Open Aneurysm Repair in Elderly Patients Not Candidates for Endovascular Repair (EVAR): Comparison with Patients Undergoing EVAR or Preferential Open Repair

Abstract

The authors reviewed a 2-year experience with abdominal aortic aneurysm (AAA) repair to determine if patients who were excluded from endovascular aneurysm repair (EVAR) because of anatomic criteria (Group III) represented a higher risk for subsequent open aneurysm repair than either patients undergoing EVAR (Group II) or those patients who preferentially underwent open repair (Group I). Between January 2001 and December 2003, 107 patients underwent AAA repair. Open repair was recommended in patients <70 years of age and without significant comorbidities (Group I). There were 35 patients in Group I; 72 patients were evaluated for EVAR; 29 patients underwent EVAR (Group II), and 43 were excluded and underwent open repair (Group III). Exclusion criteria were those recommended by the graft manufacturers. Patients in Group I were significantly younger than those in Groups II and III (p<0.0001). Gender, incidence of diabetes, and hypertension were similar in all groups. Patients in Group III had a greater incidence of coronary artery disease (CAD) than those in Groups I and II, trending toward statistical significance (p=0.06). Aneurysm size in Group II was statistically smaller than in Group I or III. Group III had significantly more complications (25.6% vs 5.7% and 6.9%) than either Group I or II (p<0.015). Cardiac complications were similar in all groups. Three patients in Group III required prolonged intubation and 3 in Group III developed renal insufficiency. A history of CAD was predictive of complications (21.8% vs 5.8%, p<0.024), as was inclusion in Group III. There were 2 deaths in this series, both in Group III. Length of stay was significantly less in Group II (4.17 ±2.36 days) than in Group I (6.57 ±1.84 days) or Group III (12.30 ±9.82 days) (p=0.0001). Open aneurysm repair can be safely performed in younger good-risk patients (Group I) with results equivalent to EVAR (Group II) but with slightly longer length of stay (LOS). In older patients with suitable anatomy EVAR can be performed with minimal morbidity and short LOS. Older patients not suitable for EVAR (Group III) constitute a higher risk group of patients because of increased incidence of CAD and the need for more complex repairs. However, the mortality rate in this group was only 4.6%.

References

Parodi JC , Palmaz JC , Barone HD : Transfemoral intraluminal graft implantation for abdominal aortic aneurysm. Ann Vasc Surg 5:491-499, 1991.

Zarins CK , White RA , Moll FL , et al: The AneuRx stent graft: Four-year results and worldwide experience 2000. J Vasc Surg 33:S135-S145, 2001.

Makaroun MS : The Ancure endografting system: An update. J Vasc Surg 33:S129-S134, 2001.

Criado RJ , Wilson EP , Fairman RM , et al: Update on the Talent aortic stent-graft: A preliminary report from the United States phase I and II trials. J Vasc Surg 33:S146-S149, 2001.

Matsumura JS , Katzen BT , Hollier LH , et al: Update on the bifurcated EXCLUDER endoprosthesis: Phase I results. J Vasc Surg 33:S150-S153, 2001.

Greenberg RK , Lawrence-Brown M , Bhandari G , et al: An update of the Zenith endovascular graft for abdominal aortic aneurysms: Initial implantation and mid-term follow-up date. J Vasc Surg 33:S157-S164, 2001.

Rutherford RB , Krupski WC : Current status of open versus endovascular stent-graft repair of abdominal aortic aneurysm. J Vasc Surg 39:1129-1139, 2004.

Anderson PL , Arons RR , Moskowitz AJ , et al: A statewide experience with endovascular abdominal aortic aneurysm repair: Rapid diffusion with excellent early results. J Vasc Surgery 39:10-19, 2004.

Elkour S , Gloviczki P , McKusick M , et al: Perioperative complications and early outcome after endovascular and open surgical repair of abdominal aortic aneurysms. J Vasc Surg 39:497-505, 2004.

10.

Lee Wa , Carter JW , Upchurch G , et al: Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surgery 39:491-496, 2004.

11.

Chuter TAM , Reilly LM , Faruqu RM , et al: Endovascular aneurysm repair in high-risk patients. J Vasc Surg 31;122-133, 2000.

12.

Moore WS , Brewster DC , Bernhard WM , for the EVT/Guidant Investigators: Aorto-uni-iliac endograft for complex aortoiliac aneurysms compared with tube/bifurcation endografts: Results of the EVT/ Guidant trials. J Vasc Surg 36:118-126, 2002.

13.

Fairman RM , Baum RA , Carpenter JP , et al: Limb interventions in patients undergoing treatment with an unsupported bifurcated aortic endograft system: A review of the Phase II EVT Trial. J Vasc Surg 36:118-126, 2002.

14.

Piergiorgia C , Verzini F , Parlani G , et al: Predictive factors and clinical consequences of proximal aortic neck dilatation in 230 patients undergoing abdominal aorta aneurysm repair with self-expandable stentgrafts. J Vasc Surg 37:1200-1205, 2003.

15.

Buth J , Laheij RJF , on behalf of the EUROSTAR Collaborators: Early complications and endoleaks after endovascular abdominal aortic aneurysm repair: Report of a multicenter study. J Vasc Surg 31:134-146, 2000.

16.

Faries PL , Cadot H , Agarwal G , et al: Management of endoleak after endovascular aneurysm repair: Cuffs, coils, and conversion. J Vasc Surg 37:1155-1161, 2003.

17.

Rzuciedlo EM , Powell RJ , Zwolak , et al: Early results of stent grafting to treat diffuse aortoiliac occlusion disease. J Vasc Surg 37:1175-1180, 2003.

18.

Kallifas S , Albertini JN , Mcierewicz J , et al: Stent graft migration after endovascular repair of abdominal aortic aneurysm. J Endovasc Ther 9:743-747, 2002.

19.

Hua HT , Cambria RP , Chuang SK , et al: Early outcomes of endovascular versus open abdominal aortic aneurysm repair in the National Surgical Quality Improvement Program–Private Sector (NSQIP-PS). J Vasc Surg 41:382-389, 2005.

20.

Leon Jr LR , Labropoules N , Laredo J , et al: To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the State of Illinois? J Vasc Surg 41:568-574, 2005.

21.

Abraham N , Lemech L , Sandrolessi C , et al: A prospective study of subclinical myocardial damage in endovascular versus open repair of infrarenal abdominal aortic aneurysm. J Vasc Surg 41:337-381, 2005.