Retroperitoneal vs. Transperitoneal Approach for Non-Ruptured Open Conversion after Endovascular Aneurysm Repair

Sara Allievi; Elisa Caron; Vinamr Rastogi; Sai Divya Yadavalli; Gabriel Jabbour; Tim J Mandigers; Thomas F X O'Donnell; Virendra I Patel; Francesco Torella; Hence J M Verhagen; Santi Trimarchi; Marc L Schermerhorn

doi:10.1016/j.jvs.2024.09.009

Retroperitoneal vs. Transperitoneal Approach for Non-Ruptured Open Conversion after Endovascular Aneurysm Repair

J Vasc Surg. 2024 Sep 17:S0741-5214(24)01888-3. doi: 10.1016/j.jvs.2024.09.009. Online ahead of print.

Affiliations

¹ Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
² Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
³ Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
⁴ Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
⁵ Division of Vascular and Endovascular Interventions, New York Presbyterian/Columbia University Irving Medical Center, New York, NY.
⁶ Liverpool Vascular and Endovascular Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; School of Physical Sciences, University of Liverpool, Liverpool, UK; Liverpool Centre for Cardiovascular Science, Liverpool, UK.
⁷ Section of Vascular Surgery, Cardio Thoracic Vascular Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical and Community Sciences, University of Milan, Milan, Italy.
⁸ Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address: mscherm@bidmc.harvard.edu.

PMID: 39299528
DOI: 10.1016/j.jvs.2024.09.009

Abstract

Objective: Several studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach 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 are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after EVAR.

Methods: We included all patients who underwent open conversion after EVAR between 2010-2022 in Vascular Quality Initiative (VQI). 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 (IPW) 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. 5-year mortality was evaluated using Kaplan-Meier and Cox regression.

Results: We identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 [IQR, 70-79] years vs. 73.5 [IQR, 68-79] years, p<.001), and more frequently had prior myocardial infarction (33% vs. 22%, p=.002). Compared with the TP approach, the RP approach was less frequently used in case of associated iliac aneurysm (19% vs. 27%, p=.026), but more frequently with associated renal bypass (7.8% vs. 1.7%, p<.001) and by high volume physicians (highest quintile, >7 AAA annually: 41% vs. 17%, p<.001) and in high volume centers (highest quintile, >35 AAA annually: 36% vs. 20%, p<.001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs. 21%, p<.001), and an infrarenal clamp (25% vs. 36%, p<.001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs. TP: 3.8% vs. 7.5%; p=.077). After risk adjustment, RP patients had similar odds of perioperative mortality (aOR, 0.49; 95%CI, 0.22-1.10; p=.082), and lower odds of intestinal ischemia (aOR, 0.26; 95%CI, 0.08-0.86; p=.028) and in-hospital reintervention (aOR, 0.43; 95%CI, 0.22-0.85; p=.015). No significant differences were found in the other perioperative complications, and 5-year mortality (aHR, 0.79; 95%CI, 0.47-1.32; p=.37).

Conclusions: - Our findings suggest that the RP approach may be associated with lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.

Keywords: EVAR; open conversion; retroperitoneal; surgical approach; transperitoneal.