Outcomes of elective open surgical repair or fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms in Sweden

Background: A juxtarenal abdominal aortic aneurysm is defined as a short (less than 4 mm) or no-neck aneurysm, which is often treated with open or complex endovascular repair. The evidence to support the best treatment strategy is scarce. The aim of this study was to assess the short- and mid-term outcomes of elective open surgical repair or fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms in Sweden. Methods: Patients who underwent elective open surgical repair or fenestrated endovascular aneurysm repair for juxtarenal abdominal aortic aneurysms between 2018 and 2021 were identified in the Swedish Vascular Registry. Demographics, practice patterns, and operative details were assessed. The primary outcome was 30-day mortality. Secondary outcomes included perioperative complications and mid-term survival. Results: Among 3777 aortic aneurysm repairs performed, 418 involved juxtarenal abdominal aortic aneurysms (open surgical repair 228 (54.5%), fenestrated endovascular aneurysm repair 176 (42.1%), chimney endovascular aneurysm repair 6 (1.4%), and branched endovascular aneurysm repair 8 (1.9%)). Some 25 centres performed juxtarenal abdominal aortic aneurysm repairs with open surgical repair and fenestrated endovascular aneurysm repair. The caseload varied from 2 to 54 repairs per centre. The mean aneurysm diameter was 61 mm. Endovascularly treated patients were older and had more pulmonary co-morbidities. The 30-day mortality rate was 2.2% (open surgical repair 2.6% and fenestrated endovascular aneurysm repair 1.7%; P = 0.397). Perioperative major complications occurred in 14.1% of patients (open surgical repair 19.3% and fenestrated endovascular aneurysm repair 7.4%; P < 0.001) and perioperative vascular complications occurred in 12.1% of patients (open surgical repair 8.8% and fenestrated endovascular aneurysm repair 11.9%; P = 0.190). The survival rate (estimated using Kaplan-Meier analysis) at 1 year and 3 years was 93.1% and 85.9% respectively for open surgical repair and 95.2% and 80.9% respectively for fenestrated endovascular aneurysm repair (P = 0.477). Conclusion: This nationwide study reveals considerable variations in volume and treatment strategy between Swedish centres performing juxtarenal abdominal aortic aneurysm repairs. Survival is comparable for open surgical repair and fenestrated endovascular aneurysm repair, although there are significant baseline demographic differences between patients selected for the two treatment modalities.