Treatment of abdominal aortic aneurysms and coexisting cancer. Endovascular versus traditional approach

BACKGROUND: In this retrospective study, we analyze the role of endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) in patients with concomitant cancer of digestive and urinary system in terms of morbidity and mortality and beneficial outcomes in the management of malignancy. METHODS: Between January 1991 and December 2018, 87 patients with AAA >4 cm and concomitant abdominal cancer with life expectancy over two years, were treated. Thirty-one cases (group A) were submitted to open AAA repair that was simultaneous with cancer surgery in 23 (ten with renal cancer, ten with prostatic cancer, one with gastric cancer, one with bladder cancer, and one with liver cancer) while in the remaining eight cases colon cancer resection followed the AAA surgery. In group B (N.=56) EVAR was always performed before the surgical and/or pharmacological therapy of malignancy (19 colon cancer, 15 bladder cancer, 13 prostate cancer, four gastric cancer, two kidney cancer, two liver cancer, and one lymphoma). RESULTS: The postoperative mortality rate was 13.3% in group A (three myocardial infarctions [MI] and one multiorgan failure), while it was nil in group B. The 30-days postoperative morbidity rate was 10% in group A (two MI and one pulmonary complication) and 1.8% in group B (one Ml). No bowel ischemia occurred in the 20 patients submitted to colorectal resection after EVAR. The time delays between EVAR and cancer treatment in groups A and B were 63 and 15 days, respectively (PO.0001). No graft infection was observed in both groups. Long-term morbidity and mortality were similar in groups A and B. CONCLUSIONS: The analysis of the results obtained in this retrospective study suggests EVAR, when feasible, may be considered the choice treatment in patients with AAA and concomitant abdominal cancer due to its lower perioperative mortality and morbidity when compared with open surgery. This alternative approach allows to expand treatment indications also for small AAA, in relation to the objective observation that laparotomy and chemotherapy improve the AAA rupture incidence; in our experience, 14 patients of group B had an AAA diameter ranging from 4 to 4.5 cm. Furthermore, this less invasive approach reduces significantly the waiting time for following cancer management. It must be underlined that, when colon-rectal resection is needed, the perfusion of at least one hypogastric artery during EVAR is mandatory to avoid sigmoid ischemia. It is well known that abdominal surgery implies an increased risk of aortic graft infection; our feeling that EVAR could minimize the risk of this complication in comparison to conventional surgical approach either combined or sequential, is high.