Fenestrated Endograft Repair is Associated with Improved Perioperative Outcomes but Absence of Hospital Volume Relationship in Comparison to Open Surgical Repair of Complex Abdominal Aortic Aneurysms
Frank M Davis1, Jeremy Albright1, Jonathan Eliason1, Nicholas Osborne1, Dawn Coleman1, Nicolas Mouawad2, Jordan Knepper3, Ashraf Mansour4, Matthew Corriere1, Peter K Henke1
1University of Michigan, Ann Arbor, MI;2McLaren Bay Regional, Bay City, MI;3Henry Ford Health System, Jackson, MI;4Spectrum Health System,, Grand Rapids, MI
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. During this time, the 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 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 relationships, hospitals were stratified into low and high-volume aortic centers based on an annual procedural volume of four juxtarenal AAA repairs per year. To account for baseline differences, we calculated propensity scores and employed probability-weighting.
Results: A total of 590 patients underwent FEVAR (n=187) or OSR (n=403) for a cAAAs. After adjustment, OSR was associated with higher rates of 30-day mortality (10.6% vs. 3.2%, p=0.001), myocardial infarction (3.9% vs. 0.81%; p=0.29) and need for dialysis (13.5% vs. 3.7%; p=0.001). Postoperative pneumonia (6.8% vs. 0.44%; p=0.001) and need for transfusion (35.3% vs. 9.6%; 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 11.6% of patients at 30 days and 5.4% 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 during this period. 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 no difference in 30-day morbidity or mortality between low and high volume centers, although long-term durability warrants further research.
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