The impact of concomitant procedures during endovascular abdominal aortic aneurysm repair on perioperative outcomes

Abstract

Introduction Concomitant procedures during endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) are performed to either facilitate endograft delivery, simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aims to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR Methods We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014, and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes. Results 4033 patients were included in the study, with 1168 (29.0%) patients undergoing one or more additional procedure. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (OR: 4.8, 95% CI: 2.1–11.2) and renal angioplasty or stenting (3.1, 1.2–8.3). Postoperative bowel ischemia was associated with hypogastric embolization (3.8, 1.1–13.4) and iliac angioplasty or stenting (3.5, 1.3–9.6). Leg ischemia was associated with unplanned graft extension (2.3, 1.02–5.0), other artery reconstruction (5.2, 1.8–15.1), thrombo-embolectomy (5.2, 1.3–20.8), and repair of arterial injury (4.6, 1.2–18.3). Risk factors for deterioration of renal function were ilio-femoral bypass (3.9, 1.3–12.2), other artery reconstruction (2.7, 1.3–5.8), renal angioplasty or stenting (2.5, 1.3–4.6), and repair of arterial injury (4.5, 1.6–12.2). Myocardial infarction was associated with femoro-femoral bypass (3.9, 1.7–8.7), other artery reconstruction (3.9, 1.6–9.2) and repair of arterial injury (6.1, 1.8–21.0). Wound complications were predicted by femoro-femoral bypass (13.4, 5.8–31.1). Conclusions Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thrombo-embolic events where possible.

Implications of concomitant hypogastric artery embolization with endovascular repair of infrarenal abdominal aortic aneurysms

“…Some investigators have reported an increased risk of such complications, whereas others do not. [5][6][7] As a result, further data are needed on outcomes of EVAR with HAE. Continued advancement of endovascular techniques and endograft design has allowed preservation of hypogastric artery flow.…”

Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure

“…This result is similar to the reported odds of in-hospital renal dysfunction after elective EVAR in the study by Ultee et al, in which concomitant renal angioplasty or stenting was found to be an independent risk factor for both 30-day mortality and in-hospital renal dysfunction. 9 This adverse role had also been observed in a prior study by Protack et al, in which the investigators demonstrated a significant rise in creatinine concentration within 1 month of intervention in patients who had EVAR + RAAS compared with patients who had RAAS for other indications. 21 That study had an objective slightly different from ours as the authors compared two distinct populations of patients, although they shared the same atherosclerotic pathologic process; patients with AAA and patients with renal artery stenosis.…”

“…A recent study using the Vascular Study Group of New England registry showed that 29% of elective EVAR was performed with one or more concurrent interventions, and renal artery angioplasty was done in 3% of all elective EVAR. 9 …”

Patient-perceived health-related quality of life before and after laparoscopic aortobifemoral bypass

“…Previously, studies have shown increased morbidity and mortality related to concomitant procedures with open or endovascular repair of abdominal aorta 22,23. However, in patients with advanced atherosclerotic disease, it is sometimes necessary to perform additional procedures, for example, thromboendarterectomy of the groin arteries or even infrainguinal bypass, to ensure postoperative graft patency.…”

“…Previously, studies have shown increased morbidity and mortality related to concomitant procedures with open or endovascular repair of abdominal aorta. 22 , 23 However, in patients with advanced atherosclerotic disease, it is sometimes necessary to perform additional procedures, for example, thromboendarterectomy of the groin arteries or even infrainguinal bypass, to ensure postoperative graft patency. We have previously, in a comparative cohort study design in the same patient population, found a significant relative reduction of the composite events (all-cause mortality, graft occlusion and systemic morbidity) in patients with LABFB as compared to open ABFB, during a median follow-up time period of 4.12 years.…”