Outcome in cirrhotic patients after elective surgical repair of infrarenal aortic aneurysm

Objective: Abdominal surgery in patients with advanced liver disease has been reported to be associated with high morbidity and mortality rates. However, the surgical risk of infrarenal abdominal aortic aneurysm (AAA) repair in cirrhotics remains ill-defined. We reviewed our experience to investigate the predictors of the outcome in cirrhotic patients after elective AAA open repair. Methods: Between January 2001 and March 2006, 1189 patients underwent elective open repair of infrarenal AAA and 24 (2%) had a biopsy-proven cirrhosis (23 male, 1 female; mean age, 68 +/- 7 years). The latter were retrospectively stratified according to the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score. Operative variables, perioperative complications, and survival were recorded and compared with those of 48 concurrent noncirrhotic controls matched (2:1) by gender, age, aneurysm size, preoperative glomerular filtration rate, and type of reconstruction. The effect of CTP and MELD scores on midterm survival was investigated in cirrhotics with the Kaplan-Meier log-rank method. Results: No intraoperative or 30-day deaths were recorded. No significant differences in terms of major perioperative complications were observed between cirrhotic patients and controls. Operative time and intraoperative blood transfusion requirement were significantly higher in cirrhotics (162 +/- 49 vs 132 +/- 39 minutes; P = .007 and 273 +/- 364 vs 84 +/- 183 mL; P = .040, respectively). Hospital length of stay was nearly doubled in cirrhotic patients (11.0 +/- 2.8 vs 5.8 +/- 1.5 days; P < .0001). Twenty-two cirrhotic patients were classified as CTP A and two as CTP B. Median MELD score was 8 (range, 6-14). CTP class B was associated with higher intraoperative blood transfusion requirement (941 +/- 54 vs 213 +/- 314 mL; P = .029). At a mean follow-up of 30.7 +/- 22.1 months, five deaths were recorded in cirrhotics, and three in controls. Actuarial survival at 2 years was 77.4% in cirrhotics and 97.8% in controls (log-rank test, P = .026). Both CTP B patients died within 6 months. CTP class B and a MELD score >= 10 were associated with reduced midterm survival rates (log-rank test, P < .0001 and P = .021, respectively). Conclusions: In our experience, elective AAA open repair in relatively compensated cirrhotics was safely performed with an acceptable increase of the magnitude of the operation. However, the reduced life expectancy of cirrhotics with a MELD score >= 10 suggests that such a procedure may not be warranted in this subgroup of patients. (J Vasc Surg 2011;53:906-11.)