Cross-clamp location affects short-term survival in patients undergoing open abdominal aortic aneurysm repair

Introduction: Open abdominal aortic aneurysm (oAAA) repair in the era of advanced endovascular aortic techniques is used in challenging anatomy. The impact of the location of the proximal aortic cross-clamp (suprarenal [SR] vs infrarenal [IR]) on outcomes remains to be determined. The aim of this study was to analyze the effect of proximal aortic cross-clamp location on short-term and overall survival after oAAA repair in a contemporary series. Methods: A retrospective cohort study was performed comparing the outcomes of patients undergoing oAAA repair with SR and IR aortic cross-clamping using the Vascular Quality Initiative registry from January 2003 to September 2018. Our primary end point was short-term mortality. Results: There were 7601 patients who underwent oAAA repair. Their mean age was 69.3 +/- 8.5 years and 5555 patients (73.1%) were male. The aortic cross-clamp location was IR in 4044 patients (53.2%). The SR group had increased maximum AAA diameter (58 mm vs 56 mm; P <.0001), hypertension (85.5% vs 82.0%; P <.0001), preoperative creatinine (1.11 vs 1.08; P =.001), and were more likely to be in American Society of Anesthesiologists class IV (37.4% vs 30.6%; P <.0001). Postoperative renal failure occurred significantly more often in the SR group (24.4 vs 11.4%; P <.0001). Short-term mortality was 2.7% in the IR group and 4.7% in the SR group (P <.0001). Kaplan-Meier survival estimates were 93.7% and 83.8% in the IR group and 90.9% and 81.2% in the SR group at 1 and 5 years, respectively (P =.007). Multivariable analysis demonstrated that SR cross-clamping was significantly associated with short-term mortality (hazard ratio, 1.38; 95% confidence interval, 1.07-1.78; P =.01); however, it did not affect overall survival (hazard ratio, 1.13; 95% confidence interval, 1.00-1.28; P =.06). Conclusions: A SR cross-clamp location is associated with an increased short-term mortality in patients undergoing oAAA repair. Overall survival is not affected by a SR cross-clamp location.