Endovascular Stent Grafting Versus Open Surgical Operation in Patients With Infrarenal Aortic Aneurysms

Abstract

Background— Although transfemoral endovascular aneurysm management (TEAM) of infrarenal abdominal aortic aneurysms (AAA) is widely performed, open graft replacement is still considered the standard of care. The aim of this study was to investigate whether clear indications for TEAM can be established in patients with significant comorbidities without investigating differences in relative procedure efficacy or durability. Methods and Results— A propensity score–based analysis of 454 consecutive patients treated electively for AAA from January 1995 through December 2000 was performed. Of those 454 patients, 248 received open surgery and 206 received TEAM. In-hospital mortality rates (MRs) were compared. After adjusting for propensity scores, a Cox proportional hazard model (COX) was employed to test the influence of the respective treatment on postoperative 900-day survival estimates (SEs). Several potential preoperative risk factors were used as covariates. The MR of all patients was 3.7%. Explorative analysis demonstrated that patients treated by TEAM presented with significantly more risk factors. In American Society of Anesthesiologists class IV patients, a significant difference in MR was detected (4.7% for TEAM versus 19.2% for open surgery; P <0.02). After adjusting for the propensity to receive TEAM or open surgery, a regression analysis of survival based on COX revealed predictive influences of impaired kidney ( P <0.047) or pulmonary function ( P <0.001), increased age ( P <0.05), and selection of treatment modality ( P <0.002) on SE. Conclusions— TEAM represents a less invasive procedure for AAA therapy in patients with significant preoperative risk factors. Especially in geriatric patients with multiple morbidities, TEAM offers a method of therapy with acceptable MRs and SEs, making active treatment possible in otherwise incurable patients.

Epidural Anesthesia and Endovascular Repair of Abdominal Aortic Aneurysm Case Presenting With Severe Pulmonary Disease

“…Although endovascular technique costs much more compared to open surgery, it compensates for the difference with shorter hospital stay and fewer complications. This difference is especially notable in elderly patients presenting with co-morbid diseases and complications due to analgesic therapies 6 . Epidural anesthesia in endovascular abdominal aortic aneurysm repair is advantegous because it totally eliminates postoperative pain and provides hemodynamic stability during the procedure.…”

Aaa Elective Treatment Indication Tactics in Evar Era

“…Elective OS has acceptable morbidity (10-15 %) and mortality (2-8 %) but only in fit patients (ASA II). Hemodynamically loading aortal clamping and invasivity significantly increase the morbidity (40 %) and mortality (19 %) rates in high operating risk patients (ASA III, IV) 6,[13][14][15] . These patients comprise a significant portion of AAA patients.…”

“…These patients comprise a significant portion of AAA patients. Therefore, the hemodynamically less loading and miniinvasive EVAR, with acceptable mortality also in high operating risk patients (4.7 %), has come into focus in the last decade [12][13][14][15] . Unfortunately, EVAR has technical limitations caused by the present stent-graft system construction and the indication depends on AAA morphology.…”

“…The best comparision of OS and EVAR mortality and morbidity rates is in the ASA III group of AAA patients and also when we compare OS in ASA II versus EVAR in the ASA III group [13][14][15][24][25][26] . The increased invasiveness of the combined strategy associated with additional open surgery leads to higher, yet acceptable morbitidy.…”

“…During the last decade, endovascular stentgrafting (EVAR) highly influenced the indications for AAA elective treatment [10][11][12] . This miniinvasive and hemodynamically less loading method has extended the elective treatment posibilities of AAA patients who show a high operating risk and are unfit for open surgery [13][14][15] . Another AAA treatment possibility, based on primary association of both of the previous methods, is the combined strategy (CS) for AAA of complicated morphology for EVAR 16 ( Fig.…”