Transabdominal open abdominal aortic aneurysm repair is associated with higher rates of late reintervention and readmission compared with the retroperitoneal approach

Objective: Limited data exist comparing the transabdominal and retroperitoneal approaches to open abdominal aortic aneurysm (AAA) repair, especially late mortality and laparotomy-related reinterventions and readmissions. Therefore, we compared long-term rates of mortality, reintervention, and readmission after open AAA repair through a transabdominal compared with a retroperitoneal approach. Methods: We identified all patients in the Vascular Quality Initiative (VQI) undergoing open AAA repair from 2003 to 2015. Patients with rupture or supraceliac clamp were excluded. We used the VQI linkage to Medicare to ascertain rates of long-term outcomes, including rates of AAA-related and laparotomy-related (ie, hernia, bowel obstruction) reinterventions and readmissions. We used multivariable Cox regression to account for differences in comorbidities, aneurysm details, and operative characteristics. Results: We identified 1282 patients in the VQI with linkage to Medicare data, 914 (71%) who underwent a transperitoneal approach and 368 (29%) who underwent a retroperitoneal approach. Patients who underwent a retroperitoneal approach were slightly more likely to have preoperative renal insufficiency but were otherwise similar in terms of demographics and comorbidities. They more often had a clamp above at least one renal artery (61% vs 36%; P <.001) and underwent concomitant renal revascularization (9.5% vs 4.3%; P <.001). Patients who underwent a transabdominal approach more often presented with symptoms (14% vs 9.0%; P <.01) and had a femoral distal anastomosis (15% vs 7.1%; P <.001). There was no difference in 5-year survival (62% vs 61%; log-rank, P = .51). However, patients who underwent a transabdominal approach experienced higher rates of repair-related reinterventions and readmissions (5-year: 42% vs 34%; log-rank, P <.01), even after adjustment for demographic and operative differences (hazard ratio, 1.5; 95% confidence interval, 1.1-1.9; P <.01). Conclusions: A transabdominal exposure for AAA repair is associated with higher rates of late reintervention and readmission than with the retroperitoneal approach, which should be considered when possible in operative decision-making.