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

Results

Demographic Characteristics

Of the 92 patients whose clinical and surgical records we reviewed, 88 (95.6%) had degenerative atherosclerotic JR-AAAs and 4 patients (4.4%) had inflammatory lesions. None of the patients had connective tissue disorders. The mean aneurysm diameter was 53 mm (range 32–100 mm). Most patients were men (Table 1). The mean age was 71.5 years. The most frequent risk factors for atherosclerosis were hypertension and smoking. Only 13 patients had diabetes. The most frequent comorbidity was mainly coronary artery disease. The mean serum creatinine value was 1.39 mg/dL (range 0.8–2.4 mg/dL), with a mean creatinine clearance rate of 70.5 mL/min. On preoperative assessment, only five patients (5.4%) had evidence of chronic renal insufficiency, with a mean creatinine clearance value of 29.3 mL/min (range 20–37 mL/min); preoperative renal failure was more frequent in females.

When hospitalized for AAA repair, none of the patients were in dialysis.

Intraoperative Data

Of the 92 patients who had JR-AAA repairs, 76 (82.6%) underwent standard laparotomy through a xiphoid-pubic midline incision and only 6 (6.5%) obese patients with severe respiratory insufficiency through a transverse subcostal incision. For both procedures, the aortic vessels were exposed via a transperitoneal approach. In 10 patients (10.9%), surgery consisted of a left lumbotomy incision and the aortic vessels were exposed via a retroperitoneal approach. Of these 10 patients, 6 had a hostile abdomen and 4 had clinical and imaging findings suggesting inflammatory aneurysms. In two of these four patients, we had to dissect and reconstruct the left renal vein. Surgery lasted a mean 204.8 minutes (range 110–338 minutes) (Table 2). The mean clamping time was shorter when clamps were placed on both renal arteries than when they were placed over one alone (24.4 vs 31.2 minutes; 67 and 25 patients). Only four patients (4.4%) needed an aortoiliac-femoral graft repair (see Table 2). None of the patients in this series needed renal revascularization. The renal arteries were always amenable to cannulation, and none of these procedures led to arterial dissection.

Operative Morbidity and Mortality

In two patients (2.2%), a reintervention was needed: in one patient a second laparotomy for bleeding and in the other a Fogarty catheter embolectomy for acute lower limb ischemia. Major complications arose in 22 patients (23.9%) and were accounted for mainly by renal insufficiency. None of these patients needed hemodialysis. Of the 92 patients who underwent open JR-AAA repair, 1 patient (1.1%) died after an acute myocardial infarction with pulmonary edema on postoperative day 2 (Table 3).

Of the major independent predictors of postoperative cardiac, respiratory, and renal insufficiency tested on univariate analysis, the only significant association was between a preoperative history of coronary artery disease and postoperative ischemic heart disease (p = .01; chi-square test). None of the variables tested in the univariate analysis predicted postoperative respiratory insufficiency. Factors that were significant predictors of postoperative renal insufficiency were female sex (p = .004) and a preoperative creatinine clearance of ≥ 40 mL/min (p = .03) (Table 4).

Overall Survival

Kaplan-Meier survival analysis showed that during follow-up lasting at least 6 months (mean 54.3 ± 37.2 months), nine patients (9.8%) died: the causes of death were cancer (three patients), myocardial infarction (one patient), senile marasmus (one patient), hospital-acquired pneumonia during hospitalization elsewhere (one patient), and old age (one patient). Overall survival was 98.9% at 1 year and 88.6% at 3 and 5 years (Figure 1).

Figure 1.

Overall survival Kaplan-Meier curve for the 91 patients. Note the high rate (almost 90%) at 5 years.

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