Factors Influencing Outcome after Open Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms

Francesco Speziale; Massimo Ruggiero; Enrico Sbarigia; Mario Marino; Danilo Menna

Disclosures

Vascular. 2010;18(3):141-146. 

In This Article

Abstract and Introduction

Abstract

The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance ≤ 40 mL/min (p = .03) and female sex (p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.

Introduction

About 5 to 7% of the population older than 60 years in Western countries has an abdominal aortic aneurysm (AAA).[1] Most AAAs involve the subrenal abdominal aorta, and 20% of AAAs extend proximally to the renal artery origin. Because 60% of all subrenal AAAs can now be treated by endovascular aneurysm repair (EVAR), progressively fewer need conventional open repair.[1,2]

The strict anatomic criteria used for selecting patients to undergo EVAR include a detailed study of aortic anatomy, especially the proximal neck. These procedures now increasingly detect subrenal aneurysms with a thrombosed neck that necessitate clamping above the renal arteries and aneurysms extending proximally to involve the pararenal aorta. Pararenal AAAs are classified as juxtarenal (JR-AAAs) and suprarenal (SR-AAAs). JR-AAAs extend proximally to the renal artery origins without involving the artery itself and require clamping above one or both renal arteries and subrenal open repair. SR-AAAs involving the renal artery origins require clamping above the superior mesenteric or celiac artery and open surgical repair, including renal revascularization.[3] Although these surgical maneuvers increase the risk of cardiorespiratory stress and ischemic organ damage,[1,4] after the first publication on JR-AAAs reporting a mortality rate of 7.95% and a high rate of postoperative dialysis,[5] numerous series suggested that suprarenal clamping does not substantially increase the rate of major postoperative complications.[6–8] Whether suprarenal clamping increases postoperative cardiorespiratory and renal morbidity therefore remains unclear[6,9]—hence the importance of improving patient selection, shortening clamping time, and using appropriate surgical management.

In this retrospective, single-center study, we reviewed outcomes prospectively collected and inserted into our database in our case series of consecutive patients selected to undergo conventional open JR-AAA repair with suprarenal clamping during the past 10 years. We especially sought possible factors predicting operative cardiorespiratory and renal morbidity and mortality and analyzed overall survival at 1, 3, and 5 years.

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