Open aneurysm repair at an endovascular center

Value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms

Palma M. Shaw, Frank J. Veith, Evan C. Lipsitz, Takao Ohki, William D. Suggs, Manish Mehta, Katherine Freeman, Jamie McKay, George L. Berdejo, Reese A. Wain, Nicholas J. Gargiulo

Research output: Contribution to journalArticle

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Abstract

Objective: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. Methods: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P = .04-.001) in the retroperitoneal group. All factors were correlated with outcome. Results: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P > .2). Conclusion: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.

Original languageEnglish (US)
Pages (from-to)504-510
Number of pages7
JournalJournal of Vascular Surgery
Volume38
Issue number3
DOIs
StatePublished - Sep 2003

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Abdominal Aortic Aneurysm
Aneurysm
Ventral Hernia
Cicatrix
Obesity
Morbidity
Mortality
Therapeutics

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Open aneurysm repair at an endovascular center : Value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms. / Shaw, Palma M.; Veith, Frank J.; Lipsitz, Evan C.; Ohki, Takao; Suggs, William D.; Mehta, Manish; Freeman, Katherine; McKay, Jamie; Berdejo, George L.; Wain, Reese A.; Gargiulo, Nicholas J.

In: Journal of Vascular Surgery, Vol. 38, No. 3, 09.2003, p. 504-510.

Research output: Contribution to journalArticle

Shaw, Palma M. ; Veith, Frank J. ; Lipsitz, Evan C. ; Ohki, Takao ; Suggs, William D. ; Mehta, Manish ; Freeman, Katherine ; McKay, Jamie ; Berdejo, George L. ; Wain, Reese A. ; Gargiulo, Nicholas J. / Open aneurysm repair at an endovascular center : Value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms. In: Journal of Vascular Surgery. 2003 ; Vol. 38, No. 3. pp. 504-510.
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title = "Open aneurysm repair at an endovascular center: Value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms",
abstract = "Objective: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. Methods: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15{\%}-30{\%}) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55{\%} in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P = .04-.001) in the retroperitoneal group. All factors were correlated with outcome. Results: Despite these risk factors, overall 30-day mortality was 3.5{\%} (retroperitoneal group, 3.8{\%}), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P > .2). Conclusion: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.",
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T2 - Value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms

AU - Shaw, Palma M.

AU - Veith, Frank J.

AU - Lipsitz, Evan C.

AU - Ohki, Takao

AU - Suggs, William D.

AU - Mehta, Manish

AU - Freeman, Katherine

AU - McKay, Jamie

AU - Berdejo, George L.

AU - Wain, Reese A.

AU - Gargiulo, Nicholas J.

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N2 - Objective: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. Methods: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P = .04-.001) in the retroperitoneal group. All factors were correlated with outcome. Results: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P > .2). Conclusion: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.

AB - Objective: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. Methods: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P = .04-.001) in the retroperitoneal group. All factors were correlated with outcome. Results: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P > .2). Conclusion: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.

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