Journal of Vascular Surgery
Volume 46, Issue 1 , Pages 16-23, July 2007

Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy

  • Massimo Porcellini, MD

      Affiliations

    • Department of General and Vascular Surgery, Federico II University, Naples, Italy
    • Corresponding Author InformationReprint requests: Massimo Porcellini, MD, Department of General and Vascular Surgery, Federico II University, via Pansini 5, 80131 Naples, Italy.
    • ,
  • Piero Nastro, MD, MRCS

      Affiliations

    • Department of Surgery, Whipps Cross University Hospital, London, United Kingdom.
    • ,
  • Umberto Bracale, MD

      Affiliations

    • Department of General and Vascular Surgery, Federico II University, Naples, Italy
    • ,
  • Stephen Brearley, MD, FRCS

      Affiliations

    • Department of Surgery, Whipps Cross University Hospital, London, United Kingdom.
    • ,
  • Pasquale Giordano, MD, FRCS(Ed)

      Affiliations

    • Department of Surgery, Whipps Cross University Hospital, London, United Kingdom.

Received 17 May 2006; accepted 16 September 2006.

Article Outline

Background

The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies.

Methods

All patients who underwent surgery for a nonruptured infrarenal AAA of ≥5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed.

Results

Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of ≥5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P = NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% (P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103)

Conclusions

With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.

 

Cross-sectional imaging and, in particular, computed tomography (CT) scanning is increasingly being used in the preoperative investigations of patients for a variety of pathologies, including cancer and abdominal aortic aneurysm (AAA), and is likely to increase the proportion of patients in whom the two conditions are found to coexist.1 Although the true incidence is difficult to establish, it has been reported to be as high as 13.4%.2, 3, 4 These patients present a therapeutic dilemma, and their management is controversial.5, 6, 7 In those fit to undergo major surgery, one of three strategies might be adopted: (1) to repair the aneurysm first and resect the malignancy later, (2) to treat the malignancy first and repair the aneurysm later, or (3) to undertake both procedures under the same anesthesia.

Many authors have reported excellent results in patients who have undergone open AAA repair combined with resection of a malignancy with curative intent. This approach avoids delay in the treatment of either pathology and minimizes the risk that one or the other will progress or give rise to complications in the interim between two operations.8, 9, 10, 11

Advocates of the combined approach argue that there appears to be an increased risk of aneurysm rupture in the immediate aftermath of other major operations. Rupture of the AAA after laparotomy for an unrelated condition may occur because of collagen lysis induced by operation itself or may be due to weakening of the aneurysm wall from nutritional depletion and surgical dissection.12, 13 Corticosteroid administration and chemotherapy, if required postoperatively for associated malignancy, may also contribute to aneurysm enlargement and rupture.14 Potential mechanisms may involve inhibition of smooth muscle cell proliferation and collagen and elastin synthesis, and a blood volume increase from hydration included in chemotherapeutic protocols.15

A concern when treating both pathologies during the same intervention is the risk of aortic graft infection, especially in patients undergoing procedures in which there is contamination. However, successful outcomes have been reported for procedures combining treatment for both AAA and colorectal cancer4, 16, 17, 18, 19, 20 as well as for AAA and bladder cancer.21 Furthermore the aggregate risk of a staged aneurysm repair and cancer resection has not been shown to be lower than the risk of a single combined procedure, whereas from the patient’s point of view, having one operation rather than two is likely to be preferable.

Because of all these uncertainties, there is no consensus on the best therapeutic approach for patients with simultaneous AAA and malignancy. In the past, surgical strategy has been determined by the patient’s general condition, the patient’s symptoms, the surgeon’s preference, the aneurysm size, and the cancer features and stage.3, 4, 5, 6, 7

Although the long-term effectiveness of endovascular aneurysm repair (EVAR) is still controversial,22, 23 and some authors consider the presence of a concurrent malignancy a contraindication to the EVAR,24, 25 this technique has recently been proposed as a treatment option for patients with AAA and coexistent malignancy. A few small series and reports have described the successful use of EVAR in patients with synchronous colorectal, renal, lung, esophageal, pancreatic, and bladder cancer (Table I).26, 27, 28, 29, 30, 31 To our knowledge, however, no studies to date have compared the results of EVAR and open repair (OR) for the treatment of patients with concomitant AAA and malignancy. The aim of this study was to assess retrospectively the outcome of EVAR and OR for the treatment of AAA in patients undergoing curative treatment for concomitant malignancy.

Table I. Endovascular aneurysm repair in patients with concomitant malignancy: review of literature
Reference (first author)NCancer locationOutcomeEVAR complicationsLOS (days)Interval between EVAR and cancer treatment (days)
Herald,26 19981RectumAlive (12 months)Embolic occlusion of popliteal artery6NS
Hafez,27 20003KidneyNSNSNSNS
Lee,28 20023EsophagusDied: metastases (6 months)04NS
LungDied: complications of cancer treatment (15 days)03NS
BladderDied: neoplasm-induced event (35 days)Groin wound infection3NS
Kiskinis,29 20042RectumAlive (12 months)08Combined treatment
RectumAlive (6 months)0814
Chai,30 20042RectumAlive (12 months)Endograft limb occlusion17
RectumAlive (12 months)Endograft limb occlusion77
Sheen,31 20061PancreasAlive (1 month)0289

EVAR, Endovascular aneurysm repair; NS, not stated.

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Patients and methods 

A retrospective review was done of all patients admitted with a diagnosis of a nonruptured infrarenal AAA of ≥5.5 cm and concomitant malignancy to the Department of General and Vascular Surgery of the Federico II University of Naples (UN), Italy, and the Department of Surgery of Whipps Cross University Hospital, London, United Kingdom, during an 8-year period (1997-2005). Only patients who were considered suitable for cancer treatment with curative intent were included in the study.

Data were collected through hospital chart review. Including criteria were nonruptured AAA ≥5.5 cm, AAA repair (OR or EVAR), and concomitant malignancy treated with curative surgical intervention with or without adjuvant therapy. Patient data collected were age, sex, smoking history, comorbidity (hypertension, diabetes, chronic obstructive pulmonary disease, coronary artery disease, cerebrovascular disease, renal failure), aneurysm size, cancer (type, location, and stage), cancer treatment and timing, type of anesthesia, postoperative length of stay, perioperative mortality and morbidity, survival outcome, and cause of death.

Operative risk was assessed according to The American Society of Anesthesiologists (ASA) physical status classification.32 All tumors were staged according to the TNM classification system.33 Indications for EVAR were based on the agreed criteria for the European Collaborators on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) trial.34 EVAR was offered to all patients clinically considered suitable.

Baselines characteristics of the EVAR and OR groups and 30-day morbidity and mortality were compared using the two-tailed t test for continuous variables and the χ2 or Fisher’s exact test for categoric data. Cumulative survival rate at 1 and 2 years were analyzed using the Kaplan-Meier method and log-rank test.

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Results 

We identified 25 patients (22 men; 17 from the UN), with a mean age of 70.3 years (range, 58 to 84 years), who had a nonruptured infrarenal AAA of ≥5.5 cm (range, 5.6 to 9 cm; mean size, 6.4 cm) and a concomitant malignancy amenable for curative treatment. The malignancy originated from the urinary tract in 12 (48%), including two prostatic cancers, six bladder cancers, and four renal cancers. Nine patients (36%) had colorectal cancer, three (12%) had lung cancer, and one (4%) had pancreatic cancer. In 14 patients (56%), the cancer was an incidental finding on CT scanning for AAA assessment. In the other 11 (44%), the aneurysm was found during investigations for symptomatic malignancy. There were no cases of intraoperative accidental diagnosis of tumor or AAA.

All patients underwent surgical treatment for AAA. EVAR was done in 11 (44%; 9 men; Table II) and OR in 14 (56%; 13 men; Table III). The mean patient age was 71.3 years (range, 59 to 84 years) in the EVAR group and 69.6 years (range, 58 to 83 years) in OR group (P = NS). No significant differences were observed in other patient demographics, comorbidity, risk factors, and ASA grade between the two groups. Aneurysm size was larger in the OR group (mean, 6.8 cm vs 5.9 cm; P = .006; Table IV).

Table II. Endovascular treatment of abdominal aortic aneurysm in 11 patients with malignancy
Age/sexAAA diameter (cm)Prosthesis implantCancer locationStageTreatmentCurative intentInterval (days)Major complicationsLOS (d) AAA/cancerOutcome
82 M5.7Excluder,⁎ bifurcated, IFXBladderIITransurethral resection, local chemoYes2Endograft limb occlusion (14 mo)2/2Alive (60 mo)
72 M6.4Zenith,† bifurcated, IFXPancreasIITotal pancreatectomy, chemoYes9 7/11Died: metastases (25 mo)
59 M5.8Zenith,† bifurcated, IFXLeft colonIILeft hemicolectomyYes5 4/10Died: stroke (46 mo)
73 F6.1AneuRX,‡ bifurcated, IFXRight colonIIIRight hemicolectomy, chemoYes6 5/8Alive (50 mo)
68 M5.8Excluder,⁎ bifurcated, IFXBladderIIIRadical cystectomy, chemoYes6 5/11Alive (55 mo)
65 M5.6Excluder,⁎ bifurcated, IFXProstateIIProstatectomy, hormonal/chemoYes7 4/7Alive (40 mo)
74 M5.9Talent,‡ aortouniiliac, IFXRectumIIIAnterior resectionYes11Intraop. endograft limb occlusion; colonic anastomotic leak7/19Died: metastases (39 mo)
71 F5.7Talent,‡ bifurcated, TFXKidneyIIINephrectomy, interferon therapyYes6 2/7Alive (32 mo)
73 M5.6Talent,‡ bifurcated, TFXBladderIITransurethral resection, radiation/local chemoYes4 3/2Alive (27 mo)
63 M5.8Talent,‡ bifurcated, IFXProstateIIProstatectomy, hormonal/chemoYes8 4/9Alive (25 mo)
84 M6.5Zenith,† bifurcated, IFXLeft colonIIILeft hemicolectomy/chemoYes7 4/8Died: MI (16 mo)

AAA, Abdominal aortic aneurysm; IFX, infrarenal fixation; TFX, transrenal fixation; chemo, chemotherapy; MI, myocardial infarction.

⁎W. L. Gore & Assoc, Flagstaff, Arizona.

†Cook, Bloomington, Indiana.

‡Medtronic, Minneapolis, Minnesota.

Table III. Open repair treatment of abdominal aortic aneurysm in 14 patients with malignancy
Age/sexAAA diameter (cm)Graft typeCancer locationStageCancer treatmentCurative intentInterval (days)Major complicationsLOS (d)AAA/cancerOutcome
65 M7.3TubeLungIILobectomy/chemoYes35 AAA first 8/7Died: metastases (11 mo)
70 M5.8TubeBladderIIIRadical cystectomyYesOne stage 18Alive (44 mo)
73 F6.4AortobiiliacKidneyIINephrectomyYesOne stage 9Alive (41 mo)
58 M5.9AortobifemSigmoid colonIIIL hemicolectomy/chemoYes15 AAA firstGraft infection8/34Died: sepsis (23 mo)
68 M6.1AortobifemLungIII ADied after AAA repair?DeadRetroperitoneal bleeding4Died: DIC (4 d)
71 M6.0AortobiiliacBladderIITUR/chemotherapyYes14 AAA first 10/3Alive (35 mo)
64 M7.1TubeKidneyIINephrectomyYesOne stage 10Alive (27 mo)
73 M5.9AortobiiliacBladderIIIDied after AAA repair?DeadMI18Died: cardiac failure (18 d)
83 M6.6TubeKidney L UreterIIIL nephroureterectomyYesOne stageMI15Died: metastases (15 mo)
72 M7.6TubeL ColonIIIL hemicolectomyYesOne stageColonic anastomotic leak28Died: sepsis (28 d)
69 M8.2TubeR ColonIIR hemicolectomyYesOne stageColonic anastomotic leak23Died: metastases (39 mo)
62 M6.4TubeLungIILobectomyYes28 AAA firstMI9/12Died: metastases (15 mo)
82 M6.3TubeRectumIIIAP resection/neoadj therapyYes82 Cancer firstAAA rupture11/10Alive: (55 mo)
64 M9.0TubeR ColonIIR hemicolectomyYesOne stage 13Alive: (21 mo)

AAA, Abdominal aortic aneurysm; DIC, disseminated intravascular coagulopathy; MI, myocardial infarction.

Table IV. Patient demographics and comorbidity conditions
FactorEVAR, n (%)⁎OR, n (%)⁎P
Patients (n)1114
Age, mean years71.3(59-84)69.6(58-83)NS
Male gender9(81.8)13(92.9)NS
Smoking history8(72.7)9(64.3)NS
Hypertension6(54.5)7(50)NS
Diabetes mellitus1(9.1)0(0)NS
COPD2(18.2)1(7.1)NS
CAD/MI4(36.4)4(28.6)NS
Cerebrovascular disease1(9.1)0(0)NS
Renal failure0(0)1(7.1)NS
ASA III or IV6(54.5)6(42.9)NS
Aneurysm size, median cm5.9(5.6-6.5)6.8(5.8-9.0).006

EVAR, Endovascular aneurysm repair; OR, open repair; NS, not significant; COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease; MI, myocardial infarction; ASA, American Society of Anesthesiologists classification.

⁎Categoric data presented as number (%), continuous data presented with the range.

Patients in the EVAR group were followed up at 1, 6, and 12 months with CT scan and then every year with a duplex scan. Patients in OR group were followed up at 6 and 12 months and annually thereafter.

The cancer was surgically resected in all patients treated with EVAR and in 12 (85.7%) of the 14 patients in the OR group because two patients in the latter group died after the AAA repair.

All the EVAR procedures occurred before the oncologic treatment, and all patients in this group were treated in two different admissions. The mean interval between the two procedures was 6.5 days (range, 2 to 11 days). In the OR group, the AAA and cancer were treated with a one-stage procedure in seven patients (50%). Five patients (35.7%) underwent a two-stage treatment, in all cases with two different hospital admissions; in four, the AAA was treated first. The last patient underwent an abdominoperineal excision of the rectum as the initial treatment, followed by adjuvant chemotherapy. The AAA enlarged, became symptomatic, and required urgent repair 82 days after the original operation. Two patients (14.3%) died after the AAA repair and never received cancer treatment (Table III).

The mean AAA diameter in EVAR patients was 5.9 cm (range, 5.6 to 6.5 cm). Talent grafts (Medtronic, Minneapolis, Minn) were placed in 4 patients, Excluder grafts (W. L. Gore & Associates, Flagstaff, Ariz) in 3, Zenith grafts (Cook, Bloomington, Ind) in 3, and an AneuRx graft (Medtronic) in 1. Device configuration included 10 bifurcated grafts and one aortouniiliac graft, combined with femorofemoral bypass repair. Eight patients had infrarenal fixation of the endografts, and three patients had transrenal fixation. Epidural anesthesia was used in nine patients and local anesthesia in two.

In the OR group, the mean AAA diameter was 6.8 cm (range, 5.8 to 9 cm). Fourteen aortic reconstructions consisted of nine straight grafts, three aortobiiliac grafts, and two aortobifemoral bypass grafts, all through a transperitoneal approach.

The mean postoperative length of stay (LOS) for the AAA repair was 4.3 days (range, 2 to 7 days) in the EVAR group and 9.2 days (range, 8 to 11 days) for the five patients in the OR group who had a two-stage procedure (P = .001). The LOS for the cancer treatment was 8.5 days (range, 2 to 19 days) in the EVAR group and 13.2 days (range, 3 to 34 days) for the OR group (P = NS). The mean interval between the two procedures in the five patients in the OR group who had two-stage procedure was 23 days (range, 14 to 35), which was significantly longer than the EVAR group (P < .05). In the seven patients that had a one-stage procedure, the average LOS was 19 days (range, 9 to 23). The last two patients planned for a two-stage approach died 4 and 18 days after the AAA repair. The cumulative LOS for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26 days) for EVAR and 18.2 days (range, 9 to 42 days) for OR.

No patients in the EVAR group died perioperatively. Three patients (21.4%) in the OR group died perioperatively (P = NS), one each from disseminated intravascular coagulopathy, cardiac failure, and sepsis. Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% (P = .04).

The patient in the EVAR group with complication underwent EVAR and left internal iliac artery coil embolization. This procedure was complicated by intraoperative graft limb occlusion, which required conversion to an aortouniiliac graft and femorofemoral bypass grafting. The patient recovered well and underwent an anterior resection of the rectum 11 days later. An anastomotic leak developed 5 days after the operation, which required the formation of a temporary stoma. No sign of endograft infection developed, but the patient died of metastasis 39 months later. The seven major postoperative complications in the OR group included one retroperitoneal bleeding, three acute myocardial infarctions, two colonic anastomotic leaks, and a graft infection. In the EVAR group, one late complication (9.1%) occurred when graft limb thrombosis developed in a patient at 14 months, which required reintervention. There were no late complications in the OR group.

The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. During the follow-up, four patients in the EVAR group and five in the OR group died. In the EVAR group, two deaths were cancer-related (18.2%) and two (18.2%) were secondary to a cardiac event. In the OR group, four patients (28.6%) died of cancer and one (7.1%) died at 23 months of prosthetic graft infection after a left hemicolectomy, despite an attempted salvage procedure. The 1-year and 2-year survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103; Fig).

  • View full-size image.
  • Fig. 

    Kaplan-Meier life-table curves for cumulative survival rates for the patients that had endovascular aneurysm repair (EVAR, red line) and open surgical repair (OR, blue line.)

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Discussion 

When treating patients with AAA and concurrent malignancy, the surgical approach and timing for the AAA repair remain very controversial. Decision-making may depend on many variables, including surgeon experience and preference, local expertise, aneurism size, and type and stage of cancer. Although our study might not resolve the dilemma about which strategy is best in patients needing both aneurysm repair and resection of a malignancy, to our knowledge, it is the first to compare the results of EVAR and OR in the management of patients with concomitant AAA and malignancy.

In our study, seven of the 14 patients in the OR group had a combined procedure, with one death secondary to a complication of cancer surgery. The other seven were intended to have staged procedures, but two died after the first operation (AAA repair) and the cancer surgery was not done. The difference in mortality between these two groups is not significant, but even if it is real, it is offset by the occurrence of one late death from a postoperative graft infection in a patient who had a combined procedure. It is therefore impossible from this small group of patients to conclude whether a combined approach is preferable than a staged one when treating the AAA with OR. With three postoperative deaths in 14 patients who had OR, the overall mortality in this group appears high, although patients with associated neoplastic condition might be expected to have a higher surgical risk than that of patients reported in large series of aneurysm repairs. Conversely, none of 11 patients who had EVAR died postoperatively. Major postoperative complications were also higher in the OR group. Furthermore, the patient who had a complication related to the EVAR was still able to undergo surgical treatment for the cancer 11 days later.

This apparent advantage of EVAR in patients with AAA and concomitant malignancy needs to be seen in the context of the recently published EVAR trials. In EVAR 1, the 30-day mortality of patients undergoing EVAR was 1.7%, compared with 4.6% for OR (P = .007). After 4 years of follow-up, all cause mortality in the two groups was similar, but there was a persistent reduction in aneurysm-related death in patients who had EVAR (4% vs 7%, P = .04). This was offset by a much higher incidence of complications in those who had EVAR (41%) compared with those who had OR (9%, P < .0001).35 However, a recent meta-analysis of randomized controlled trials confirmed a reduction in the 30-day mortality (1.6 vs 4.7%) and showed a lower incidence of major complications (cardiac, respiratory, renal, and hemorrhagic) after EVAR. Furthermore, hospital stay was shorter in the EVAR group, thus suggesting a quicker recovery after this procedure.36

Similar results have been shown in a recent series of 1904 patients who underwent elective AAA repair with OR or EVAR (37.7%). Patients undergoing EVAR had significantly lower 30-day (3.1% vs 5.6%, P = .01) and 1-year mortality rates (8.7% vs 12.1%, P = .018) than patients having OR. EVAR was associated with a decrease in 30-day postoperative mortality (P = .04). The risk of perioperative complications was much less after EVAR (15.5% vs 27.7%; P < .001).37 These short-term benefits are extremely important in patients who require further treatment for the concomitant neoplastic condition.

In line with these results, the patients in our series who had EVAR had a lower operative mortality than those who had OR, and this advantage was maintained after a mean follow-up of approximately 3 years. In fact, although the number of cancer-related deaths in the two groups was similar, surgically related deaths occurred only in the OR group.

The difference in AAA size between EVAR and OR group in our study reflects the selection criteria used for the EVAR. Evidence in literature shows that patients with larger aneurysms are less suitable for EVAR,38 and larger aneurysms are often associated with arterial anatomy that is less favorable for EVAR.39 It has also been shown that patients with an AAA >60 mm and a proximal aortic neck >26 mm have worse clinical outcome after EVAR.40 It is unlikely that the difference in AAA size would have influenced the outcome of the repair, however.

The high incidence of late complications in EVAR patients reported in the literature raises the concern that its short-term advantage may be lost with longer follow-up.41 However, this is a less important consideration in patients with AAA who require further intervention for concomitant malignancy and who, as a group, may have a shorter life expectancy than those without malignancy and in whom the long-term durability of EVAR is relatively less important. Furthermore, it is also likely that improvement of endovascular devices, refined technique, and enhanced operator experience will have an impact on the long-term outcome of EVAR. In our study, one late graft complication occurred in the EVAR group, which was successfully treated. One fatal late graft complication occurred in the OR group in a patient who underwent a left hemicolectomy and the AAA repair in one stage.

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Conclusion 

We conclude from these clinical results that EVAR should be considered as an attractive treatment option in the treatment of patients with AAA and a concomitant malignancy. Further experience, and possibly randomized trials, is required to further assess the role of EVAR in the management of these challenging patients.

We thank Raimondo Costabile, MSD, for performing the statistical analysis for this article.

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Author contributions 


Conception and design: MP, PN, UB, PG

Analysis and interpretation: MP, PN, SB, PG

Data collection: PN, UB

Writing the article: MP, PN, PG

Critical revision of the article: MP, SB, PG

Final approval of the article: MP, PN, UB, SB, PG

Statistical analysis: RC, UB

Obtained funding: Not applicable

Overall responsibility: MP

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 Competition of interest: none.

PII: S0741-5214(07)00452-1

doi:10.1016/j.jvs.2006.09.070

Journal of Vascular Surgery
Volume 46, Issue 1 , Pages 16-23, July 2007

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