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Comparison of Endovascular and Open Repair for Juxtarenal and Pararenal Aneurysms
Nathan T Orr, Daniel L Davenport, Eleftherios S Xenos
University of Kentucky, Lexington, KY

Endovascular aneurysm repair (EVAR) for infra-renal aortic aneurysms has largely become the standard of care for patients with appropriate anatomy. However, the use of endovascular repair of juxta- and pararenal aortic aneurysms often falls outside the instructions for use (IFU) of the associated devices. We assess the short-term mortality and morbidity of EVAR for juxta- and pararenal aneurysms verses open aortic repair (OAR).
We queried the ACS-NSQIP public use file from 2012 which included the first year of reported data from select centers tracking additional “procedure-targeted” variables for repair of abdominal aortic aneurysms. This data specifically listed the proximal extent of the aneurysm if documented in the operative note. We selected open or endoluminal repair of juxta- or pararenal aneurysms for analysis. Juxtarenal aneurysms were defined as those that approached the renal artery origin and pararenal aneurysms were those that involved the renal artery origin. We excluded cases that were for failed prior repairs.
A total of 284 juxta- (234) and pararenal (50) aneurysm repairs were identified with 113 repaired via EVAR and 171 via OAR. Preoperative characteristics were equivalent except that EVAR patients were significantly older, had a lower ASA class, smoked less, and had a higher baseline creatinine. Over 35% of the EVAR procedures required renal stents. Only 16.8% were repaired using fenestrated devices, implying that the other 83.2% were repaired outside the device IFU. There was no difference in 30-day mortality between EVAR and OAR (2.7% v. 3.5%). The 30-day morbidity was significantly higher for OAR compared to EVAR (76.0% v. 26.5%) with the highest contributing morbidities including the need for perioperative transfusion (72.5% v. 15.9%), a return to the operating room (11.7% v. 1.8%), and cardiac or respiratory failure (17.5% v. 7.1%). The median ICU and hospital length of stay significantly favored EVAR over OAR.
Unlike traditional infra-renal aneurysm repair with favorable anatomy, there is no advantage for EVAR over OAR in juxta- and pararenal aortic aneurysm repair in terms of 30-day mortality. Advantages of EVAR regarding decreased short-term morbidity and length of stay must be weighed against the increasing evidence showing long-term challenges with the outcomes for endoluminal repair of juxta- and pararenal aneurysm repairs occurring outside device IFU. Our data does not support the use of EVAR as the primary modality in the approach of juxtarenal and pararenal aneurysms, and we suggest that open repair should remain the gold standard.
Selected post-operative outcomes up to 30 days after the operation
No. of Procedures113171
Median ICU LOS, days (IQR)0 (0 - 1)3 (2 - 5)< .001
Median Length of Hospital Stay, days (IQR)3 (1 - 5)6 (8 - 11)< .001
% 30-day mortality2.73.51.000
% 30-day morbidity (any of the following)26.576.0< .001
%Transfused w/in 72 h. of operation,15.972.5< .001
% Return to the OR1.811.7.002
% Cardiac or Respiratory Failure7.117.5.012
% Renal Insufficiency or Failure7.19.4.664

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