Aortobifemoral Reconstruction in Open Abdominal Aortic Aneurysm Repair Is Associated With Increased Morbidity and Mortality

Authors

Benjamin King, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
Caron Rockman, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
Sukgu Han, Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
Jeffrey J. Siracuse, Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA.
Virendra I. Patel, Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Hospital/Columbia University Irving Medical Center/Columbia University College of Physicians and Surgeons, New York, NY.Follow
William S. Johnson, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.Follow
Heepeel Chang, Westchester Medical Center, New York Medical College, Valhalla, NY.Follow
Neal Cayne, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
Thomas Maldonado, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
Glenn Jacobowitz, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
Karan Garg, Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY. Electronic address: karan.garg@nyulangone.org.

Author Type(s)

Faculty

DOI

10.1016/j.jvs.2023.03.019

Journal Title

Journal of Vascular Surgery

First Page

77

Last Page

88.e3

Document Type

Article

Publication Date

7-1-2023

Department

Surgery

Abstract

OBJECTIVE: Much attention has been given to the influence of anatomic and technical factors, such as maximum abdominal aortic aneurysm diameter and proximal clamp position, in open abdominal aortic aneurysm repair (OSR). However, no studies have rigorously examined the correlation between site of distal anastomosis and OSR outcomes despite conventional wisdom that more proximal sites of anastomosis are preferrable when technically feasible. This study aimed to test the association between sites of distal anastomosis and clinical outcomes for patients undergoing primary elective OSR. METHODS: Our study included 5683 patients undergoing primary elective OSR at 233 centers from 2014 to 2020. Using a variety of statistical methods to account for potential confounders, including multivariable logistic regression and Cox proportional hazards modeling, as well as subgroup analysis, we examined the association between site of distal anastomosis and clinical outcomes in elective OSR. Primary outcomes were major in-hospital complication rate, 30-day mortality, and long-term survival. RESULTS: Patients undergoing elective aortobifemoral reconstruction (n = 672) exhibited significantly increased rates of smoking, chronic obstructive pulmonary disease, and peripheral artery disease in comparison to patients undergoing elective OSR with distal anastomosis to the aorta (n = 2298), common iliac artery (n = 2163), or external iliac artery (n = 550). Patients undergoing aorto-aortic tube grafting were significantly less likely to exhibit iliac aneurysmal disease and significantly more likely to be undergoing elective OSR with a suprarenal or supraceliac proximal clamp position. Using multivariable logistic regression and Cox proportional hazards analysis to control for important confounders, such as age, smoking status, and medical history, we found that distal anastomosis to the common femoral artery was associated with increased odds of major in-hospital complications (adjusted odds ratio, 1.79; 95% confidence interval, 1.46-2.18; P < .001) and reduced long-term survival (adjusted hazard ratio, 1.44; 95% confidence interval, 1.09-1.89; P = .010). We observed no significant differences in 30-day mortality across sites of distal anastomosis in our study population. CONCLUSIONS: It is generally accepted that more proximal sites of distal anastomosis should be selected in OSR when technically feasible. Our findings support this hypothesis by demonstrating that distal anastomosis to the common femoral artery is associated with increased perioperative morbidity and reduced long-term survival. Careful diligence regarding optimization of preoperative health status, perioperative care, and long-term follow-up should be applied to mitigate major complications in this patient population.

Recommended Citation

King, B., Rockman, C., Han, S., Siracuse, J. J., Patel, V. I., Johnson, W. S., Chang, H., Cayne, N., Maldonado, T., Jacobowitz, G., & Garg, K. (2023). Aortobifemoral Reconstruction in Open Abdominal Aortic Aneurysm Repair Is Associated With Increased Morbidity and Mortality. Journal of Vascular Surgery, 78 (1), 77-88.e3. https://doi.org/10.1016/j.jvs.2023.03.019