Open vs endovascular repair of abdominal aortic aneurysm involving the iliac bifurcation

Abstract

Introduction: Aneurysmal involvement of the iliac bifurcation increases the level of difficulty during surgery for abdominal aortic aneurysm (AAA) repair, potentially increasing the risk of early postoperative complications. Three previous randomized trials comparing endovascular aneurysm repair (EVAR) and open repair (OR) for AAAs showed that EVAR is associated with a lower early mortality rate. However, whether these results are valid for AAA involving the iliac bifurcation (AAAIB) remains unclear. The aim of this study was to evaluate early and late results after OR and EVAR for patients with AAA involving the iliac bifurcation.

Methods: Of 1116 patients treated for elective AAA repair between January 1998 and January 2008, 131 presented with AAAIB as detected by computed tomography (CT) scan. Sixty-eight patients were treated by EVAR and 63 by OR. Clinical and anatomic data, operative intervention, and outcomes were collected prospectively and analyzed retrospectively. The median duration of follow-up was 38 months for both groups.

Results: Patients in the EVAR group (72 +/- 10 years) were older than those in the OR group (64 +/- 8 years; P < .0001), but there were no differences in cardiac, renal, or pulmonary comorbidities between the two groups. Inhospital mortality rates were 2.9% vs 6.3% for EVAR and OR groups, respectively (P = .43). Systemic postoperative complications occurred in 7.4% vs 9.5% (P = .76) and postoperative colonic ischemia in 0% vs 6.3% (P = .051) of patients with EVAR and OR, respectively. Survival rates by Kaplan-Meier analysis were 91 +/- 7% for patients with EVAR and 90 +/- 8% for patients with OR at 2 years, and 61% +/- 15 for EVAR and 79% +/- 13 for OR at 5 years. All-cause reoperation rates were 25% with EVAR and 22% with OR (P = .83). Patients with EVAR were more likely to develop buttock claudication (33.3% vs 3.6%; P < .0001), whereas patients with OR were more prone to develop abdominal wall complications (19.6% vs 0%; P < .001).

Conclusion: In this series, the postoperative mortality and systemic complication rates after either EVAR or OR for AAAIB were not statistically different. In the OR group, there were more abdominal wall complications and a trend toward a higher rate of colonic ischemia. In the EVAR group, buttock claudication was more frequent.