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• W4377264033 abstract "Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approaches for AAA repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion is lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR). We included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. Five-year mortality was evaluated using Kaplan-Meier and Cox regression. We identified 618 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years; interquartile range [IQR], 70-79 years vs 73.5 years; IQR, 68-79; P = .006), and more frequently had prior myocardial infarction (33% vs 23%; P = .004). Compared with TP approach, RP approach was less frequently used in case of associated iliac aneurysm (19% vs 27%; P = .012), but more frequently with associated renal bypass (7.8% vs 1.6%; P < .001) and by high-volume physicians (highest quintile, >35 abdominal aortic aneurysm repairs annually: 34% vs 12%; P < .001) and center volume (highest quintile, >7 abdominal aortic aneurysm repairs annually: 38% vs 18%; P < .001). RP patients, compared with TP patients had less frequently external iliac or femoral distal anastomosis (7.8% vs 21%; P < .001), and distal clamping zone (infrarenal: 24% vs 35%; P = .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP 3.7% vs 7.5%; P = .076). Furthermore, following univariable analysis, compared with TP, RP approach had similar 5-year mortality rates (13% vs 20%; hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.56-1.34; P = .60). After risk adjustment, perioperative mortality was still not significantly different between approaches (odds ratio [OR], 0.43; 95% CI, 0.17-1.08; P = .073) (Table), although RP patients had lower odds of bowel ischemia (OR, 0.21; 95% CI, 0.06-0.73; P = .014) and reintervention (OR, 0.37; 95% CI, 0.17-0.82; P = .014). No significant differences were found in the other perioperative complications and 5-year mortality (RP vs TP 16% vs 14%, HR 0.76; 95% CI, 0.44-1.32; P = .333) (Figure). Our findings suggest that an RP approach may be associated with lower rates of perioperative complications compared with the TP approach. RP approach may lead to improved perioperative outcome following open conversion after EVAR.TablePostoperative outcomes in transperitoneal and retroperitoneal approach for open conversion after endovascular aneurysm repair (EVAR), before and after adjustmentUnadjustedWeightedaTransperitoneal (n = 374)Retroperitoneal (n = 244)P valueOR [95% CI]P valueICU stay (>5 days)85 (22.7%)58 (23.8%).8390.96 [0.31-1.52].354Postoperative complications132 (35.3%)87 (35.7%).9950.88 [0.53-1.24].539 Myocardial infarction25 (6.7%)16 (6.6%)10.64 [0.31-1.52].243 Dysrhythmia46 (12.3%)37 (15.2%).3681.17 [0.66-2.09].593 Congestive heart failure14 (3.7%)8 (3.3%).9340.93 [0.30-2.92].901 Pneumonia11 (2.9%)7 (2.9%)10.71 [0.24-2.04].520 Reintubation32 (8.6%)17 (7.0%).5740.52 [0.24-1.14].102 Intestinal ischemia17 (4.5%)4 (1.6%).0850.25 [0.08-0.82].021 Acute kidney injury81 (21.7%)56 (23.0%).781.21 [0.76-1.91].426 Temporary dialysis13 (3.5%)9 (3.7%)10.76 [0.25-2.36].640 Permanent dialysis9 (2.4%)5 (2.0%).9880.37 [0.09-1.60].184 Leg ischemia4 (1.1%)1 (0.4%).6630.53 [0.05-5.14].600 Wound complication10 (2.7%)8 (3.3%).8471.08 [0.40-2.94].900Reintervention during hospitalization42 (11.2%)15 (6.1%).0460.49 [0.25-0.99].046Length of stay (>14 days)67 (17.9%)33 (13.5%).1810.70 [0.40-1.20].200Perioperative mortality28 (7.5%)9 (3.7%).0760.43 [0.17-1.08].073CI, Confidence interval; ICU, intensive care unit; OR, odds ratio.Boldface entries indicate statistical significance.aAge, gender, race, obesity, hypertension, prior myocardial infarction, clamping site, distal anastomosis, iliac aneurysm, surgery year class, diameter class, presentation, early vs late conversion, anemia, physician volume, smoking history, prior cardiac insufficiency, prior chronic obstructive pulmonary disease, renal function, diabetes, and concomitant renal bypass. Open table in a new tab" @default.
• W4377264033 created "2023-05-23" @default.
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• W4377264033 date "2023-06-01" @default.
• W4377264033 modified "2023-09-30" @default.
• W4377264033 title "Retroperitoneal versus Transperitoneal Approach for Open Conversion After Endovascular Aneurysm Repair" @default.
• W4377264033 doi "https://doi.org/10.1016/j.jvs.2023.03.415" @default.
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