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National outcomes after open repair of abdominal aortic aneurysms with visceral or renal bypass

Michelle Martin, MD, Kristina A Giles, MD, Frank Pomposelli, MD, Allen D. Hamdan, MD, Mark C. Wyers, MD, Marc L. Schermerhorn, MD,
Beth Israel Deaconess Medical Center- Department of Vascular Surgery Research; Boston, MA


PURPOSE OF STUDY
To evaluate national outcomes after open repair of abdominal aortic aneurysms with visceral or renal bypass (VRB).

METHODS USED:
Using the NIS database from 1993-2005, AAA repairs were identified by ICD9 codes for diagnosis of intact AAA combined with a procedure of open AAA repair. VRB patients also had an aorto-renal and/or mesenteric bypass, or mesenteric endarterectomy. Dissections, thoracic, and thoracoabdominal aneurysms were excluded. Demographics and comorbidities were noted. Mortality and complications were compared to infrarenal AAA repairs without visceral or renal bypass (IRA). Predictors of perioperative mortality were analyzed by multivariate logistic regression.

SUMMARY OF RESULTS:
A total of 39,734 VRB and 349,806 IRA repairs were identified. VRB repairs had a 57.14% volume decrease (IRA 52.8% volume decrease). Mortality and complications including acute renal failure, acute mesenteric ischemia, and bowel resection were higher after VRB (Table). Acute myocardial infarction was similar between cohorts. Patients requiring a bowel operation or with a complication of acute renal failure were 10 times more likely to die within the hospital stay. Independent preoperative predictors of mortality were age, chronic renal failure, congestive heart failure, and pulmonary disease. Post-operative complications were predictive of mortality as well.

CONCLUSIONS:
VRB repair volume decreased per year similarly to open IRA repair volume and may be related to the advances of endovascular therapy. Mortality after VRB is high and dependent upon age, renal failure, acute mesenteric insufficiency and bowel surgery. Recommendations include avoiding concomitant bypass and consideration of visceral/renal stenting.

TABLES AND CHARTS:
Mortality after Open Abdominal Aortic Aneurysm Repair With and Without Visceral/Renal Bypass
  VRB IRA P-value
Overall 5.8% 4.4% <.001
Age: <55 1.7% 1.5% .84
55-59 1.9% 1.5% .52
60-64 3.4% 1.9% <.01
65-69 4.4% 2.6% <.001
70-74 4.9% 4.0% .08
75-79 7.6% 5.5% <.001
80+ 11.3% 9.1% <.05
Male 5.3% 3.9% <.001
Female 8.0% 6.2% <.01
Complications after Open Abdominal Aortic Aneurysm Repair With and Without Visceral/Renal Bypass
Acute Renal Failure 9.2% 5.8% <.001
Acute Mesenteric Ischemia 2.0% 1.1% <.001
Bowel Resection 1.1% 0.8% <.01
Acute Myocardial Infarction 2.6% 3.0% .06
Predictors of Mortality After Open Abdominal Aortic Aneurysm Repair With and Without Visceral/Renal Bypass
  OR 95% CI P Value
Visceral / Renal Bypass + AAA Repair 1.3 1.2-1.5 <.001
Age (per year) 1.1 1.1-1.1 <.001
Female Gender 1.6 1.5-1.7 <.001
Comorbidities      
Chronic Renal Failure 6.4 5.6-7.3 <.001
Congestive Heart Failure 7.5 6.0-9.2 <.001
Chronic Pulmonary Disease 1.2 1.1-1.3 <.001
Hypertension 0.4 0.3-0.4 <.001
Complications as Predictors of Mortality After Open Abdominal Aortic Aneurysm Repair With and Without Visceral/Renal Bypass
(adjusted for age, gender, and repair type)
Acute Renal Failure 10.2 9.4-11.2 <.001
Bowel Operation 9.7 7.9-12.6 <.001
Acute Myocardial Infarction 6.1 5.3- 7.0 <.001

 

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