Concurrent comparison of endoluminal versus open repair in the treatment of abdominal aortic aneurysms: analysis of 303 patients by life table method

Purpose: The aim of this study was to compare the outcome in consecutive patients with abdominal aortic aneurysm (AAA) treated by means of open operation versus endoluminal intervention, performed by the same surgeons during a defined interval. Methods: Between May 1992 and May 1996, 362 consecutive patients with AAA underwent repair. Fifty-three patients who underwent open operations for ruptured AAA plus two who underwent endoluminal repair of false AAA and four who underwent secondary endoluminal repair of AAA were excluded, leaving 303 patients who underwent elective repair of true AAA. The elective operations were conventional open repair in 195 patients (151 men, 44 women; mean age, 69 years) and endoluminal repair in 108 patients (100 men, eight women; mean age, 70 years). The decision to perform endoluminal repair was based on comorbidities that precluded open repair (n - 48) or patient choice (n = 60). The graft configuration in the open repair group was tubular (n = 180) or bifurcated (n = 15) and in the endoluminal repair group, tubular (n = 48), aortoiliac/femoral (n = 25), or bifurcated (n = 35). All procedures were performed in the operating department, and radiographie guidance was used in the endoluminal repair group. Follow-up was by means of interview, examination, and telephone. In addition, contrast material-enhanced computed tomography was performed within the first 10 days after operation, 6 months and 12 months after operation, and then annually thereafter in the endoluminal repair group. Outcome measures were successful exclusion of the aneurysm sac from the general circulation and survival. Data were analyzed by the life-table method. Other outcome measures were length of hospital stay, length of intensive care unit stay, and operative blood loss. Results: No significant difference was found between the perioperative mortality rate for open repair (11 deaths [5.6%] in 195 patients) and endoluminal repair (six deaths [5.6%] in 108 patients). Three of the six deaths in the latter group occurred in patients with successful endoluminal repair, and three occurred in 18 patients with failed endoluminal repair who were converted to open repair. Similarly, no significant difference was seen in the survival rate between the endoluminal repair and open repair groups according to log-rank analysis (P = .14). The rate of graft failure, however, was significantly higher in the endoluminal repair group than in the open repair group (Fisher exact test, P < .001). Success in the endoluminal repair group was defined as continuing graft function without endoleak or conversion to open repair. The Kaplan-Meier curve for graft failure times for the endoluminal group revealed a 3-year graft success probability of 70%. Conclusions: This study suggests that endoluminal repair is safe, sharing the same perioperative mortality risk as open repair despite 44% of the endoluminal repair group being rejected as unfit for open repair. Conventional open repair is the most reliable method of successfully managing AAA. The endoluminal method, however, results in shorter length of hospital stay, shorter length of intensive care unit stay, and less blood loss than the open method. Patients who opt for the endoluminal method of repair should be made aware that the minimally invasive technique carries the disadvantage of a higher failure rate.