[en] INTRODUCTION The infrarenal abdominal aortic aneurysm (AAA) is a relatively frequent and serious disease which ends in rupture causing a high mortality. There might be two solutions: open surgery or endovascular repair (EVAR). The first one changed the prognosis for the disease since its instauration and in experienced teams shows a very low morbi-mortality. The second one, more recent and less aggressive, has allowed the treatment of patients who, because of their comorbidity, could not successfully overcome the open surgery. This last procedure has better perioperative results. However, it shows in the medium and long term a higher percentage of complications and even of aneurysm rupture. This makes it necessary a rigorous follow-up, which could harm the quality of life of the patients and increase costs. OBJECTIVE The objective of this study is to compare both therapeutic modalities from the clinic, social and economic perspective, starting from the assumption that the patients have been well selected for each kind of treatment and that are operated by a surgical team, always led by the same experienced surgeon. MATERIAL AND METHODS Retrospective study of all the patients with AAA electively operated by the doctoral student from January 2006 to December 2015. The variables were obtained by reviewing medical records, radiological images and consulting the database of the hospitals of Salamanca, Zamora and Avila. First, a comparative clinical study was conducted between both therapeutic modalities. First comparing the perioperative results and those obtained during the follow-up; then, subdividing the cohort according to the surgical risk and finally, analyzing the results within each modality based on time, which in the case of the EVAR group coincided with the change of the endoprosthesis model used. Secondly, a comparative study of the degree of satisfaction was carried out, for which we sent a letter to the living patients with a survey prepared by us. Third, a comparative study of the costs in the first admission and during the follow-up was carried out; to obtain them invoices were requested to the department of supplies and the prices for the use of the hospital services to the billing service. Finally, the causes of mortality were compared and the number of patients who could not have intervened in the absence of both options was calculated. The results were analyzed with the SPSS program, version 23.0, considering the level of statistical significance when it was <0.05. RESULTS 119 patients were studied, with an average age of 73 years: 63 belonged to the open group and 56 to the EVAR, with a similar age and sex distribution. There was an initial conversion rate of 1.75%. The EVAR group had patients with worse medical comorbidity. In the open, the morphological characteristics were worse. The perioperative results show significant differences in favor of the EVAR group in the duration of the intervention, the hospital stay and the lowest bleeding and in favor of the open group in the number of associated procedures performed. There were no significant differences in mortality (0,0% in EVAR vs 1,58 % in open) (p=0.244), complications (p=0.960) and reinterventions (p>0.05). In the follow-up there were differences against the EVAR group: there were more revisions (p=0.007), TACS made (p=0.000), complications (37.5% vs 6.4%) (p=0.000), reinterventions (23.6% vs 3.2%) (p=0.001), failures (10.7% vs 1.6%) and mortality (48.2% vs 20.6%) (p=0.001). There was a 5.4% reconversion rate to open surgery. According to the surgical risk, 64 low-risk patients were found (44 belonged to the open and 20 to the EVAR) and 55 to the moderate-high (19 in the open and 36 in the EVAR). There were no differences in the perioperative period in any of the subgroups, but there were differences during the follow-up. Within the subgroup of low risk, there were more complications (36.1% vs 9.0%) (p=0.015), reinterventions (25.0% vs 4.5%) (p=0.015) and failures (15.0% vs 2.2%) (p=0.048) in the EVAR group; and mortality was also higher, although without statistical significance (30.0% vs 13.6%) (p=0.12). In the subgroup of moderate-high risk, EVAR group also had more complications (36.1% vs 0.0%) (p=0.003) and reinterventions (22.9% vs 0.0%) (p=0.024); but, although being higher, there were no significant differences neither in mortality (58.3% vs 36.8%) (p=0.13), nor in failures (8.3% vs 0.0%) (p=0.196). Of the 63 patients in the open group, 28 were intervened in the first five-year period and 35 in the second, and no differences were found in the perioperative period or during the follow-up. Of the 56 patients of the EVAR group, in the first four years the Talent? prosthesis was used in 29 and in the last six years, in 27 were used Endurant? or Endurant II? prostheses and no statistically significant perioperative differences were found, nor during the follow-up. The satisfaction survey was answered by 70 patients (88.6% of the living): 45 from the open group and 25 from the EVAR. No statistically significant qualitative differences were found, but there were quantitative differences in favor of the EVAR group (83.49% versus 79.19%) (p?0.034) in the degree of satisfaction. There were no differences in the quality of life, nor in the state of health. Having pain or sexual dysfunction negatively influenced the degree of satisfaction, but there were no differences between the groups. The EVAR group costs are higher both in the first admission (? 16,493 vs ? 9,043) (p?0,000), and throughout the follow-up (? 21,018 vs ? 9,809) (p?0.000) and are due to the prosthetic material. The history of pulmonary obstructive chronic disease (EPOC) has a negative effect on survival (p?0.012). The history of renal chronic failure (IRC) also presents a greater risk of death, without being significant (p=0.059) and has a decisive influence on the risk of the appearance of an immediate postoperative complication (p?0.002). The larger diameter of the aneurysm negatively influences the appearance of a type II leak (p?0.05) and the anchoring of the endoprosthesis in the external iliac artery increases the risk of branch thrombosis at follow-up (p?0.036). Other procedures were performed in 12 patients of the open group with a saving of ? 26,100 and only 1 in the EVAR with a saving of ? 3,721. Finally, if there were no open technique, 36 patients would have remained untreated (30%) and if there was no EVAR, 13 (10.9%). CONCLUSION Both therapeutic modalities are optimal if a correct indication is made, but open surgery offers better long-term clinical results with lower cost, while patients with EVAR show a higher degree of satisfaction.

[es] INTRODUCCI?N El aneurisma de la aorta abdominal infrarrenal (AAA) es una enfermedad relativamente frecuente y grave que, sin tratamiento, acaba en la rotura con una elevada mortalidad. La soluci?n puede ser mediante la reparaci?n por cirug?a abierta o con tratamiento endovascular (EVAR). La primera, tras su instauraci?n cambi? el pron?stico de la enfermedad y en equipos con experiencia tiene una morbi-mortalidad muy baja. La segunda, m?s reciente, dada su menor agresividad, ha permitido tratar pacientes que por su comorbilidad podr?an no superar con ?xito la intervenci?n abierta. Sin embargo, esta modalidad terap?utica que tiene mejores resultados perioperatorios, presenta a medio y largo plazo un porcentaje mayor de complicaciones e incluso de rotura del aneurisma. Esto obliga a hacer un riguroso seguimiento, que podr?a menoscabar la calidad de vida de los pacientes y aumentar los costes. OBJETIVO El objetivo de este trabajo es comparar ambas modalidades terap?uticas desde el punto de vista cl?nico, social y de los costes econ?micos, partiendo de la hip?tesis que los pacientes han sido bien seleccionados para cada tipo de tratamiento y son intervenidos por un equipo quir?rgico en el que el cirujano principal es siempre el mismo, con experiencia suficiente. MATERIAL Y M?TODOS Estudio retrospectivo de todos los pacientes con AAA intervenidos de forma electiva por el doctorando desde enero del 2006 hasta diciembre del 2015. Las variables se obtuvieron revisando las historias cl?nicas, las im?genes radiol?gicas y consultando la base de datos de los hospitales de Salamanca, Zamora y ?vila. En primer lugar, realizamos un estudio cl?nico comparativo entre ambas modalidades terap?uticas. Primero, comparando los resultados perioperatorios (<30 d?as) y durante el seguimiento; despu?s, subdividiendo la cohorte seg?n el riesgo quir?rgico y finalmente, analizando los resultados dentro de cada modalidad en funci?n del tiempo, que en el caso del grupo EVAR coincidi? con el cambio del modelo de endopr?tesis utilizada. En segundo lugar, hicimos un estudio comparativo del grado de satisfacci?n, para lo que enviamos una carta a los pacientes vivos con una encuesta elaborada por nosotros. En tercer lugar, se realiz? un estudio comparativo de los costes en el primer ingreso y durante el seguimiento. Para obtenerlos se solicitaron las facturas al departamento de suministros y los precios por el uso de los servicios hospitalarios al servicio de facturaci?n. Finalmente, se compararon las causas de mortalidad y se calcul? el n?mero de pacientes que no se hubieran podido intervenir de no existir ambas opciones. Los resultados se analizaron con el programa SPSS, versi?n 23.0, considerando el nivel de significaci?n estad?stica cuando era <0.05. RESULTADOS Se encontraron 119 pacientes, con una edad media de 73 a?os: 63 pertenecieron al grupo abierto y 56 al EVAR, con una distribuci?n por edad y sexo similares. Hubo una tasa de reconversi?n inicial del 1,75%. En el grupo EVAR los pacientes ten?an m?s comorbilidad m?dica. En el abierto las caracter?sticas morfol?gicas del aneurisma eran peores. Los resultados perioperatorios muestran diferencias estad?sticamente significativas a favor del grupo EVAR en la duraci?n de la intervenci?n, la estancia hospitalaria y en el menor sangrado y a favor del grupo abierto en el n?mero de procedimientos asociados realizados. No hubo diferencias en la mortalidad (0,0% en EVAR vs 1,58% en abierto) (p?0.244), las complicaciones (p?0.960) y las reintervenciones (p>0.05). En el seguimiento hubo diferencias en contra del grupo EVAR: m?s revisiones (p?0.007), tomograf?as axiales computerizadas (TAC) realizados (p?0.000), complicaciones (37,5% vs 6,4%) (p?0.000), reintervenciones (23,6% vs 3,2%) (p?0.001), fracasos (10,7% vs 1,6%) (p?0.035) y mortalidad (48,2% vs 20,6%) (p?0.001). Hubo una tasa de reconversi?n a cirug?a abierta del 5,4%. Seg?n el riesgo quir?rgico se encontr? 64 pacientes de bajo riesgo (44 pertenecieron al abierto y 20 al EVAR) y 55 de moderado-alto (19 en el abierto y 36 en el EVAR). No hubo diferencias en el periodo perioperatorio en ninguno de los subgrupos, pero s? durante el seguimiento. Dentro del subgrupo de bajo riesgo, hubo m?s complicaciones (40,0% vs 9,0%) (p?0.001), reintervenciones (25,0% vs 4,5%) (p?0.015) y fracasos (15,0% vs 2,2%) (p?0.048) en el grupo EVAR, sin embargo, aunque fue mayor, la mortalidad no mostr? significaci?n estad?stica (30,0% vs 13,6%) (p?0.12). En el subgrupo de moderado-alto riesgo, tambi?n tuvo el grupo EVAR m?s complicaciones (36,1% vs 0,0%) (p?0.003) y reintervenciones (22,9% vs 0,0%) (p?0.024) pero, aun siendo mayores, no hubo diferencias estad?sticamente significativas en la mortalidad (58,3% vs 36,8%) (p?0.13) ni en los fracasos (8,3% vs 0,0%) (p?0.196). De los 63 pacientes del grupo abierto, 28 se intervinieron en el primer quinquenio y 35 en el segundo y no se descubrieron diferencias en el periodo perioperatorio ni durante el seguimiento. De los 56 pacientes del grupo EVAR, en los primeros cuatro a?os se us? la pr?tesis Talent? en 29, y en los ?ltimos seis a?os las pr?tesis Endurant? o Endurant II? en 27 y no se encontraron diferencias estad?sticamente significativas perioperatorias, ni durante el seguimiento. La encuesta de satisfacci?n la contestaron 70 pacientes (88,6% de los vivos): 45 del grupo abierto y 25 del EVAR. No se encontr? diferencias cualitativas estad?sticamente significativas, pero s? cuantitativas a favor del grupo EVAR (83,49% frente al 79,19%) (p?0.034) en el grado de satisfacci?n. No hubo diferencias en la calidad de vida ni en el estado de salud. Padecer dolores o disfunci?n sexual influ?a negativamente en el grado de satisfacci?n, pero no hubo diferencias entre los grupos. Los costes del grupo EVAR son mayores tanto en el primer ingreso (16.493 ? vs 9.043 ?) (p?0.000), como durante todo el seguimiento (21.018 ? vs 9.809 ?) (p?0.000) y son debidos al material prot?sico. De las causas de mortalidad, la m?s frecuente fue el c?ncer (37%), seguida de la cardiol?gica (23%) y se observ? que exist?a diferencia estad?sticamente significativa, en contra del EVAR, en las causas cardiol?gica (p?0.012) y respiratoria (p?0.046). El antecedente de enfermedad pulmonar obstructiva cr?nica (EPOC) influye negativamente en la supervivencia (p?0.012). El antecedente de insuficiencia renal cr?nica (IRC) tambi?n tiene un riesgo mayor de muerte, sin llegar a ser significativo (p?0.059) e influye de forma determinante en el riesgo de aparici?n de alguna complicaci?n postoperatoria inmediata (p?0.002). El di?metro mayor del aneurisma influye negativamente en la aparici?n de una fuga tipo II (p?0.05) y el anclaje de la endopr?tesis en la arteria iliaca externa aumenta el riesgo de trombosis de rama en el seguimiento (p?0.036). Se realizaron otros procedimientos en 12 pacientes del grupo abierto con un ahorro de 26.100 ? y s?lo 1 en el EVAR con un ahorro de 3.721 ?. Finalmente, si no existiese la t?cnica abierta habr?an quedado 36 pacientes sin tratar (30%) y si no existiese la EVAR, 13 (10,9%). CONCLUSI?N Ambas modalidades terap?uticas son ?ptimas si se hace una correcta indicaci?n, pero la cirug?a abierta ofrece mejores resultados cl?nicos a largo plazo con menor coste, mientras que con la EVAR los pacientes manifiestan mayor grado de satisfacci?n.