J.-B Ricco, J. Cau, A. Valagier, G Régnault de la MotheUniversity hospital, Poitiers, France

XV. ULUSAL VASKÜLER CERRAHi KONGRESİ

No conflict of interest to declare

LAPAROSCOPIC AORTIC SURGERYAORTOiLiAK TIKAYICI HASTALIKLAR iÇiN

LAPAROSKOPiK CERRAHi

A Failed Innovation ?

PURPOSE

The purpose of laparoscopic vascular surgery

is to replicate the good and durable results of

the classical open approach in patients with

TASC D lesions or with AAA not amenable to

endovascular treatment

FEASIBILITY

1993: Dion et al. in Surg Laparosc Endosc

First laparoscopy-assisted aortobifemoral bypass

1993-2011: 45 publications (29 from EU)• 1244 patients

830 for occlusive disease

414 for aneurysm

STUDY QUALITY

• All studies were observational, no RCT’s

• Heterogeneity of the studies

• Inadequate description of the study population

• Suspected selection bias of patients

Nio et al. Eur J Vasc Endovasc Surg 2007Nio et al. Eur J Vasc Endovasc Surg 2007

A LESS INVASIVE PROCEDURE !

LAPAROSCOPIC REVOLUTION ?LAPAROSCOPIC REVOLUTION ?

TOTAL LAPAROSCOPY

Coggia et al. Eur J Vasc Endovasc Surg. 2002;24:274-5.

RETROCOLIC PRERENAL APPROACH

AORTIC OCCLUSIVE DISEASE-TASC D

AORTIC OCCLUSIVE DISEASE

LEFT RENAL ARTERY RESTENOSIS

AORTIC ANEURYSM

JUXTA RENAL AORTIC ANEURYSM

LUMBAR ARTERY PLUG

A NEW SURGICAL EXPERTISE ?A NEW SURGICAL EXPERTISE ?

CLINICAL STUDYThis study was planned by a group of vascular

surgeons trained in laparoscopic aortic surgery

to identify potential differences in the 30-day

complication rate of total laparoscopic vs. open

approach for aortic surgery.

Cau J, Ricco JB et al. Total laparoscopic aortic repair for occlusive and aneurysmal disease: first 95 cases. Eur J Vasc Endovasc Surg. 2006

Cau J, Ricco JB. Laparoscopic aortic surgery: Techniques and results. J Vasc Surg 2008 Cau J, Ricco JB. Total laparoscopic renal artery bypass. J Vasc Surg. 2011

METHODS January 2006 to December 2009 228 consecutive patients with AAA or occlusive disease Total laparoscopic aortic surgery =83 open repair =145

Prospective study with propensity scoring

Endpoint : composite adverse event at 30-day:

Death, bleeding, graft thrombosis, MI, respiratory failure,

colon ischemia, evisceration.

VARIABLES OPEN REPAIR(n=145)

LAPAROSCOPY(n=83)

p

Female gender 19 (13.1) 11 (13.3) 0.97

Body mass index 25.6±4.1 25.1±4.4 0.38

COPD 45 (31.0) 24 (28.9) 0.74

Diabetes 12 (8.3) 7 (8.4) 0.97

Dyslipidemia 96 (66.2) 55 (66.3) 0.99

Coronary disease 54 (37.2) 26 (31.3) 0.39

Values in parentheses are percentages

BASELINE CHARACTERISTICS

(*) All variables included in a regression model for propensity score

VARIABLESOPEN REPAIR

(n=145)LAPAROSCOPY

(n=83)p

* Age (years) 67.5±9.8 59.5±11.1 <0.001

* Smoker 88 (60.7) 64 (77.1) 0.01

* eGFR (mL/m/1.73m2) 85±28 96±26 0.005

* AAA 109 (75.2) 30 (36.1) <0.001

* Aortic clamping LevelSupra: 44 (30.3)Infra: 101 (69.7)

Supra: 9 (10.8)Infra: 74 (89.2)

0.007

* ASA classes

ASA 1: 0ASA 2: 36 (24.8)ASA 3: 90 (62.1)ASA 4: 19 (13.1)

ASA 1: 2 (2.4)ASA 2: 30 (36.1)ASA 3: 44 (53.0)ASA 4: 7 (8.4)

0.056

BASELINE CHARACTERISTICS

DATA OPEN REPAIR(n=145)

LAPAROSCOPY(n=83) p

AAA 109 (75.2) 30 (36.1) <0.001

• Aortoaortic• Aorto-bi-iliac• Aorto-bi-femoral

46 (31.7)57 (39.3)42 (29.0)

23 (27.7)5 (6.0)

55 (66.3)<0.001

• Lateral anastomosis• End-to-end

24 (16.6)121 (83.4)

48 (57.8)35 (42.2)

<0.001

IMA reimplantation 36 (24.8) 2 (2.4) <0.001

Aortic clamping Level Supra: 44 (30.3) Supra: 9 (10.8) 0.007

Operative time (min) 243±76 282±97 0.002

Aortic clamping time 100±33 116±34 <0.001

INTRAOPERATIVE DATA

RESULTS IN OVERALL SERIES

VARIABLESOPEN REPAIR

(n= 145)LAPAROSCOPY

(n= 83)p

30-day mortality 1 (0.7) 2 (4.1%) 0.14

30-day composite adverse endpoint *

8 (5.5) 23 (27.7) <0.001

Bleeding (mL) 1239±848 1343±1228 0.46

Respiratory complications 23 (15.9) 7 (8.4) 0.11

Any reintervention 6 (4.1) 13 (15.7) 0.002

Graft patency 142 (97.9) 79 (95.2) 0.26

Intensive care unit stay (days)

1.5±6.0 1.0±4.5 0.51

In-hospital stay 11.1±7.3 8.9±5.9 <0.001

* Endpoint : composite adverse event at 30-day: Mortality, Bleeding, graft thrombosis, MI, respiratory failure,

colon ischemia, evisceration, reoperation.

RESULTS IN OVERALL SERIES

End-point: 30-day mortality

• Logistic regression showed that ASA class was the only

independent predictor [OR 8.5, 95%CI 1.3-54.2].

Laparoscopic repair showed a tendency toward higher

mortality risk [OR 7.9, 95%CI 0.76-83.5]

• The small number of patients with AAA prevented

sensitivity analysis in subgroups of patients (AAA vs.

PAOD)

RESULTS IN OVERALL SERIES

End-point: Composite adverse events

• Logistic regression showed that laparoscopic repair was

the only independent predictor of composite adverse

events [OR 7.1, 95%CI 2.9 - 17.6]

PROPENSITY SCORE

The treatment groups differed markedly to

some variables

Need to develop a propensity score by logistic

regression

The calculated propensity score was employed

for a one-to-one matching as well as to adjust

for other variables

MATCHING BASED ON PROPENSITY SCOREMATCHING BASED ON PROPENSITY SCORE

PS Trt A vs. Trt B

Compare treatments based on matched pairs This methodology simulates a RCT

PS1

PS2

PSm

PROPENSITY SCORE-MATCHED PAIRS

VARIABLESOPEN REPAIR

(n=49/145)LAPAROSCOPY

(n=49/83)p

* Age (years) 64.0±10.6 64.0±10.6 0.98

* Smoker 38 (77.6) 32 (65.3) 0.18

* eGFR (mL/m/1.73m2) 96±30 90±25 0.19

* AAA 20 (40.8) 21 (42.9) 0.84

* Aortic clamping LevelSupra: 5 (10.2)Infra: 44 (89.8)

Supra: 6 (12.2)Infra: 43 (87.8)

0.60

* ASA classes

ASA 1: 0ASA 2: 15 (30.6)ASA 3: 27 (55.1)ASA 4: 7 (14.3)

ASA 1: 2 (2.4)ASA 2: 17 (34.7)ASA 3: 27 (55.1)ASA 4: 5 (10.2)

0.84

RESULTS - MATCHED PAIRS

VARIABLESOPEN REPAIR

(n=49/145)LAPAROSCOPY

(n=49/83)p

30-day mortality 0 2 (4.1%) 0.50

30-day composite adverse endpoint *

1 (2.0) 17 (34.7) <0.001

Bleeding (mL) 1210±761 1611±1380 0.30

Respiratory complications 7 (14.3) 4 (8.2) 0.52

Any reintervention 1 (2.0) 10 (20.4) 0.008

Graft patency 47 (95.9) 45 (91.8) 0.68

Intensive care unit stay (days)

1.5±6.9 0.9±3.6 0.74

In-hospital stay 10.7±8.2 9.5±5.7 0.029

* Endpoint : composite adverse event at 30-day: Mortality, Bleeding, graft thrombosis, MI, respiratory failure,

colon ischemia, evisceration, reoperation.

PROPENSITY SCORELOGISTIC REGRESSION

• Patient’s age, indication for surgery and suprarenal

clamping were independent predictors for assigning

patients to laparoscopic or open repair group

• Laparoscopic repair was associated with a higher risk of

30-day composite adverse events [OR 6.5, 95%CI 2.7-

15.5]

• Laparoscopic repair was not associated with lower risk of

respiratory complications [OR 0.76, 95%CI 0.28 – 2.04]

CONCLUSIONS

This study suggests that total laparoscopic

aortic surgery even in well trained hands is not

as safe as open surgery to treat abdominal

aortic aneurysms and TASC D aortic disease.

MINIMALLY INVASIVE AORTIC SURGERY