Purpose: The purpose of this study was to compare the transabdominal approach with the retroperitoneal approach for elective aortic reconstruction in the patient who is at high risk.

Methods: From January 1992 through January 1997, 148 patients underwent aortic operations: 92 of the patients were classified as American Society of Anesthesia (ASA) class IV. Forty-four operations on the patients of ASA class IV were performed with the transabdominal approach (25 for abdominal aortic aneurysms and 19 for aortoiliac occlusive disease), and 48 operations were performed with the retroperitoneal approach (27 for abdominal aortic aneurysms and 21 for aortoiliac occlusive disease). There were no significant differences between the groups for comorbid risk factors or perioperative care.

Results: Among the patients of ASA class IV, eight (8.7%) died after operation (retroperitoneal, 3 [6.26%]; transabdominal, 5 [11.3%]; P = .5). There was no difference between groups in the number of pulmonary complications (retroperitoneal, 23 [47.9%]; transabdominal, 19 [43.2%]; P = .7) or in the development of incisional hernias (retroperitoneal, 6 [12.5%]; transabdominal, 5 [11.3%]; P = .5). The retroperitoneal approach was associated with a significant reduction in cardiac complications (retroperitoneal, 6 [12.5%]; transabdominal, 10 [22.7%]; P = .004) and in gastrointestinal complications (retroperitoneal, 5 [8.3%]; transabdominal, 15 [34.1%]). Operative time was significantly longer in the retroperitoneal group (retroperitoneal, 3.35 hours; transabdominal, 2.98 hours; P = .006), as was blood loss (retroperitoneal, 803 mL; transabdominal, 647 mL; P = .012). The patients in the retroperitoneal group required less intravenous narcotics (retroperitoneal, 36.6 ± 21 mg; transabdominal, 49.5 ± 28.5 mg; P = .004) and less epidural analgesics (retroperitoneal, 39.5 ± 6.4 mg; transabdominal, 56.6 ± 9.5 mg; P = .004). Hospital length of stay (retroperitoneal, 7.2 ± 1.6 days; transabdominal, 12.8 ± 2.3 days; P = .024) and hospital charges (retroperitoneal, $35,587 ± $980; transabdominal, $54,832 ± $1105; P = .04) were significantly lower in the retroperitoneal group. The survival rates at the 40-month follow-up period were similar between the groups (retroperitoneal, 81.3%; transabdominal, 78.7%; P = .53).

Conclusion: In this subset of patients who were at high risk for aortic reconstruction, the postoperative complications were common. However, the number of complications was significantly lower in the retroperitoneal group. Aortic reconstruction in patients of ASA class IV appears to be more safely and economically performed with the retroperitoneal approach. (J Vasc Surg 1999;30:400-6.)