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Paper |

Open Abdominal Aortic Aneurysm Repair in the Endovascular Era:  Effect of Clamp Site on Outcomes FREE

Gregory Landry, MD, MCR; Ignatius Lau; Timothy Liem, MD; Erica Mitchell, MD; Gregory Moneta, MD
[+] Author Affiliations

Author Affiliations: Division of Vascular Surgery, Department of Surgery, Oregon Health [[amp]] Science University, Portland.


Arch Surg. 2009;144(9):811-816. doi:10.1001/archsurg.2009.157.
Text Size: A A A
Published online

Objective  To describe a contemporary series of open abdominal aortic aneurysm (AAA) repairs in patients not anatomically suitable for endovascular AAA repair.

Methods  A prospectively maintained database including consecutive nonruptured open aneurysm repairs from March 1, 2000, through July 31, 2007, was reviewed. Patient demographic characteristics and perioperative outcomes were evaluated and stratified based on proximal aortic cross-clamp placement.

Results  A total of 185 patients with AAA underwent 103 infrarenal and 82 suprarenal cross-clamp repairs. Overall, the complication rate was 37.0% with infrarenal and 61.0% with suprarenal cross-clamps (P = .001). The 30-day mortality was 2.9% with infrarenal and 6.1% with suprarenal cross-clamps (P = .18). Postoperative renal insufficiency (29.3% vs 7.8%; P < .001) and pulmonary complications (25.6% vs 12.6%; P = .03) were more frequent with suprarenal cross-clamps. Suprarenal cross-clamps were associated with greater intraoperative blood loss (2586 mL vs 1638 mL; P = .006), operative duration (391 min vs 355 min; P = .005), use of adjunctive renal and/or visceral grafts (43.9% vs 1.9%; P < .001), duration of intensive care unit stay (4.5 days vs 3.0 days; P = .006), and hospital length of stay (9 days vs 7 days; P = .04). Of patients who received a suprarenal cross-clamp, 25.6% required temporary nursing home placement vs 17.5% with an infrarenal cross-clamp (P = .14).

Conclusions  Until fenestrated and branched endografts are available, open AAA repairs will become increasingly complex. Suprarenal cross-clamping is associated with increased rates of complications but similar mortality rates and need for nursing home placement. With the disappearance of straightforward open aneurysm repair, trainees in vascular surgery will have to learn AAA repair almost exclusively by operating on patients with complex AAAs. Fewer surgeons will perform these repairs, and fewer fellows will be able to complete the operation independently immediately after training.

Figures in this Article

Endovascular abdominal aortic aneurysm repair (EVAR) has gradually supplanted open surgical repair in anatomically suitable patients. Although initially touted as an alternative repair method in patients who were not deemed good candidates for open surgical repair, EVAR has become accepted as the preferred surgical treatment. Currently, 55% or more of abdominal aortic aneurysms (AAAs) are treatable with endovascular grafts approved by the US Food and Drug Administration (FDA).1

The most frequent anatomic restriction to the use of EVAR is an inadequate infrarenal neck for proximal fixation.2 Available EVAR devices specify a proximal fixation length of at least 1½ cm, and AAAs with shorter fixation lengths, ie, juxtarenal and suprarenal aneurysms, are not currently treatable with FDA-approved devices. Although fenestrated and branched endografts are forthcoming and will potentially expand the anatomic spectrum of AAAs that can be treated with EVAR,3 patients without suitable anatomy for currently approved devices still generally require standard open surgical repair. As a result, there has been a dramatic shift toward proportionately more complicated open AAA repairs because most routine AAAs are now repaired with EVAR. This shift will undoubtedly lead to a concomitant change in the demographic characteristics of patients undergoing open AAA repair, with implications for both surgical outcomes and training of residents and fellows. We report the results of a contemporary series of open AAA repairs in patients who were not candidates for EVAR to determine how the shift in open-repair demographic characteristics affects surgical outcomes.

Consecutive patients with nonruptured, open aneurysms from March 1, 2000, through July 31, 2007, for whom data were recorded in a prospectively maintained operative database were included in the study. Patients with associated connective tissue disorders (eg, Ehlers-Danlos syndrome, Marfan syndrome), prior endovascular repairs, and infected aneurysms were excluded. Demographic data derived from the database include age, sex, and preoperative comorbidities (coronary, pulmonary, and renal comorbidities, smoking status, hypertension, and hyperlipidemia). Coronary comorbidities included any history of coronary artery disease, congestive heart failure, or arrhythmia. Pulmonary comorbidities included any history of chronic obstructive pulmonary disease or malignant pulmonary neoplasms. Renal comorbidities were classified as either renal insufficiency (serum creatinine level >1.5 mg/dL [to convert to micromoles per liter, multiply by 88.4]) or dialysis-dependent renal failure. Smoking status was defined as either active smokers, patients with any smoking history (active or prior), or nonsmokers. History of hypertension and hyperlipidemia was obtained from the medical records. Details of the operative procedures and short-term outcomes were also obtained from the medical records.

The aneurysm operations were performed either through a left lateral retroperitoneal approach or midline transabdominal approach, as selected by the operating surgeon. In general, the retroperitoneal approach was favored when treating juxtarenal aneurysms to facilitate suprarenal clamping. A transabdominal approach was generally favored to treat concomitant iliac artery aneurysms or right renal artery disease. For straightforward infrarenal aneurysms not involving iliac, renal, or visceral vessels, either approach was used, although the retroperitoneal approach was generally preferred.

Patients in whom a suprarenal cross-clamping was anticipated were initially treated with mannitol (50 mg intravenous) for renal protection. A cell saver device was available for all repairs at the discretion of the operating surgeon. Adjunctive grafts were placed in renal and visceral arteries if these arteries were involved in the aneurysm or for severe associated occlusive disease. Adjunctive grafts were constructed with 6-, 7-, or 8-mm polyester grafts, depending on the size of the target vessel, and were attached as side branches to the main body of the aortic graft. Direct renal artery reimplantation was occasionally performed if a tension-free anastomosis could be constructed. Intraoperative data were obtained from the anesthesia records and included operative duration, measured from the beginning to the end of general anesthesia; amount of blood lost; and the need for blood products and crystalloid replacement.

Postoperative complications were assessed. Cardiac complications included postoperative myocardial infarction, based on either changes on electrocardiograms or troponin elevation, and new-onset arrhythmia requiring either medical management or cardioversion. Pulmonary complications included pulmonary embolism, pneumonia, and the need for mechanical ventilation for longer than 3 days. Renal complications included either renal insufficiency, defined as an increase in postoperative serum creatinine levels of more than 0.5 mg/dL above baseline, or renal failure requiring either hemodialysis or continuous veno-venous hemofiltration. Gastrointestinal complications included ischemic colitis, pancreatitis, cholecystitis, gastrointestinal bleeding, or a prolonged ileus beyond 1 week postoperatively. Wound complications included any dehiscence or other wound breakdown or any infection requiring treatment with antibiotics. Bleeding complications included any hemorrhage requiring a return to the operating room. The need for postoperative blood transfusions alone was not considered a complication. In addition to postoperative complications, intensive care unit and total hospital lengths of stay as well as discharge status (to home vs a skilled nursing facility) were recorded.

Outcomes were stratified based on placement of the proximal aortic cross-clamp. Cross-clamp placement above the renal arteries, including suprarenal, intermesenteric, and supraceliac clamps, indicates a juxtarenal or suprarenal aneurysm that would not be amenable to endovascular treatment using devices currently approved by the FDA. Placement of the cross-clamp in the infrarenal position implies adequate infrarenal neck length and quality (ie, lack of significant calcification or mural thrombus) for cross-clamping and sewing of the proximal graft, and, therefore, indicates an aneurysm that may potentially be suitable for currently approved devices.

All data were recorded as continuous, ordinal, or categorical variables. Univariate and multivariate analyses were performed to assess outcomes based on proximal clamp placement. Normally distributed continuous variables were compared using an independent samples t test. Ordinal or continuous data not normally distributed were compared using the Mann-Whitney test. Categorical variables were compared with either the Pearson χ2 test with continuity correction or the Fisher exact test, as appropriate. Linear regression was used to determine coefficients of determination (r2). Stepwise logistic regression analysis was performed to determine predictors of complications following AAA repair. The goodness-of-fit of the multivariate model was evaluated with the Hosmer-Lemeshow test. All tests were 2-tailed with statistical significance determined with a P value of .05.

From March 1, 2000, when an EVAR program was introduced, to July 31, 2007, 185 open AAA repairs were performed at the Oregon Health & Science University. An infrarenal cross-clamp was used in 103 patients (55.7%), and a suprarenal clamp was used in 82 (44.3%), including 16 patients with a supramesenteric or supraceliac clamp. There was a linear increase in the percentage of AAA repairs requiring suprarenal clamping during the study period from approximately 40% in the first year post-EVAR to 60% in the final year (r2 = 0.612; P = .04) (Figure). Patient demographic characteristics are listed in Table 1. No significant demographic differences were noted between patients undergoing repairs with suprarenal vs infrarenal cross-clamps. During the same period, 90 patients with infrarenal AAAs underwent endovascular repairs. From January 1, 1995, to March 1, 2000, 116 open AAA repairs were performed, of which 56 (48.3%) involved a suprarenal cross-clamp and 60 (51.7%) involved an infrarenal cross-clamp (P = .58 compared with post-EVAR).

Place holder to copy figure label and caption
Figure.

Regression curve demonstrating the linear increase in the percentage of open abdominal aortic aneurysm repairs requiring suprarenal cross-clamping since the start of endovascular repairs.

Graphic Jump Location

The characteristics of operative repairs are noted in Table 2. Aneurysms repaired with a suprarenal cross-clamp were larger in diameter than those repaired with infrarenal cross-clamps. Repairs with the use of a suprarenal clamp involved a longer operative time with increased blood loss and use of blood products. Adjunctive grafts to renal or visceral vessels were more frequently needed with suprarenal repairs (Table 2). There were 31 adjunctive grafts to the left renal artery in this series, 22 for renal artery association with aneurysm, 1 for renal artery stenosis, and 8 for both aneurysmal involvement and renal artery stenosis. There were 10 adjunctive right renal artery procedures, all of which were for aneurysmal involvement of the right renal artery. There were 5 adjunctive grafts to the superior mesenteric artery, 4 for high-grade stenosis or occlusion of the superior mesenteric artery and 1 for aneurysm extension to the superior mesenteric artery.

Table Graphic Jump LocationTable 2. Operative Characteristics of Infrarenal vs Suprarenal Cross-Clampinga

Tube grafts were used in 43 infrarenal cross-clamp cases (41.7%) and 47 suprarenal cross-clamp cases (57.3%) (P = .13). Bifurcated grafts were used in the remaining cases to treat associated iliac artery aneurysmal or occlusive disease. If possible, the entire repair was performed through the abdominal exposure to avoid additional inguinal incisions. In infrarenal cross-clamp cases, the distal right anastomosis was to the common iliac artery in 40 cases (38.8%), external iliac artery in 10 (9.7%), and common femoral artery in 10 (9.7%). Corresponding distal right anastomoses for suprarenal clamp repairs were to the common iliac artery in 31 cases (37.8%), external iliac artery in 1 (1.2%), and common femoral artery in 6 (7.3%) (P = .09). The distal left anastomosis in infrarenal and suprarenal cross-clamp cases was to the common iliac artery in 39 (37.9%) vs 28 (34.1%), the external iliac artery in 14 (13.6%) vs 6 (7.3%), and the common femoral artery in 7 (6.8%) vs 4 (4.9%), respectively (P = .63). Postoperatively, patients undergoing a suprarenal repair also required longer stays in the intensive care unit, more ventilatory assistance, more use of blood products, and longer overall hospital stays (Table 3).

Table Graphic Jump LocationTable 3. Postoperative Outcomes, Complications, and Mortalitya

Overall complication rates were significantly higher among patients undergoing a repair involving a suprarenal cross-clamp (Table 3). Specific complications that were more prevalent with suprarenal repairs included renal and pulmonary insufficiency. In all cases, the renal and pulmonary insufficiency was transient, and only 5 patients in the suprarenal cross-clamp group and 1 in the infrarenal cross-clamp group required temporary hemodialysis or continuous veno-venous hemofiltration. None required long-term dialysis. There was no statistical difference in the mortality rates, which were 6.1% at 1 month's follow-up in the suprarenal cross-clamp group and 2.9% in the infrarenal cross-clamp group (P = .18). There were 5 deaths in the suprarenal group (2 from cardiac causes and 3 from bowel ischemia) and 3 in the infrarenal group (1 from pulmonary complications/acute respiratory distress syndrome, 1 from cardiac causes, and 1 from multisystem organ failure). Of the surviving patients, 17.5% with infrarenal repairs required temporary nursing home placement, compared with 25.6% of those who underwent suprarenal repairs (P = .14).

Univariate predictors of a postoperative complication included intraoperative blood loss (mean [SD], 2520 [2921] mL among patients with complications vs 1650 [1593] mL among those without; P = .01), operative duration (399 + 88 min vs 346 ± 83 min [mean {SD}]; P < .001), history of cerebrovascular disease (37.5% vs 19.6%; P = .01), and suprarenal cross-clamping (58.0% vs 34.0%; P = .002). By multivariate logistic regression analysis, the use of a suprarenal cross-clamp (odds ratio, 2.42; 95% confidence interval, 1.29-4.57; P = .006), operative duration (1.007; 1.003-1.011; P ≤ .001), and history of cerebrovascular disease (2.84; 1.40-5.75; P = .006) were independent predictors of postoperative complications.

Endovascular AAA repair has clearly changed the landscape of aortic aneurysm repair. Since its initial FDA approval in 1999, EVAR has been transformed from an alternate procedure for those at high risk for open repair to the preferred method of repair among anatomically suitable patients. As such, straightforward open infrarenal aneurysm repairs are rapidly declining in frequency. Open aneurysm repairs are now performed primarily in patients who are not anatomically suitable for EVAR, with the primary limitation being an anatomically unsuitable proximal neck.2 Although there is great interest and much research in developing branched and fenestrated endografts to treat suprarenal and juxtarenal aneurysms, for the foreseeable future, most of these aneurysms will likely require standard open repair, and, by extension, the frequent use of suprarenal cross-clamping to address difficult neck anatomy.

As noted in this study, suprarenal cross-clamping presents significant technical challenges. Treating juxtarenal and suprarenal aneurysms requires that one be proficient in a number of advanced operative techniques, including high retroperitoneal access and the use of adjunctive renal and visceral grafts. In this series of contemporary AAA repairs, 44% required a suprarenal cross-clamp, of which more than 80% involved high retroperitoneal exposure and 44% required adjunctive renal or visceral grafts. Commensurate with these technical challenges were increases in operative duration, use of blood products, time spent receiving mechanical ventilation, intensive care unit and hospital length of stay, and overall complication rate compared with repairs involving infrarenal clamping.

Despite the added complexity, however, the need for temporary skilled nursing facility placement was not different than in cases involving an infrarenal cross-clamp (26% vs 17%). Furthermore, there was no difference in 30-day mortality rates based on intraoperative cross-clamping (7% for suprarenal vs 3% for infrarenal), which is commensurate with other current series.4,5 One could certainly argue that these data are subject to type II error and that the difference may have been significant with a larger sample size. However, it appears that, in experienced hands, complex AAA repairs involving suprarenal cross-clamping with frequent need for adjunctive renal and visceral grafts can be safely performed with acceptable morbidity and mortality rates.

The techniques involved in the repair of juxtarenal and suprarenal AAAs have been well established for many years.68 With the advent of EVAR, the changing scope of open AAA repairs was anticipated.9 A number of recent studies have addressed the changing nature of open AAA repairs since the widespread adoption of EVAR in many, if not most, vascular surgery practices.1013 Knott and associates4 from the Mayo Clinic described 126 consecutive juxtarenal AAA repairs performed following the start of their own EVAR program. The authors reported findings consistent with our study, namely, that juxtarenal AAA repairs can be performed with low 30-day mortality rates (0.8%). The reason for the lower mortality in the Mayo Clinic series cannot be determined with certainty; however, the percentage of patients requiring adjunctive renal and visceral grafts was significantly lower than in our study (12% vs 44%), possibly indicating greater overall aneurysm complexity in the current series. Knott et al also reported comparable cardiac (13%) but lower pulmonary (11%) and renal (18%) morbidity rates. Again, the reason for this difference is not clear, but, as with the current series, complications rarely lead to any permanent disability.

One technical difference between the studies is the use of intraoperative renal cooling by the Mayo Clinic group, in most cases with a combination of lactated Ringer solution, mannitol, and heparin sodium, which is certainly a reasonable consideration in cases involving prolonged suprarenal cross-clamping. Renal protection measures during aortic procedures remain controversial. The use of antioxidants14 and hypothermic perfusion15 have been advocated based on small clinical trials. A recent review from the Cochrane Collaboration found “no reliable evidence from the available literature” to support renal protective measures in aortic procedures, although no differentiation was made between infrarenal and suprarenal clamping.16(p2)

Costin and colleagues5 also assessed changes in their open abdominal aortic practice following the institution of an EVAR program. They found a significant increase in the percentage of repairs requiring suprarenal cross-clamps, from 6% pre-EVAR to 20% in the 5 initial years post-EVAR. This is still significantly less than the 44% rate of suprarenal cross-clamping noted in the current study but supports the general concept of increased complexity of open aneurysm repairs. Despite the increased complexity of repair, the authors found no difference in hospital length of stay or morbidity and mortality rates pre- and post-EVAR.

An important question alluded to in this study is the effect of practice pattern shifts on residency and fellowship training. In the past decade, there has been an extensive, albeit necessary, shift in emphasis in residency and fellowship training to accommodate endovascular training. Although there was an initial struggle for some training programs to compete and provide necessary endovascular training, this transition is now essentially complete, and most programs approved by the Accreditation Council for Graduate Medical Education now provide comprehensive endovascular training.17,18

During this time, there has been less emphasis on the maintenance of open surgical skills. As the numbers of open aneurysm repairs continue to decline, and the AAAs treated with open repair increase in complexity, there will likely be fewer residents and fellows who will gain suitable experience to be independent in these procedures at the completion of their training. This may lead to the “regionalization” of certain complex procedures such as juxtarenal and suprarenal AAA repairs.

Fenestrated and branched stent graft technology remains on the horizon and may eventually supplant open repair of juxtarenal and suprarenal AAAs. Early and midterm results at selected centers have been favorable. Muhs et al19 described 38 patients treated with fenestrated or branched stent grafts using the Zenith platform (Cook, Inc, Bloomington, Indiana) with a 2.6% 1-month mortality, 97% immediate proximal and distal fixation, and 94% immediate visceral and renal stent patency. At a median of 25 months' follow-up, the all-cause mortality was 13% (0% from aneurysm rupture), with 92% visceral branch patency.

In a similar trial from the Cleveland Clinic, Greenberg et al20 reported a series of 50 branched endografts, also based on the Zenith system, to treat thoracoabdominal, suprarenal, and aortoiliac aneurysms not amenable to standard FDA-approved devices. Technical success was achieved in 45 of 50 cases (90.0%) with no branch vessel loss noted at a mean follow up of 7 to 11 months. The 30-day mortality was 2%.

Similarly, Bicknell et al21 reported 1-year of follow-up for 29 branched or fenestrated endografts from a single institution with 98% technical success at stent placement, a 0% operative mortality, and 97% one-year target vessel patency.

These reports are from high-volume investigational centers with selected patients. Although certainly promising, fenestrated and branched endograft technology is clearly still in its developmental stages and not yet ready for general dissemination. The exact time frame for more widespread availability of this technology is uncertain, but it does seem clear that, for the immediately foreseeable future, open surgical repair will remain the procedure of choice for juxtarenal and suprarenal AAA.

The ongoing need for open surgical repair of complex AAA will present a significant challenge for the next generation of vascular surgery educators and trainees. Acquisition and maintenance of the requisite surgical skills will become increasingly difficult to achieve and will likely lead to a regionalization of this procedure. From a public health standpoint it is nonetheless essential to maintain this skill set to safely provide this service to an aging population.

Correspondence: Gregory J. Landry, MD, MCR, Division of Vascular Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code OP11, Portland, OR 97239-3098 (landryg@ohsu.edu).

Accepted for Publication: May 21, 2009.

Author Contributions:Study concept and design: Landry. Acquisition of data: Landry, Lau, Liem, and Moneta. Analysis and interpretation of data: Landry, Liem, Mitchell, and Moneta. Drafting of the manuscript: Landry. Critical revision of the manuscript for important intellectual content: Landry, Lau, Liem, Mitchell, and Moneta. Statistical analysis: Landry. Administrative, technical, and material support: Moneta. Study supervision: Landry.

Financial Disclosure: None reported.

Previous Presentations: This paper was presented at the Pacific Coast Surgical Association Annual Meeting; February 14, 2009; San Francisco, California. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript.

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Fred A. Weaver, MD, Los Angeles, California: The reported experience from the University of Oregon is typical of the past decade, as EVAR has supplanted open repair for abdominal aortic aneurysms. The object of this report is the negative impact EVAR has had on the ability to adequately train surgeons to perform open aortic procedures. The increasing complexity of open repair, the decrease in open volume along with the increasingly litigious environment and outcome focus all serve to decrease the overall involvement of the trainee in an open operative procedure. Increasingly, the attending surgeon must assume the primary operator role rather than that of the skilled assistant to the vascular resident. Lack of open vascular experience is an insidious process that begins in the general surgery training programs, making the vascular resident less capable of performing straightforward, let alone more complex, procedures.

The residents' awareness of this reality is evident when interviewing applicants to our vascular surgery training program. Whereas a decade ago, questions about the depth, number, and scope of endovascular procedures were common, these are rarely mentioned today. Rather, applicants are concerned with the open vascular experience, particularly aortic procedures, and well they should be, as documented in this report. I have a number of questions:

  • You still are performing a healthy number of infrarenal open aortic aneurysm repairs. These are presumably patients that could be treated by EVAR as well. What is the reason for this, and what criteria are used to select patients for EVAR vs an open repair?

  • Related to this comment is the small number of EVARs at your institution over the study period. Only a third of patients, 92, underwent an endovascular repair compared with most centers where EVAR constitutes at least 50% of aortic aneurysm repairs. At the University of Southern California, during the same time period we have performed over 300 endovascular repairs, which is approximately 60% of all repairs. Are you still not sold on the technology, and, if so, what are your reservations? Given your historical ambivalence about endovascular therapy in general, I would be interested in your view of the future for EVAR and other endovascular procedures.

  • The open procedures were a mixture of retroperitoneal and transperitoneal repairs. There is a long-standing debate regarding the benefits of these repairs with respect to pulmonary and cardiac complications. Did you find any differences in outcome between the 2 approaches? For your trainees, given the decrease in open repairs, has your group attempted to standardize your aortic approach to facilitate the learning curve?

  • Finally, your observation is one we all have seen at our respective institutions. What are you doing at Oregon to address this by way of simulation, cadaver dissection, or other methods to facilitate learning of open vascular and aortic surgery?

Dr Moneta: Clearly, we have a healthy volume of open aneurysm repairs at our institution. There may be a couple of reasons for this. One may be referral bias. We are the only academic medical center in our state. More than half of our aneurysm patients are referred by other surgeons who perform at least some aneurysm surgery. Many travel hundreds of miles for their AAA repair. Therefore, our pool of patients may be a bit self-selected to be more complicated and less suitable for EVAR. Also, we recognize that open aneurysm repair is a good operation with low mortality in experienced hands and excellent long-term durability; EVAR is also good if you select the patients properly with respect to the anatomic limits of the currently available devices and the patient's willingness to be followed up for life with serial computed tomographic scans. If the patient is a good candidate for an open procedure and a suboptimal candidate for EVAR, I would likely recommend an open repair. Pushing the limits of EVAR when the patient is a good candidate for open repair is perhaps more about the doctor's ego, marketing, and fascination with technology than care of the patient.

All of this has implications for training. There are fewer open operations available. Some vascular residents finish their vascular residency having performed fewer than 5 open aneurysm repairs. This mandates continuing training beyond their formal training. Their senior partners will notice this, I am sure, and this trend is not unique to vascular surgery. I suspect regionalization of aneurysm surgery for complex patients will eventually be mandated by payers or by simple practicality and market forces.

There is continuous discussion with regard to the retroperitoneal or transperitoneal approach to the abdominal aorta. Retrospective case series have suggested benefits of the retroperitoneal approach, especially with respect to gastrointestinal and pulmonary complications and lengths of stay. However, randomized trials have not fully supported these observations. We have less blood loss and fewer gastrointestinal and renal complications with suprarenal repairs via a retroperitoneal approach. The data may reflect all of the vagaries of patient selection of a nonrandomized series. However, it also suggests that our selection of patients for that approach is reasonable.

Finally, we have recognized the need for additional training out of the operating room, and one of our faculty members is heavily involved with developing a skills laboratory for vascular training.

Figures

Place holder to copy figure label and caption
Figure.

Regression curve demonstrating the linear increase in the percentage of open abdominal aortic aneurysm repairs requiring suprarenal cross-clamping since the start of endovascular repairs.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Operative Characteristics of Infrarenal vs Suprarenal Cross-Clampinga
Table Graphic Jump LocationTable 3. Postoperative Outcomes, Complications, and Mortalitya

References

Wolf  YGFogarty  TJOlcott  C  IV  et al.  Endovascular repair of abdominal aortic aneurysms. J Vasc Surg 2000;32 (3) 519- 523
PubMed Link to Article
Armon  MPYusuf  SWLatief  K  et al.  Anatomical suitability of abdominal aortic aneurysms for endovascular repair. Br J Surg 1997;84 (2) 178- 180
PubMed Link to Article
Ricotta  JJ  IIOderich  GS Fenestrated and branched stent grafts. Perspect Vasc Surg Endovasc Ther 2008;20 (2) 174- 189
PubMed Link to Article
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