Comparative analysis of open and endovascular abdominal aortic aneurysm in high risk patients

Uvod: Premda je endovaskularni tretman aneurizmatske bolesti (EVAR) abdominalne aorte osmišljen upravo za pacijente koji nisu pogodni kandidati za klasičnu otvorenu hirurgiju, njegov inicijalno dobar rezultat ubrzao je implementiranje ove proceduru u kliničku rutinu, a odmah zatim i kod bolesnika sa niskim operativnim rizikom. Ipak, svaki tretman aneurizmatske bolesti infrarenalne abdominalne aorte kod visoko rizičnih bolesnika predstavlja i dalje pravi izazov. Nedavni rezultati pojednih studija doveli su u pitanje apsolutnu korist ovih procedura kod visoko rizičnih bolesnika. Ovo je posebno važno imajući u vidu očekivani životni vek ovih bolesnika kao i značajan komorbiditet. Ciljevi: Cilj srpske multicentrične studije u ukupnoj populaciji tretiranih visoko rizičnih bolesnika sa aneurizmatskom bolešću abdominalne aorte, je poređenje ishoda lečenja dva različita tretmana, endovaskularnog (EVAR) i otvoreno hirurškog (OH). Metodologija: Podaci pacijenata koji su hirurški i endovaskularno lečeni zbog aneurizmatske bolesti abdominalne aorte u periodu januara 2007 do jula 2015, su retrospektivno i prospektivno sakupljani sa četiri Univerzitetske Klinike u Srbiji. Kriterijum visoko rizičnog bolesnika definisan je kao rezultat bodovanja Udruženja američkih anesteziologa klasa 3 ili 4, i jedan od sledećih varijabli komorbiditeta po tipu: bolesti srca, respiratorna insuficijencija, hepatična insuficijencija, revaskularizacija srca, bubrežna insuficijencija, hostilni abdomen i životna dob preko 80 godina. 328 bolesnika od 421 je zadovoljilo ove kriterijume (EVAR, n=180; OH, n=148). Primarni ciljevi istraživanja bili su tridesetodnevni mortalitet i petogodišnje preživljavanje. Sekundarni ciljevi bili su postoperativne komplikacije. Korišćena je Kaplan-Majer-ova analiza preživljavanja i Cox regresiona analiza...Objective: Although, endovascular aneurysm repair (EVAR) was originally designed for patients that are unfit to undergo invasive open repair (OR), the initial positive results, have lead quickly to the implementation of EVAR in clinical routine and also to its frequent use for low-risk patients. However, infrarenal aortic aneurysm repair in high-risk patients still remains a challenge. Recent results after endovascular abdominal aortic aneurysm repair (EVAR) have brought into question its value in patients deemed at high-risk for surgical intervention. In addition, the life span in this category of patients is often limited because of serious comorbidity, so the efficacy of EVAR or open repair in prolonging life expectancy also remains uncertain. Aims: The aim of the Serbian multicentric population-based study was to evaluate the outcome after elective EVAR compared with OR in a high-risk patient cohort. Methodology: Using data from 4 University vascular hospitals in Serbia, we retrospectively and prospectively evaluated patients who underwent elective abdominal aortic aneurysm repair from January 2007 to July 2015. The high-risk cohort was defined as age >60 years, American Anesthesiologists Association (ASA) class 3 or 4, the comorbidity variables of history of cardiac, respiratory, hepatic disease, cardiac revascularization, renal insufficiency and hostile abdomen. These criteria were met by 328 of 421 patients (EVAR, n=180; OR, n=148). Primary end points were 30-day mortality and 5-years survival and the secondary end point was perioperative complications. Kaplan-Meier curves for survival and multivariate Cox regression analyses were performed. Results: Mean age (years) was 69±7.3 (OR 67±6.8; EVAR 70±7.6; p=0.001). Male patients 91.5%, female patients 8.5%. The 30-day mortality rates for EVAR vs OR were 0% vs 4.1%, p=0.008..