Transperitoneal versus retroperitoneal approach for open abdominal aortic aneurysm repair in the targeted vascular National Surgical Quality Improvement Program

Abstract

Objective We sought to compare current practices in patient selection and 30-day outcomes for transperitoneal and retroperitoneal AAA repairs. Methods All patients undergoing elective transperitoneal or retroperitoneal surgical repair for AAA between January 2011 and December 2013 were identified in the Targeted Vascular NSQIP database. Emergent cases were excluded. Baseline characteristics, anatomical detail, intra-operative and post-operative outcomes were evaluated among those with infrarenal or juxtarenal AAA only. Results 1,135 patients were identified; 788 transperitoneal (69%), 347 retroperitoneal (31%). Evaluating infrarenal and juxtarenal aneurysms only, the retroperitoneal patients were less likely to have an infrarenal clamp location (43% vs. 68%), had more renal revascularizations (15% vs. 6%, p<.001), more visceral revascularizations (5.6% vs. 2.4%, p=0.014) and more lower extremity revascularizations (11% vs. 7%, p=0.021) compared to the transperitoneal approach. Post-operatively there were no differences in mortality, or return to OR. Transperitoneal patients had a higher rate of wound dehiscence (2.4% vs. 0.4%, p=0.045), while retroperitoneal patients had higher incidence of pneumonia (9% vs 5%, p=0.034), transfusions (77% vs. 71%, p=0.037), reintubations (11% vs. 7%, p=0.034) and a longer LOS (median 8 vs. 7 days, p=0.048). After exclusion of all concomitant procedures, only transfusions remained more common in the retroperitoneal approach (78% vs. 70%, p=0.036). Multivariable analyses showed only higher rates of reintubation in the retroperitoneal group (OR1.7, 95% CI 1.0-3.0, p=0.047). Conclusions The retroperitoneal approach is more commonly used for more proximal aneurysms and was associated with higher rates of pneumonia, reintubations, transfusions and a greater length of stay on univariate analyses. However, multivariable analysis demonstrated similar results between groups. The long-term benefits and frequency of reinterventions remain to be proven.

Patient selection and perioperative outcomes are similar between targeted and nontargeted hospitals (in the National Surgical Quality Improvement Program) for abdominal aortic aneurysm repair

“…Our recent targeted- NSQIP analysis found longer operative times with the retroperitoneal approach when accounting for graft configuration (tube vs. bifurcated) and higher rates of transfusion as well. [35] Importantly, however, increased operative times did not translate into increased mortality, morbidity, or length of stay. In addition to operative time, targeted hospitals also had higher rates of transfusion for non-complex and complex intact open repairs.…”

Transabdominal open abdominal aortic aneurysm repair is associated with higher rates of late reintervention and readmission compared with the retroperitoneal approach

“…19 We previously evaluated the impact of surgical approach in more recent years using two large national databases: the targeted vascular module of the National Surgical Quality Improvement Program and the VQI. 5,7 Within the National Surgical Quality Improvement Program, we identified higher rates of wound dehiscence with the transabdominal approach but higher rates of postoperative reintubation in patients with a retroperitoneal approach. 5 In our previous study using VQI data without linkage to Medicare, we could evaluate only early in-hospital outcomes and late survival.…”

“…5,7 Within the National Surgical Quality Improvement Program, we identified higher rates of wound dehiscence with the transabdominal approach but higher rates of postoperative reintubation in patients with a retroperitoneal approach. 5 In our previous study using VQI data without linkage to Medicare, we could evaluate only early in-hospital outcomes and late survival. Few previous studies have been able to compare late reinterventions and readmissions by surgical approach.…”

“…6,14 We previously used two large national databases to compare incisional approaches and found mixed results regarding early outcomes, but neither database could assess laparotomy-related complications or late outcomes. 5,7 Our previous studies of Medicare beneficiaries demonstrated higher rates of late laparotomy-related complications including reintervention for bowel obstruction and hernia in patients undergoing open AAA repair compared with EVAR, but this study could not evaluate surgical approach. 15 Therefore, we aimed to use Medicare-linked late outcomes data in conjunction with the Vascular Quality Initiative (VQI) to compare late mortality, readmissions, and reinterventions, including aneurysm-related reintervention, laparotomy-related reintervention, and nonoperative readmission for laparotomy-related complications, after a transabdominal vs a retroperitoneal approach to open AAA repair.…”

“…We and others previously compared the transabdominal with the retroperitoneal approach to open AAA repair. [4][5][6][7] Many surgeons prefer the transabdominal approach, given its familiarity and ease of access to the aorta as well as to the intra-abdominal organs. [8][9][10] Whereas we demonstrated higher rates of hernia and intraperitoneal adhesions from nonaortic transperitoneal procedures compared with retroperitoneal procedures, data regarding the incisional approach to aortic surgery have been more mixed.…”