Fenestrated Repair Improves Perioperative Outcomes but Lacks a Hospital Volume Association for Complex Abdominal Aortic Aneurysms

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Journal of vascular surgery


BACKGROUND: Complex abdominal aortic aneurysms (cAAAs) have traditionally been treated with an open surgical repair (OSR). Over the past decade, fenestrated endovascular graft repair (FEVAR) has emerged as a viable option. Hospital procedural volume to outcome relationship for OSR of cAAAs has been well established but the impact of procedural volume on FEVAR outcomes remains undefined. This study investigates the outcomes of OSR and FEVAR for the treatment of cAAAs and examines the hospital volume-outcome relationship for these procedures.

METHODS: A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012-2018 who underwent elective repair of a juxtarenal/pararenal abdominal aortic aneurysm with FEVAR or OSR. The primary outcomes were 30-day mortality, myocardial infarction, or new dialysis. Secondary endpoints included post-operative pneumonia, renal dysfunction (creatine concentration increase of >2 mg/dl from preoperative baseline), major bleeding, early procedural complications, length of stay, and need for reintervention. To evaluate procedural volume-outcomes relationship, hospitals were stratified into low and high-volume aortic centers based on a FEVAR annual procedural volume. To account for baseline differences, we calculated propensity scores and employed inverse probability of treatment weighting when comparing outcomes between treatment groups.

RESULTS: A total of 589 patients underwent FEVAR (n=186) or OSR (n=403) for a cAAAs. After adjustment, OSR was associated with higher rates of 30-day mortality (10.7% vs. 2.9%, p<0.001) and need for dialysis (11.3% vs. 1.8; p<0.001). Postoperative pneumonia (6.8% vs. 0.3%; p<0.001) and need for transfusion (39.4% vs. 10.4%; p<0.001) were also significant higher in the OSR cohort. The median length of stay for OSR and FEVAR was 9 days and 3 days; respectively. For those who underwent FEVAR, endoleaks were present in 12.1% of patients at 30 days and 6.1% of patients at 1-year, with the majority being Type II. One percent of FEVAR patients required a secondary procedure with a median follow-up period of 331 days [229, 378], and there were no FEVAR conversions to an open aortic repair. Hospitals were divided into low and high-volume aortic centers based on their annual FEVAR cAAA volume. After adjustment, hospital FEVAR procedural volume was not associated with 30-day mortality or myocardial infarction.

CONCLUSIONS: FEVAR was associated with lower perioperative morbidity and mortality compared to OSR for the management of complex AAAs. Procedural FEVAR volume outcome analysis suggests limited differences in 30-day morbidity although long-term durability warrants further research.

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ePub ahead of print