Open Aortic Reconstruction Configurations for Retroperitoneal Approach to Aortic Aneurysms: AortoFemoral Reconstruction is a Negative Predictor of Long-Term Outcomes

Left retroperitoneal approach for open repair of abdominal aortic aneurysms is well established for safety and efficacy. The proliferation of endovascular aortic repairs has changed the landscape and the pattern of aneurysmal disease treated with open repairs. The purpose of this study is to evaluate the outcomes of open aortic repairs performed via left retroperitoneal approach based on the outflow configurations. A single-institution surgery management system was queried for open abdominal aortic aneurysm repairs performed from 1979 to 2022. Demographics, comorbidities, indications, and operative details were recorded. Reconstruction configurations were grouped into tube graft (TUBE), aortobiiliac (ABI), aortobifemoral (ABF), and aorto-unifemoral-uniiliac bypass (AUI). The groups were compared using standard statistics. A total of 4425 open abdominal aortic aneurysm repairs were performed, of which 3318 (75%) were males with a mean age of 71 years (range, 36-95 years). Comorbidities included hypertension 1062 (24%), diabetes 438 (9.9%), coronary disease 610 (13.8%), pulmonary disease 274 (6.2%), renal failure 115 (2.6%), and tobacco use 1371 (31%). Indications were asymptomatic (3407; 77%), rupture (575; 13%), symptomatic (398; 9%), and pseudoaneurysm (44; 1%). Mean aneurysm size was 6 cm (range, 2.2-20 cm). Configurations included TUBE (1457, 32.9%), ABI (2064, 46.6%), ABF (620, 14.0%), and AUI (284, 6.4%). Rupture rate by configuration included TUBE 233 (16%), ABI 165 (8%), ABF 133 (21.6%), and AUI 47 (16.6%). Operative mortality was 3.6% (8.9% ABF, 4.6% TUBE, 2.1% AUI, and 1.5% ABI; P < .05). Non-fatal cardiac events were 11.8% ABF, 6% AUI, 5.2% TUBE, and 3.9% ABI (P < .05). Colonic ischemia was 7.3% ABF, 6.3% AUI, 3.5% TUBE, and 2.3% ABI (P = .06). Early occlusion was 2.5% AUI, 1.9% ABF, 1.8% ABI, and 0.5% for TUBE. Wound infection rates were higher in the femoral based outflow (TUBE & ABI 30 [0.85%] vs ABF & AUI 25 [2.77%]; P < .0001). Left retroperitoneal approach for treatment of abdominal aortic aneurysm offers excellent results; however, there may be some advantages to different outflow configurations. The mortality rates may be different between groups, but it reflects the degree of ruptures treated and potential pre-existing systemic atherosclerotic burden. The added complexity of a counter incision for right iliac exposure may be justified in terms of reducing wound infection rates.