Key result
Retroperitoneal AAA repair is linked to ~74% higher dialysis risk with infrarenal clamping but lower suprarenal mortality.
Why the study?
Previous literature is conflicting on optimal outcomes between retroperitoneal and transperitoneal approaches for open infrarenal abdominal aortic aneurysm repair, especially stratified by aortic cross-clamping site.
Does the retroperitoneal approach improve outcomes compared to the transperitoneal approach in open abdominal aortic aneurysm repair when stratified by aortic cross-clamping site?
Cohort (n=8,842)
Yes
Does the retroperitoneal approach improve outcomes compared to the transperitoneal approach in open abdominal aortic aneurysm repair when stratified by aortic cross-clamping site?
Odds Ratio: 1.74 (95% CI 1.07–2.83)
p-value: p=0.025
The retroperitoneal approach for open AAA repair is associated with better survival and fewer complications in cases requiring proximal cross-clamping, but higher renal complications with infrarenal clamping compared to the transperitoneal approach.
May inform approach selection by clamping level in open AAA repair; leaves open need for randomized confirmation.
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.
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Hamouda et al. (2025) conducted a cohort in open abdominal aortic aneurysm (AAA) (n=8,842). Retroperitoneal (RP) approach vs. Transperitoneal (TP) approach was evaluated on postoperative dialysis with infrarenal cross-clamping (aOR 1.74, 95% CI 1.07 to 2.83, p=0.025). The retroperitoneal approach for open AAA repair was associated with higher odds of dialysis with infrarenal clamping (aOR 1.74; P=0.025) but lower 30-day mortality with suprarenal clamping (aOR 0.48).
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