Early inflammatory response following elective abdominal aortic aneurysm repair: A comparison between endovascular procedure and conventional, open surgery

Abstract

Background/Aim. Abdominal aorta aneurysm (AAA) represents a pathological enlargment of infrarenal portion of aorta for over 50% of its lumen. The only treatment of AAA is a surgical reconstruction of the affected segment. Until the late XX century, surgical reconstruction implied explicit, open repair (OR) of AAA, which was accompanied by a significant morbidity and mortality of the treated patients. Development of endovascular repair of (EVAR) AAA, especially in the last decade, offered another possibility of surgical reconstruction of AAA. The preliminary results of world studies show that complications of such a procedure, as well as morbidity and mortality of patients, are significantly lower than with OR of AAA. The aim of this paper was to present results of comparative clinical prospective study of early inflammatory response after reconstruction of AAA between endovascular and open, conventional surgical technique. Methods. A comparative clinical prospective study included 39 patients, electively operated on for AAA within the period of December 2008 - February 2010, divided into two groups. The group I counted 21 (54%) of the patients, 58-87 years old (mean 74.3 years), who had been submited to EVAR by the use of excluder stent graft. The group II consisted of 18 (46%) of the patients, 49-82 (mean 66.8) years, operated on using OR technique. All of the treated patients in both groups had AAA larager than 50 mm. The study did not include patients who have been treated as urgent cases, due to the rupture or with simptomatic AAA. Clinical, biochemical and inflamatory parameters in early postoperative period were analyzed, in direct postoperative course (number of leucocytes, thrombocytes, serum circulating levels of cytokine - interleukine (IL)-2, IL-4, IL-6 and IL-10). Parameters were monitored on the zero, first, second, third and seventh postoperative days. The study was approved by the Ethics Commitee of the Military Medical Academy. Results. The study showed a statistically significantly shorter time of treatment in the EVAR group (average 90 min) compared to the OR group (average 136 min). Also, there was a statistically significantly less blood loss in the patients operated on by the use of EVAR surgery (average 60 mL) as compared to the patients treated with OR techinique (average 495 mL), as well as a shorter postoperative hospitalization of patients in the EVAR group (average 4 days) compared to the OR group (average 8 days). The OR group was detected with a statistically significant increase of leucocytes and statistically significant fall of the number of thrombocytes in comparison with the EVAR group in all the investigated terms. A significant concentration rise of IL-2 in the OR group and concentration rise of IL-6 in the EVAR group was shown 24 hours after the procedure, whereas on the second postoperative day there was detected a significant fall of IL-6 in the EVAR group. IL-4 concentration in the OR group was significantly higher as of the third postoperative day in comparison to the EVAR group. There was no significant difference in IL-10 concentration between the groups. Conclusion. The EVAR techinique is a safer and less invasive and less traumatic procedure for patients than the OR of AAA. Following the EVAR, there are less inflammatory reactions in the early postoperative periodas compared to the OR and therefore less possibility of the development of systemic inflammatory respons syndrome in patients treated.Uvod/Cilj. Aneurizma abdominalne aorte (AAA) predstavlja patolosko prosirenje infrarenalnog dela aorte za vise od 50% njenog lumena. Jedini vid lecenja AAA je hirurska rekonstrukcija obolelog segmenta. Sve do kraja XX veka, hirurska rekonstrukcija podrazumevala je otvorenu, klasicnu rekonstrukciju (OR) AAA koja je bila pracena znacajnim morbiditetom i mortalitetom operisanog bolesnika. Razvoj endovaskularne rekonstrukcije (EVAR) AAA, narocito u poslednjoj dekadi, pruzio je jos jednu mogucnost hirurske rekonstrukcije, pri cemu preliminarni rezultati svetskih studija pokazuju da su komplikacije ove procedure, kao i morbiditet i mortalitet bolesnika znacajnije nizi nego tokom OR AAA. Cilj rada bio je da se iznesu rezultati komparativne klinicke prospektivne studije ispitivanja ranog inflamatornog odgovora organizma nakon rekonstrukcije AAA EVAR i OR hirurskom tehnikom. Metode. Komparativna klinicka prospektivna studija obuhvatila je 39 bolesnika podeljenih u dve grupe koji su elektivno operisani zbog AAA u periodu od decembra 2008. do februara 2010. Prvu grupu sacinjavao je 21 (54%) bolesnik, starosti od 58 do 87 (prosecno 74,3) godina kod kojih je ucinjena EVAR procedura excluder stent graftom. Drugu grupu cinilo je 18 (46%) bolesnika, starosti od 49 do 82 (prosecno 66,8) godine koji su operisani OR tehnikom. Svi operisani iz obe grupe imali su AAA precnika veceg od 50 mm. Studijom nisu bili obuhvaceni bolesnici koji su operisani kao hitni slucajevi, zbog rupture ili sa simptomatskom AAA (preteca ruptura). Analizirani su klinicki, biohemijski i inflamatorni parametri reakcije organizma u neposrednom postoperativnom periodu (broj leukocita, trombocita, nivo cirkulisucih citokina: interleukina (IL)-2, IL-4, IL-6 i IL-10 u serumu). Parametri su praceni nultog, prvog, drugog, treceg i sedmog postoperativnog dana. Studiju je odobrio Eticki komitet Vojnomedicinske akademije. Rezultati. Ustanovljeno je statisticki znacajno krace trajanje operacije u EVAR grupi (prosecno 90 min) u odnosu na OR grupu (prosecno 136 min). Takodje, pokazan je statisticki znacajno manji gubitak krvi kod bolesnika operisanih EVAR tehnikom (prosecno 60 mL) u odnosu na bolesnike operisane OR tehnikom (prosecno 495 mL), i kraca postoperativna hospitalizacija bolesnika u EVAR grupi (prosecno 4 dana) u odnosu na OR grupu (prosecno 8 dana). U OR grupi otkriven je statisticki znacajan porast broja leukocita i statisticki znacajan pad broja trombocita u poredjenju sa EVAR grupom u svim ispitivanim terminima. Znacajno povecanje koncentracije IL-2 u OR grupi, a koncentracije IL-6 u EVAR grupi, utvrdjeno je 24 h nakon operacije, dok je drugog postoperativnog dana utvrdjen znacajan pad IL-6 u EVAR grupi. Koncentracija IL-4 u OR grupi znacajno se povecavala od treceg postoperativnog dana u poredjenju sa EVAR grupom. Nije utvrdjena znacajna razlika medju grupama u koncentraciji IL-10. Zakljucak. Primena EVAR tehnike predstavlja bezbedniju i za bolesnika manje invazivnu i manje traumatsku proceduru u poredjenju sa OR AAA. Nakon EVAR dolazi do manje inflamatorne reakacije organizma u ranom postoperativnom periodu u poredjenju sa OR AAA, samim tim i manje mogucnosti za nastanak sistemskog inflamatornog odgovora.