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Predictors of Decreased Short- and Long-Term Survival Following Open Abdominal Aortic Aneurysm Repair
Study Questions:
What are predictors of decreased survival after open abdominal aortic aneurysm (AAA) repair?
Methods:
A total of 408 patients undergoing open AAA repair were identified from 2003-2009 using a prospectively maintained, single-institution vascular database. Primary outcomes were 30-day and 5-year survival. Secondary outcomes included cardiac (arrhythmia, myocardial ischemia or infarction) and pulmonary complications (ventilator-dependent respiratory failure, pneumonia, pleural effusion requiring drainage, reintubation), and decreased renal function. Preoperative, intraoperative, and postoperative variables were assessed, and associated outcomes were evaluated using univariate and multivariate analysis. Kaplan-Meier analysis was used to determine survival.
Results:
Of the 408 patients who underwent open AAA repair, 70.8% were male, with a mean age of 72.4 ± 8.3 years. Mean aneurysm size was 6.3 ± 1.4 cm; 16.4% of repairs were urgent or emergent. An infrarenal aortic clamp was required in 33.6%, a suprarenal clamp in 23.8%, and a supraceliac clamp in 42.6%. Thirty-day, 1-year, and 5-year survival were 95.6%, 90 ± 1.5%, and 65.1 ± 3%, respectively. A total of 19.4% of patients had decreased renal function postoperatively; 17.4% had cardiac complications, whereas 11% experienced pulmonary complications. Patients with chronic obstructive pulmonary disease (COPD) and decreased renal function had decreased 30-day survival. Mean long-term follow-up was 38.1 ± 24.8 months, with 12% of patients lost to follow-up. Patients with COPD, decreased renal function, and cerebrovascular disease had decreased 5-year survival rates. Level of aortic cross-clamp did not affect 30-day survival, but did predict decreased 5-year survival on univariate analysis. History of coronary artery disease or cardiac complication was not associated with decreased survival.
Conclusions:
The authors concluded that open AAA repair can be performed with low morbidity and mortality. Patients with COPD, chronic renal insufficiency, and cerebrovascular disease are at increased risk, and these patients should be managed with preoperative optimization and thoughtful perioperative care. Postoperative pulmonary complications and deterioration in renal function are associated with decreased 5-year survival rates.
Perspective:
This study, in which 66% of patients required pararenal or supraceliac aortic cross-clamp, demonstrates excellent short- and long-term results in the surgical management of complex aortic aneurysmal disease. The short-term results are comparable to current studies of endovascular repair of similar aneurysms with fenestrated and branched aortic endografts. There are no 5-year data on these endovascular techniques for comparison at this time. However, endovascular techniques for treatment of complex AAAs may be of special benefit to patients with COPD, renal insufficiency, and cerebrovascular disease.
Keywords: Pulmonary Disease, Chronic Obstructive, Myocardial Ischemia, Kaplan-Meier Estimate, Multivariate Analysis, Pneumonia, Pleural Effusion, Perioperative Care, Aortic Aneurysm, Abdominal, Postoperative Period
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