in the January edition of the Journal of Vascular Surgery.

For those patients undergoing open surgical repair of AAA, the decision as to how to approach the aneurysm surgically is multifactorial. Familiarity with the approach, access to intra-abdominal organs, and the right iliac system, favours the transabdominal approach. Conversely, avoidance of a hostile abdomen, access to the visceral aorta and potential early return of bowel function favors the retroperitoneal approach.

“There is very limited data with regards to comparing these approaches long-term,” said first author Sarah Deery (Massachusetts General Hospital, Boston, USA). “Our aim in this study was to evaluate late mortality, readmissions and reinterventions, including aneurysm-related reinterventions, for both approaches, thus allowing surgeons and patients to consider these factors in their decision-making.”

A multicentre team led by Marc Schermerhorn (Beth Israel Deaconess Medical Center, Boston, USA) used prospectively collected data from the Vascular Quality Initiative (VQI) linked to Medicare data to compare the two approaches. VQI, a joint venture of M2S Inc and the Society for Vascular Surgery (SVS), collects and analyses data to improve the quality of vascular care.

Researchers evaluated 1,282 patients whose operation was performed between 2003 and 2015. The transabdominal approach was utilised in 914 patients (71%) versus the retroperitoneal approach in 368 patients (29%).

  • Baseline characteristics between the two groups were similar except:
    • Transabdominal procedures had more concomitant iliac artery aneurysms (28% versus 17%).
    • Retroperitoneal procedures had higher rates of suprarenal clamping (61% versus 36%).
  • Early 30-day mortality was equivalent for both approaches (4.7% for transabdominal, 3.8% for retroperitoneal).
  • Other postoperative complications, such as bowel ischemia, renal complications, wound complications and reoperation occurred at similar rates.
  • Long-term (five-year) outcomes included:
    • Survival was similar (62% for transabdominal, 61% for retroperitoneal).
    • Repair-related reintervention and readmission were significantly higher for transabdominal (42% versus 34%).
    • Abdominal wall reoperations were significantly higher for transabdominal (13% versus 6%).

“Even after adjustment for sex, age, symptom status, and anatomic differences, the transabdominal approach was associated with a 40% higher rate of late reintervention and readmission (hazard ratio, 1.4, 95% CI 1.1-1.7),” said Deery.

“Given changes in open training across vascular surgery, some surgeons may have especially limited exposure to the retroperitoneal approach to AAA repair compared with the transabdominal approach. Ultimately, surgeons will likely achieve better outcomes using the approach they are most comfortable with which may mean performing a transabdominal repair.”

As noted, many factors go into choosing the right approach for open AAA repair. This important and large series provides new, long-term data that enhances a professional’s decision-making, authors said.


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