Open repair of abdominal aortic aneurysm: Changing the patients and the surgical strategies in the endovascular era

Aim. The purpose of this study was to review the experience with open repair (OR) of infrarenal abdominal aortic aneurysms (AAAs) during a period of 13 years at the Department of Vascular Surgery of University of Florence, paying particular attention to the changes in patients' characteristics and to the impact of evolving surgical strategies on perioperative morbidity and mortality rates. Methods. Between January 1994 and August 2007, 1 327 consecutive elective ORs for infrarenal AAA were performed at our institution. Patients operated on from 1994 to 1999 (pre-endovascular era, 693 interventions, Group 1) were retrospectively compared with those undergoing OR from 2000 to 2007 (endovascular era, 634 interventions, Group 2) to evaluate for significant differences in patient demographics, surgical strategies and perioperative (<30 days) results. In addition, patients undergoing endovascular AAA repair during the same period as Group 2 were analyzed to evaluate for differences in comorbid conditions (338 interventions, endovascular group). Results. The groups were extremely heterogeneous on the basis of preoperative clinical characteristics. Suprarenal aortic cross-clamping was required in 0.3% of cases in Group 1 compared to 5.2% of patients in Group 2 (P<0.001). Patients in Group 1 had concomitant renal revascularization in 1% of cases, while this was performed in 6.5% of patients of Group 2 (P<0.001). A higher percentage of hypogastric revascularizations were performed in Group 2 compared to Group 1 (6.3% vs. 0.4%, respectively, P<0.001). Overall 30-day mortality rate was higher in patients of Group 2 versus Group 1 (2.4% vs. 1%, P=0.05). The 30-day mortality rate was 0.9% in the endovascular group. Overall 30-day major morbidity was increased at 8.8% for patients of Group 2 and 5.8% for patients of Group 1 (P=0.03). Conclusion. Patients undergoing OR of their AAAs during the endovascular era have substantially different clinical characteristics with respect to those operated on in the pre-endovascular era. The wide diffusion of endovascular techniques in AAA repair seem to leave a more challenging patient population for open repair with a more technically demanding procedure than in the past