Allievi Sara, Caron Elisa, Rastogi Vinamr, Yadavalli Sai Divya, Jabbour Gabriel, Mandigers Tim J, O'Donnell Thomas F X, Patel Virendra I, Torella Francesco, Verhagen Hence J M, Trimarchi Santi, Schermerhorn Marc L
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
J Vasc Surg. 2025 Jan;81(1):118-127. doi: 10.1016/j.jvs.2024.09.009. Epub 2024 Sep 18.
Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR).
We included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression.
We identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37).
Our findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.
多项比较经腹（TP）和腹膜后（RP）途径修复腹主动脉瘤（AAA）的研究表明，RP途径可能导致围手术期死亡率和发病率较低。然而，缺乏比较这些途径用于开放转换的数据。本研究旨在评估血管腔内修复术（EVAR）后开放转换的手术方式与结局之间的关联。
我们纳入了2010年至2022年期间在血管质量倡议中接受EVAR后开放转换的所有患者。排除出现破裂的患者。主要结局是围手术期死亡率。次要结局包括围手术期并发症和5年死亡率。采用逆概率加权法对具有统计学或临床意义的因素进行调整。使用逻辑回归评估加权队列中的围手术期死亡率和并发症。采用Kaplan-Meier法和Cox回归评估5年死亡率。
我们确定了660例接受EVAR后开放转换的患者（39%为RP途径）。与TP途径相比，RP途径的患者年龄更大（75岁[四分位间距，70 - 79岁]对73.5岁[四分位间距，68 - 79岁]；P <.001），且既往心肌梗死的发生率更高（33%对22%；P =.002）。与TP途径相比，RP途径在合并髂动脉瘤的病例中使用频率较低（19%对27%；P =.026），但在合并肾旁路的病例中使用频率较高（7.8%对1.7%；P <.001），并且在高年资医生（最高五分位数，每年>7例AAA：41%对17%；P <.001）和高容量中心（最高五分位数，每年>35例AAA：36%对20%；P <.001）中使用频率更高。与TP途径的患者相比，RP途径的患者较少进行髂外或股动脉远端吻合（8.2%对21%；P <.001）和肾下钳夹（25%对36%；P <.001）。未调整的围手术期死亡率在两种途径之间无显著差异（RP对TP：3.8%对7.5%；P =.077）。风险调整后，RP途径的患者围手术期死亡的几率相似（调整后的优势比[aOR]，0.49；95%置信区间[CI]，0.22 - 1.10；P =.082），肠道缺血的几率较低（aOR，0.26；95% CI，0.08 - 0.86；P =.028）以及住院期间再次干预的几率较低（aOR，0.43；95% CI，0.22 - 0.85；P =.015）。在其他围手术期并发症或五年死亡率方面未发现显著差异（调整后的风险比[aHR]，0.79；95% CI，0.47 - 1.32；P =.37）。
我们的研究结果表明，与TP途径相比，RP途径可能与围手术期并发症的调整后几率较低相关。在可行的情况下，EVAR后开放转换应考虑采用RP途径。
