Suprarenal Clamping Is a Safe Method of Aortic Control when Infrarenal Clamping Is not Desirable

Cross-clamp location and perioperative outcomes after open infrarenal abdominal aortic aneurysm repair: A Vascular Quality Initiative® review

OBJECTIVES

By analyzing national Vascular Quality Initiative (VQI) data for patients undergoing open infrarenal abdominal aortic aneurysms (AAA) repair, we sought to better characterize the effects of different suprarenal clamping positions on postoperative outcomes.

METHODS

We performed a retrospective analysis of a prospectively collected national VQI database for all open infrarenal AAA repairs performed between 2003 and 2017. Patients were initially divided into proximal (above 1 renal, above 2 renals, and supraceliac) and infrarenal clamp groups. Patients were then subdivided into those who underwent surgery between 2003-2010 and those who had surgery between 2011-2017. Univariate followed by multivariate analyses were done to compare the baseline characteristics, preoperative, intraoperative, and postoperative outcomes between the two groups.

RESULTS

During the study period, 9068 open AAA repairs were recorded in the VQI; of these, 5043 met the inclusion criteria. Aortic clamp level was infrarenal in 59% (N = 2975), above 1 renal in 15% (N = 735), above both renals in 21% (N = 1053), and supraceliac in 5% (N = 280). The average age was 69 years, and males comprised 73% (N = 3701) of the cohort. The overall 30-day mortality for the entire study group was 2.7%. On univariate analysis, patients who underwent proximal clamping had significantly higher 30-day mortality than those undergoing infrarenal clamping (3.7 vs 2.0%, p < 0.001). After adjusting for preoperative and intraoperative variables, this difference became nonsignificant. On multivariate analysis, clamping above both renals or the celiac artery was associated with an increased occurrence of postoperative myocardial infarction (odds ratio = 1.44, p = 0.037 and odds ratio = 1.78, p = 0.023, respectively). All proximal clamp positions were associated with a significant increase in the incidence of AKI and renal failure requiring dialysis. There was no significant difference when looking at overall survival times comparing the suprarenal and infrarenal clamp position groups (p = 0.1). Patients who underwent surgery in the latter half of the study period had longer intraoperative renal ischemia time, increased in estimated blood loss, and longer total procedure time.

CONCLUSIONS

Suprarenal clamping, at any level, was associated with an increased risk of AKI and renal replacement therapy. Clamping above both renal and celiac arteries was associated with increased cardiac morbidity. Perioperative and long-term mortality was unaffected by clamp level. Patients operating in the latter half of the study had increased estimated blood loss, renal ischemia time, and operative time, which may reflect decreased training in open AAA repair. During open AAA repair, the proximal clamp site should be chosen based on anatomic considerations and not a perceived perioperative mortality benefit. Proximal aortic clamping should always be performed at the safest, distal-most level to reduce cardiac morbidity and the risk of postoperative dialysis.

Pulmonary Vasodilation by Intravenous Infusion of Organic Mononitrites Of 1,2-Propanediol in Acute Pulmonary Hypertension Induced by Aortic Cross Clamping and Reperfusion: A Comparison With Nitroglycerin in Anesthetized Pigs

INTRODUCTION

Suprarenal aortic cross clamping (SRACC) and reperfusion may cause acute pulmonary hypertension and multiple organ failure.

HYPOTHESIS

The organic mononitrites of 1,2-propanediol (PDNO), an nitric oxide donor with a very short half-life, are a more efficient pulmonary vasodilator and attenuator of end-organ damage and inflammation without significant side effects compared with nitroglycerin and inorganic nitrite in a porcine SRACC model.

METHODS

Anesthetized and instrumented domestic pigs were randomized to either of four IV infusions until the end of the experiment (n = 10 per group): saline (control), PDNO (45 nmol kg min), nitroglycerin (44 nmol kg min), or inorganic nitrite (a dose corresponding to PDNO). Thereafter, all animals were subjected to 90 min of SRACC and 10 h of reperfusion and protocolized resuscitation. Hemodynamic and respiratory variables as well as blood samples were collected and analysed.

RESULTS

During reperfusion, mean pulmonary arterial pressure and pulmonary vascular resistance were significantly lower, and stroke volume was significantly higher in the PDNO group compared with the control, nitroglycerin, and inorganic nitrite groups. In parallel, mean arterial pressure, arterial oxygenation, and fraction of methaemoglobin were similar in all groups. The serum concentration of creatinine and tumor necrosis factor alpha were lower in the PDNO group compared with the control group during reperfusion.

CONCLUSIONS

PDNO was an effective pulmonary vasodilator and appeared superior to nitroglycerin and inorganic nitrite, without causing significant systemic hypotension, impaired arterial oxygenation, or methaemoglobin formation in an animal model of SRACC and reperfusion. Also, PDNO may have kidney-protective effects and anti-inflammatory properties.

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping

BACKGROUND

Juxtarenal abdominal aortic aneurysm (AAA) comprises 15-20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs.

METHODS

Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40 years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included.

RESULTS

All patients had fusiform-type AAAs and were divided into infrarenal (N = 98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4 months (95% CI: 48.6-54.2). Mean survival time was 51.4 months (95% CI: 48.6-54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P > .999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P > .999). Old age (HR: 1.084; 95% CI: 1.025-1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225-4.553; P = .010) were substantially associated with in-hospital complications.

CONCLUSIONS

Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

Cross-clamp location affects short-term survival in patients undergoing open abdominal aortic aneurysm repair

INTRODUCTION

Open abdominal aortic aneurysm (oAAA) repair in the era of advanced endovascular aortic techniques is used in challenging anatomy. The impact of the location of the proximal aortic cross-clamp (suprarenal [SR] vs infrarenal [IR]) on outcomes remains to be determined. The aim of this study was to analyze the effect of proximal aortic cross-clamp location on short-term and overall survival after oAAA repair in a contemporary series.

METHODS

A retrospective cohort study was performed comparing the outcomes of patients undergoing oAAA repair with SR and IR aortic cross-clamping using the Vascular Quality Initiative registry from January 2003 to September 2018. Our primary end point was short-term mortality.

RESULTS

There were 7601 patients who underwent oAAA repair. Their mean age was 69.3 ± 8.5 years and 5555 patients (73.1%) were male. The aortic cross-clamp location was IR in 4044 patients (53.2%). The SR group had increased maximum AAA diameter (58 mm vs 56 mm; P < .0001), hypertension (85.5% vs 82.0%; P < .0001), preoperative creatinine (1.11 vs 1.08; P = .001), and were more likely to be in American Society of Anesthesiologists class IV (37.4% vs 30.6%; P < .0001). Postoperative renal failure occurred significantly more often in the SR group (24.4 vs 11.4%; P < .0001). Short-term mortality was 2.7% in the IR group and 4.7% in the SR group (P < .0001). Kaplan-Meier survival estimates were 93.7% and 83.8% in the IR group and 90.9% and 81.2% in the SR group at 1 and 5 years, respectively (P = .007). Multivariable analysis demonstrated that SR cross-clamping was significantly associated with short-term mortality (hazard ratio, 1.38; 95% confidence interval, 1.07-1.78; P = .01); however, it did not affect overall survival (hazard ratio, 1.13; 95% confidence interval, 1.00-1.28; P = .06).

CONCLUSIONS

A SR cross-clamp location is associated with an increased short-term mortality in patients undergoing oAAA repair. Overall survival is not affected by a SR cross-clamp location.

Anatomical Considerations and Open Surgery to Treat Juxtarenal Abdominal Aortic Aneurysms

Introduction:

Historically, the open approach to the abdominal aorta has been transperitoneal (TP). In comparison, a retroperitoneal (RP) incision exposes the lateral wall of the suprarenal aorta for clamp application and midline structures such as the duodenum and pancreas are not encountered. Proximal clamp position for open repair of juxtarenal abdominal aortic aneurysm (JR-AAA) is suprarenal, supra-superior mesenteric, or supraceliac. While RP and TP approaches have previously been compared for physiological reasons, there are currently no randomized controlled trials comparing these methods from an anatomical perspective.

Aims:

The primary aim is to examine the evidence for adopting an RP approach for JR-AAA and compare it with TP approach from an anatomical perspective. The secondary aim is to assess optimum proximal clamp position and its effect on renal function and mortality for the 2 approaches.

Methods/Design:

Literature was reviewed searching databases Medline and Embase for studies on clamp positioning in JR-AAA repair using a TP or RP approach, up to December 2017.

Conclusions:

There is no clear evidence for the optimum cross-clamp position for open repair of JR-AAAs. More proximal clamps provide adequate operative space with the possible downside of increased afterload leading to visceral and renal ischemia. Clamps placed inferior to the superior mesenteric artery allow continued bowel and hepatic perfusion with the potential to cause trauma to the adjacent aortic branches during application. As far as the optimum approach is concerned, many series show a strong trend for RP as a more proximal clamp is required. Significant numbers develop renal failure after JR-AAA repair, with most recovering fully irrespective of the clamp position.

Organ protection during aortic cross-clamping

Open surgical repair of an aortic aneurysm requires aortic cross-clamping, resulting in temporary ischemia of all organs and tissues supplied by the aorta distal to the clamp. Major complications of open aneurysm repair due to aortic cross-clamping include renal ischemia-reperfusion injury and postoperative colonic ischemia in case of supra- and infrarenal aortic aneurysm repair. Ischemia-reperfusion injury results in excessive production of reactive oxygen species and in oxidative stress, which can lead to multiple organ failure. Several perioperative protective strategies have been suggested to preserve renal function during aortic cross-clamping, such as pharmacotherapy and therapeutic hypothermia of the kidneys. In this chapter, we will briefly discuss the pathophysiology of ischemia-reperfusion injury and the preventative measures that can be taken to avoid abdominal organ injury. Finally, techniques to minimize the risk of complications during and after open aneurysm repair will be presented.

Atheroembolization and potential air embolization during aortic declamping in open repair of a pararenal aortic aneurysm: A case report

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A case of microembolization in open repair of a pararenal aneurysm is presented.

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Only a few out of hundreds of small arteries contained cholesterol emboli.

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There was a possibility of remaining air in the aorta/graft at aortic de-clamping.

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Air could have been whipped into pulsating blood causing air microembolization.

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Air microembolization in open repair of pararenal aneurysms needs to be studied.

Introduction

When ischemic events ascribable to microembolization occur during open repair of proximal abdominal aortic aneurysms, a likely origin of atheroembolism is not always found.

Presentation of case

A 78-year old man with enlargement of the entire aorta underwent open repair for a pararenal abdominal aortic aneurysm using supraceliac aortic clamping for 20 min. Then the graft was clamped, the supraceliac clamp was removed, and the distal and right renal anastomoses were also completed. The patient was stable throughout the operation with only transient drop in blood pressure on reperfusion. Postoperatively the patient developed ischemia, attributable to microembolization, in legs, small intestine, gall bladder and kidneys. He underwent fasciotomy, small bowel and gall bladder resections. Intestinal absorptive function did not recover adequately and he died after 4 months. Microscopic examination of hundreds of intestinal, juxtaintestinal mesenteric, and gall bladder arteries showed a few ones containing cholesterol emboli.

Discussion

It is unsure whether a few occluded small arteries out of several hundred could have caused the ischemic injury alone. There had been only moderate backbleeding from aortic branches above the proximal anastomosis while it was sutured. Inadvertently, remaining air in the graft, aorta, and aortic branches may have been whipped into the pulsating blood, resulting in air microbubbles, when the aortic clamp was removed.

Conclusion

Although both atheromatous particles and air microbubbles are well-known causes of iatrogenic microembolization, the importance of air microembolization in open repair of pararenal aortic aneurysms is not known and need to be studied.

Large blood vessel stretch in lumbar spine through anterior surgical approach: An experimental study in adult goat

BACKGROUND

Various anterior lumbar surgical approaches, including the minimally invasive approach, have greatly improved in recent years. Vascular complications resulting from ALIF are frequently reported. Little information is available about the safety of large blood vessel stretch. We evaluated the right side stretch limit (RSSL) of the abdominal aorta (AAA) and the inferior vena cava (IVC) without blood flow occlusion and investigated stretch-induced histological injury and thrombosis in the iliac and femoral arteries and veins and the stretched vessels.

MATERIALS AND METHODS

The RSSL of blood vessels in five adult goats was measured by counting the number of 0.5-cm-thick wood slabs that were inserted between the right lumbar edge and the stretch hook. Twenty seven adult goats were divided into three groups to investigate histological injury and thrombosis under a stretch to 0.5 cm (group I) 1.5 cm (group II) for 2 h, or no stretch (group III). Blood vessel samples from groups I and II were analyzed on postsurgical days 1, 3, and 7. Thrombogenesis was examined in the iliac and femoral arteries and veins.

RESULTS

The RSSL of large blood vessels in front of L4/5 was 1.5 cm from the right lumbar edge. All goats survived surgery without complications. No injury or thrombosis in the large blood vessels in front of the lumbar vertebrae and in the iliac or femoral arteries and veins was observed. Under light microscopy, group I showed slight swelling of endothelial cells in the AAA and no histological injury of the IVC. The AAA of group II showed endothelial cell damage, unclear organelles, and incomplete cell connections by electron microscopy.

CONCLUSIONS

The AAA and IVC in a goat model can be stretched by ≤0.5 cm, with no thrombosis in the AAA, IVC, iliac or femoral arteries and veins.

Technical factors are strongest predictors of postoperative renal dysfunction after open transperitoneal juxtarenal abdominal aortic aneurysm repair

OBJECTIVE

Juxtarenal abdominal aortic aneurysms (AAAs) have predominantly been repaired using an open technique. We present a series of patients with juxtarenal AAAs and analyze multiple factors predictive of postoperative renal dysfunction.

METHODS

Between March 2000 and September 2011, all patients in our prospectively maintained database undergoing juxtarenal AAA repair were evaluated for demographics, operative details, and in-hospital outcomes. Postoperative renal dysfunction was classified using the RIFLE (risk, injury, failure, loss, end-stage renal disease) criteria (glomerular filtration rate decrease >25%). The relationship between perioperative factors and postoperative renal dysfunction was explored using both univariate and multivariate analysis (logistic regression).

RESULTS

Of 169 patients, 76 (45%) required clamping above one renal artery, whereas 93 patients (55%) required clamping above both renal arteries. Mean (standard deviation) renal ischemia time was 29.2 (8.9) minutes (range, 12-65 minutes). Twenty-seven patients (16%) underwent adjunctive renal procedures, 19 (11.3%) required left renal vein division, and 130 (76.9%) received intraoperative mannitol. Postoperative renal dysfunction occurred in 63 patients (37.3%), with the majority (69%) resolving during hospital stay. Seven patients (4.1%) required postoperative dialysis, which was permanent in two cases. Patients who developed postoperative renal dysfunction had significantly longer mean renal ischemia times (34.7 [9.3] minutes vs 25.9 [6.6] minutes; P < .001), a higher rate of bilateral suprarenal aortic clamping (68.3% vs 47.2%; P = .008), higher rates of adjunctive renal artery procedures (26.7% vs 8.8%; P = .002), and higher rates of left renal vein division (20.6% vs 5.7%; P = .003). Logistic regression identified left renal vein division, renal ischemia time, and aortic clamp position as the strongest predictors of renal dysfunction. The use of mannitol was seen to be protective. Overall in-hospital mortality was 4.1% and was 9.5% among patients with postoperative renal dysfunction.

CONCLUSIONS

Postoperative transient renal dysfunction occurred in 37.3% of patients after open juxtarenal AAA repair, with a low incidence of dialysis and a low rate of permanent dysfunction. Technical factors including renal ischemia time, aortic clamp position, and left renal vein division are the strongest predictors of renal dysfunction. The use of intraoperative mannitol was associated with decreased postoperative renal dysfunction.

Renal and abdominal visceral complications after open aortic surgery requiring supra-renal aortic cross clamping

PURPOSE

The aim of this study was to assess renal or abdominal visceral complications after open aortic surgery (OAS) requiring supra-renal aortic cross clamping (SRACC).

METHODS

We retrospectively reviewed the medical records of 66 patients who underwent SRACC. Among them, 17 followed supra-celiac aortic cross clamping (SCACC) procedure, 42 supra-renal, and 7 inter-renal aorta. Postoperative renal, hepatic or pancreatic complications were investigated by reviewing levels of serum creatinine and hepatic and pancreatic enzymes. Preoperative clinical and operative variables were analyzed to determine risk factors for postoperative renal insufficiency (PORI).

RESULTS

Indications for SRACC were 25 juxta-renal aortic occlusion and 41 aortic aneurysms (24 juxta-renal, 12 supra-renal and 5 type IV thoraco-abdominal). The mean duration of renal ischemic time (RIT) was 30.1 ± 22.2 minutes (range, 3 to 120 minutes). PORI developed in 21% of patients, including four patients requiring hemodialysis (HD). However, chronic HD was required for only one patient (1.5%) who had preoperative renal insufficiency. RIT ≥ 25 minutes and SCACC were significant risk factors for PORI development by univariate analysis, but not by multivariate analysis. Serum pancreatic and hepatic enzyme was elevated in 41% and 53% of the 17 patients who underwent SCACC, respectively.

CONCLUSION

Though postoperative renal or abdominal visceral complications developed often after SRACC, we found that most of those complications resolved spontaneously unless there was preexisting renal disease or the aortic clamping time was exceptionally long.

Comparable mortality with open repair of complex and infrarenal aortic aneurysm

BACKGROUND

A consequence of endovascular aneurysm repair (EVAR) of anatomically straightforward infrarenal abdominal aortic aneurysm repair cohort (AAA) is that open aneurysm repair is more commonly performed for complex anatomy. Complex aneurysm repair with visceral vessel involvement (CAA) or combined aneurysm repair and visceral vessel reconstruction (VVR) has traditionally been considered to increase morbidity and mortality compared with repair of infrarenal AAA. This study evaluated contemporary outcomes of open abdominal aneurysm surgery, including AAA, CAA, and VVR using the National Surgical Quality Improvement Program (NSQIP) database.

METHODS

The NSQIP Participant Use File was queried by CPT code to identify patients undergoing AAA, CAA, and VVR (2005-2008). Comparative analysis of clinical features, technical details and 30-day outcomes was performed using univariate methods. Logistic regression analysis was used to identify predictors of morbidity and mortality.

RESULTS

A total of 2820 patients underwent AAA and 592 CAA. Renal insufficiency (ie, creatinine >1.4 mg/dL) rates were similar in AAA and CAA patients, however, more frequent in patients with VVR (51% vs 31% [no bypass]; P < .01). CAA was less likely to be performed urgently (6.3% vs 9.1%; P < .05) and was associated with increased operative time (254 ± 100 vs 224 ± 93; P < .01) compared with AAA. Univariate analysis showed that CAA did not increase mortality (5.7% vs 5.1%; P = .5). CAA slightly increased overall complications (32% vs 27%; P = .01) compared with AAA. 73 (2.5%) AAA and 84 (12%) CAA patients had simultaneous VVR and these patients exhibited a trend toward increased mortality (8.9% vs 5.2%; P = .07). VVR increased complications (43% (VVR) vs 26% [no bypass]; P < .01), including ventilation >48 hours (21% [VVR] vs 12% [no bypass]; P < .01), renal failure (7.6% [VVR] vs 4.1% [no bypass]; P = .04), and sepsis (13% [VVR] vs 6.3% ([no bypass]; P < .01). Multivariate analysis demonstrated that CAA (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.6]; P = .01) and VVR (OR, 2.2 [95% CI, 1.8-3.6]; P < .01) increased the odds of any complication. Independent predictors of mortality included dependent functional status (OR, 3.6 [95% CI, 2.3-5.4]; P < .01), elevated pre-op creatinine (OR, 2.9 [95% CI, 2.2-4.0]; P < .01), type II diabetes (OR, 1.6 [95% CI, 1.05-2.4]; P = .03), and age (OR, 1.06 [95% CI, 1.03-1.08]; P < .01). Neither CAA (OR, 1.2 [95% CI, 0.84-1.8]; P = .3) nor VVR (OR, 1.6 [95% CI, 0.89-2.9]; P = .11) were associated with increased mortality compared with AAA.

CONCLUSION

In contemporary practice the migration of open repair to increasingly complex cases has been achieved with 30-day mortality essentially equivalent to open repair of infrarenal AAA. Patients who require VVR do sustain increased complications, in particular renal failure. These data also emphasize the importance of baseline renal insufficiency in clinical decision making. CAA and VVR are associated with increased morbidity in comparison to AAA repair; however, both procedures can be safely performed in patients without increased risk of operative mortality.

Remote ischemic preconditioning for renal protection during elective open infrarenal abdominal aortic aneurysm repair: randomized controlled trial

We aimed to determine whether remote ischemic preconditioning (IP) reduces renal damage following elective open infrarenal abdominal aortic aneurysm (AAA) repair. Sequential common iliac clamping was used to induce remote IP in randomized patients. Urinary retinol binding protein (RBP) and albumin-creatinine ratio (ACR) were measured following induction and 3, 24, and 48 hours postoperatively. In controls (n = 22), median urinary RBP increased from 112 microg/mL (interquartile range [IQR] 96-173 microg/mL) preoperatively to 5919 microg/mL (IQR 283-17 788 microg/mL) at 3 hours. Preoperative urinary RBP in preconditioned patients was 96 microg/mL (IQR 50 to 229 microg/mL) preoperatively, rising to 1243 microg/mL (IQR 540 to 15400 microg/mL) at 3 hours. Although control patients' median urinary RBP level was 5 times greater at 3 hours, there were no statistically significant differences in renal outcome indices. This trial could not confirm that remote IP reduces renal injury following elective open aneurysm surgery.

Open surgical repair of ruptured juxtarenal aortic aneurysms with and without renal cooling: observations regarding morbidity and mortality

OBJECTIVES

Little is known about the outcome of ruptured juxtarenal aortic aneurysm (RJAA) repair. Surgical treatment of RJAAs requires suprarenal aortic cross-clamping, which causes additional renal ischemia-reperfusion injury on top of the pre-existing hypovolemic shock syndrome. As endovascular alternatives rarely exist in this situation, open repair continues to be the gold standard. We analyzed our results of open RJAA repair during an 11-year period.

DESIGN

Retrospective observational study.

MATERIALS AND METHODS

Between July 1997 and December 2008, all consecutive patients with RJAAs were included in the study. Part of these patients received cold perfusion of the kidneys during suprarenal aortic cross-clamping. Perioperative variables, morbidity, and 30-day or in-hospital mortality were assessed. Renal insufficiency was defined as an acute rise of >or=0.5 mg/dL in serum creatinine level. Multiple organ failure (MOF) was scored using the sequential organ failure assessment score (SOFA score).

RESULTS

A total of 29 consecutive patients with an RJAA, confirmed by computed tomography-scanning, presented to our hospital. In eight patients, the operation was aborted before the start of aortic repair, because no blood pressure could be regained in spite of maximal resuscitation measures. They were excluded from further analysis. Of the remaining 21 patients, 10 died during hospital stay. Renal insufficiency occurred in 11 out of 21 of the patients. Eleven out of 21 patients developed MOF postoperatively. In a subgroup of patients who received renal cooling during suprarenal aortic clamping, the 30-day or in-hospital mortality was two of 10 vs eight of 11 in patients who did not receive renal cooling (P = .03); renal insufficiency occurred in one out of 10 patients in the subgroup with renal cooling vs 10 out of 11 without renal cooling (P < .001) and MOF in two of 10 vs nine of 11, respectively (P = .009).

CONCLUSIONS

Open surgical repair of RJAAs is still associated with high mortality and morbidity. To our knowledge, this is the first report of cold perfusion of the kidneys during RJAA repair. Although numbers are small, a beneficial effect of renal cooling on the outcome of RJAA repair is suggested, warranting further research with this technique.