Outcomes of Retroperitoneal vs Transperitoneal Approach for Open Abdominal Aortic Aneurysm Repair Stratified by Aortic Cross-Clamping Site.

Abstract

Background: The approach for open infrarenal abdominal aortic aneurysm (AAA) repair is mainly surgeon driven based on experience and previous training. Although the midline transperitoneal (TP) approach remains the most common, the retroperitoneal (RP) approach is usually used in more complex cases where suprarenal cross-clamping is necessary. As previous literature is conflicting on optimal outcomes between the 2 approaches, we aimed to compare RP vs TP outcomes stratified by aortic clamp level.

Study design: The Vascular Quality Initiative database was queried for all patients who underwent open AAA repair from January 2012 to February 2024. Patients were stratified according to aortic cross-clamp site: infrarenal, interrenal, suprarenal, and supraceliac. We used multivariate logistic regression to analyze the outcomes of RP vs TP within each clamp site while adjusting for baseline and clinically relevant variables.

Results: A total of 8,842 patients were included. Compared with TP, RP approach was associated with higher odds of postoperative dialysis (adjusted odds ratio [aOR] 1.74, 95% CI 1.07 to 2.83, p = 0.025) with infrarenal cross-clamping. However, at higher clamping sites, RP was associated with lower odds of bowel ischemia (aOR 0.40, 95% CI 0.20 to 0.80, p = 0.009) with interrenal clamping; lower odds of dialysis (aOR 0.66, 95% CI 0.44 to 0.99, p = 0.048), bowel ischemia (aOR 0.52, 95% CI 0.32 to 0.85, p = 0.009), and 30-day mortality (aOR 0.48, 95% CI 0.30 to 0.79, p = 0.004) with suprarenal clamping; and lower odds of in-hospital (aOR 0.35, 95% CI 0.16 to 0.80, p = 0.013) and 30-day mortality (aOR 0.41, 95% CI 0.17 to 0.98, p = 0.046) with supraceliac clamping.

Conclusions: In this large multi-institutional study, we identified that differential outcomes of RP vs TP approaches for open AAA are modified by aortic cross-clamping level. RP is associated with lower postoperative complications and better survival compared with TP in cases requiring more proximal cross-clamping sites. However, the TP approach is associated with lower risk of renal complications in cases restricted to infrarenal clamping.