Routine Continuous Cold Perfusion of the Kidneys during Elective Juxtarenal Aortic Aneurysm Repair

Elective open repair with the debranch, perfuse, reconstruct technique to treat suprarenal or type IV thoracoabdominal aortic aneurysms

BACKGROUND

Open surgical repair of suprarenal abdominal aortic aneurysm (SRAAA) and type IV thoracoabdominal aortic aneurysm (TAAA) remains a surgical challenge because of the inducted intraoperative visceral and renal ischemia. We report a novel three-step technique named debranch, perfuse, reconstruct (DPR), using debranching and passive arterial shunt to decrease these ischemic complications. The main aim of this study was to evaluate the 30-day and 1-year mortality rates associated with these DPR technique. The secondary aim was to evaluate the impact on renal function and the primary patency of the repaired arteries.

METHODS

This retrospective study included all consecutive patients who underwent elective surgery for SRAAA or type IV TAAA using the DPR technique between January 2011 and June 2022. In debranching, using partial side clamping, a multibranch graft was implanted side-to-end into the descending thoracic aorta. The left renal artery was anastomosed end-to-end to the graft. As needed, the superior mesenteric artery (SMA), the celiac trunk, and the right renal artery could also be anastomosed to the graft. In the perfusion step, cannulas were connected to the last branch of the multibranch graft to perfuse other arteries during aortic cross-clamping. For repair, a tube or bifurcated graft was used for the aortic repair. The branch used as a passive temporary arterial shunt was ligated at the end of the intervention. Clinical, radiological, and biological preoperative and postoperative factors were reviewed using a standardized database. Procedural complications and reinterventions were analyzed, as well as artery patency.

RESULTS

There were 40 patients who underwent DPR technique. The mean patient age was 67 ± 13 years and two were women. Twenty-three patients presented with a SRAAA and 17 with a type IV TAAA. The 30-day and 1-year mortality rates were 2.5% (one patient). Two respiratory complications (5%) and three mesenteric ischemic complications (7%) have been recorded. No patient developed signs of cardiac or spinal cord dysfunction. We did not observe a significant change in postoperative renal function. The celiac trunk, superior mesenteric artery, left renal artery, and right renal artery bypass patency rates at 1 year were 95%, 100%, 90%, and 100%, respectively.

CONCLUSIONS

The SRAAA and type IV TAAA repair with DPR technique provides short visceral and renal ischemia times with a low mortality rate. This technique could be an option to consider for visceral and renal protection during open surgical repair.

Acute kidney injury in patients undergoing endovascular or open repair of juxtarenal or pararenal aortic aneurysms

BACKGROUND

The aim of this cohort study was to report the proportion of patients who develop periprocedural acute kidney injury (AKI) after endovascular repair (ER) and open surgery (OS) in patients with juxta/pararenal abdominal aortic aneurysm and to assess potential risk factors for AKI. The study also aimed to report the short- and long-term outcomes of patients with and without AKI.

METHODS

This was a multicenter cohort study of five European academic high-volume centers (>50 OS or 50 ER infrarenal AAA repairs, plus >15 complex AAA repairs per year). All consecutively treated patients were extracted from a prospective vascular surgical registry and the data were scrutinized retrospectively. The primary end point for this study was the development of AKI. AKI was diagnosed when there is a two-fold increase of serum creatinine or decrease of glomerular filtration rate of >50% within 1 week of AAA repair. Secondary end points included long-term mortality and end-stage renal disease (ESRD).

RESULTS

AKI occurred in 16.6% of patients in the ER group vs 30.3% in the OS group (P < .001). The 30-day mortality rate was higher among patients with AKI in both ER (15.4% vs 3.1%; P = .006) and OS (13.2% vs 5.3%; P = .001) groups. Age, chronic kidney disease, presence of significant thrombus burden in the pararenal region, >1000 mL blood loss in ER group were associated with development of AKI. Age, diabetes mellitus, chronic kidney disease, presence of significant thrombus burden in the pararenal region, and a proximal clamping time of >30 minutes in the OS group were associated with the development of AKI, whereas renal perfusion during clamping was the protective factor against AKI development. After a median follow-up of 91 months, AKI was associated with higher mortality rates in both the ER group (58.9% vs 29.7%; P < .001) and the OS group (61.5% vs 27.3%; P < .001). After the same follow-up period, AKI was associated with a higher incidence of ESRD in both the ER group (12.8% vs 3.6%; P = .009) and the OS group (9.9% vs 2.9%; P < .001).

CONCLUSIONS

The current study identified important pre and postoperative factors associated with AKI after juxta/pararenal abdominal aortic aneurysm repair. Patients with postoperative AKI had significantly higher short- and long term mortality and higher incidence of ESRD than patients without AKI.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

PCSK9 and Other Metabolic Targets to Counteract Ischemia/Reperfusion Injury in Acute Myocardial Infarction and Visceral Vascular Surgery

Ischemia/reperfusion (I/R) injury complicates both unpredictable events (myocardial infarction and stroke) as well as surgically-induced ones when transient clampage of major vessels is needed. Although the main cause of damage is attributed to mitochondrial dysfunction and oxidative stress, the use of antioxidant compounds for protection gave poor results when challenged in clinics. More recently, there is an assumption that, in humans, profound metabolic changes may prevail in driving I/R injury. In the present work, we narrowed the field of search to I/R injury in the heart/brain/kidney axis in acute myocardial infarction, major vascular surgery, and to the current practice of protection in both settings; then, to help the definition of novel strategies to be translated clinically, the most promising metabolic targets with their modulatory compounds—when available—and new preclinical strategies against I/R injury are described. The consideration arisen from the broad range of studies we have reviewed will help to define novel therapeutic approaches to ensure mitochondrial protection, when I/R events are predictable, and to cope with I/R injury, when it occurs unexpectedly.

Open Surgical Treatment of Acute Spontaneous Isolated Abdominal Aortic Dissection

BACKGROUND

The aim of this paper is to report our single-center experience in the open surgical treatment of acute spontaneous infrarenal isolated abdominal aortic dissection (siIAAD).

METHODS

This was a single center retrospective study. Between January 2015 and 2020 ten patients were treated due to acute siIAAD with open surgery. There were no patients treated for chronic siIAAD in this time period. Patients who had concomitant thoracic aortic involvement were excluded from this report.

RESULTS

The group consisted of 7 male and 3 female patients. History of hypertension was present in nine patients and six were active smokers. The abdominal/back pain was described in 9 patients, two had acute limb ischemia and three had aortic rupture. Median dissection length was 91 mm (65.7 - 106), median distance from the lowest renal artery was 30 mm (20.7 - 49.3) and median abdominal aortic diameter was 58.5 mm (32.5 - 66.2). Supracoeliac clamp was used in three cases with a ruptured aorta and suprarenal in two patients. The mean duration of proximal clamping time was 24.3 ± 7.49 min. One patient died of postoperative acute myocardial infarction, one suffered nonfatal pulmonary embolism and one had deep venous thrombosis. No aortic-related deaths and/or reinterventions occurred during the median follow-up of 32 months.

CONCLUSIONS

Acute siIAAD is a rare event which affects mostly male smokers with hypertension. Open surgery is a technically demanding procedure with acceptable complication rates and should be performed in specialized high-volume centers for the treatment of aortic disease. Future efforts to establish a multicenter registry to evaluate the prevalence of the disease and treatment options could provide better and more comprehensive guidelines for the treatment of acute siIAAAD.

Surgical approaches in juxtarenal and pararenal aortic aneurysms repair

BACKGROUND

In this study, surgical tactic features and juxtarenal and pararenal treatment immediate results were analyzed depending on the use of various surgical approaches.

METHODS

Between 2015 and 2019, a total of 89 patients received surgical treatment, of which 52(58%) had juxtarenal aneurysms and 37 (42%) - pararenal aneurysms. During repairs, three types of surgical approaches were used: midline laparotomy, extended retroperitoneal approach and thoraco-phreno-retroperitoneal approach. The patients were divided into three groups accordingly.

RESULTS

At the immediate postoperative period, mortality rate equaled 2 (2.2%). The reasons were pulmonary embolism and sepsis. Statistically reliable data were obtained, confirming the advantages of midline laparotomic approach over the lateral retroperitoneal ones, which consisted in a shorter operative time, less pronounced pain syndrome, lesser blood loss, fewer postoperative days. The disadvantages were that enteroparesis occurred more often when the midline laparotomy was used in comparison to extended retroperitoneal or thoraco-phrenoretroperitoneal approaches.

CONCLUSION

Thus, open repairs of juxtarenal and pararenal aortic aneurysms have some specific technical and strategical features which are associated with intraoperative renal ischemia. During open surgical intervention, it is important to first consider the possibility of repair with midline laparotomy. However, lateral retroperitoneal approaches can also be used on a case-by-case basis noting their advantages and disadvantages.

Cold Renal Perfusion During Simulation of Juxtarenal Aortic Aneurysm Repair Reduces Systemic Oxidative Stress and Sigmoid Damage in Rats

OBJECTIVES

Juxtarenal aortic surgery induces renal ischaemia reperfusion, which contributes to systemic inflammatory tissue injury and remote organ damage. Renal cooling during suprarenal cross clamping has been shown to reduce renal damage. It is hypothesised that renal cooling during suprarenal cross clamping also has systemic effects and could decrease damage to other organs, like the sigmoid colon.

METHODS

Open juxtarenal aortic aneurysm repair was simulated in 28 male Wistar rats with suprarenal cross clamping for 45 min, followed by 20 min of infrarenal aortic clamping. Four groups were created: sham, no, warm (37 °C saline), and cold (4 °C saline) renal perfusion during suprarenal cross clamping. Primary outcomes were renal damage and sigmoid damage. To assess renal damage, procedure completion serum creatinine rises were measured. Peri-operative microcirculatory flow ratios were determined in the sigmoid using laser Doppler flux. Semi-quantitative immunofluorescence microscopy was used to measure alterations in systemic inflammation parameters, including reactive oxygen species (ROS) production in circulating leukocytes and leukocyte infiltration in the sigmoid. Sigmoid damage was assessed using digestive enzyme (intestinal fatty acid binding protein - I-FABP) leakage, a marker of intestinal integrity.

RESULTS

Suprarenal cross clamping caused deterioration of all systemic parameters. Only cold renal perfusion protected against serum creatinine rise: 0.45 mg/dL without renal perfusion, 0.33 mg/dL, and 0.14 mg/dL (p = .009) with warm and cold perfusion, respectively. Microcirculation in the sigmoid was attenuated with warm (p = .002) and cold renal perfusion (p = .002). A smaller increase of ROS production (p = .034) was seen only after cold perfusion, while leukocyte infiltration in the sigmoid colon decreased after warm (p = .006) and cold perfusion (p = .018). Finally, digestive enzyme leakage increased more without (1.5AU) than with warm (1.3AU; p = .007) and cold renal perfusion (1.2AU; p = .002).

CONCLUSIONS

Renal ischaemia/reperfusion injury after suprarenal cross clamping decreased microcirculatory flow, increased systemic ROS production, leukocyte infiltration, and I-FABP leakage in the sigmoid colon. Cold renal perfusion was superior to warm perfusion and reduced renal damage and had beneficial systemic effects, reducing sigmoid damage in this experimental study.

Juxtarenal Abdominal Aortic Aneurysm: Results of Open Surgery in an Academic Center

BACKGROUND

The objective of the study is to report our experience with conventional surgery for juxtarenal abdominal aortic aneurysms (JRAs) by evaluating incidence of acute renal failure and perioperative mortality. Secondary objectives are to evaluate general morbidity and the need for permanent postoperative dialysis and to assess the influence on long-term survival of preoperative risk factors and deterioration of perioperative renal function.

METHODS

A retrospective cohort study of 110 patients with JRA electively treated by open surgery between March 1992 and March 2018 was made. Data were obtained from clinical records, describing demographics, perioperative variables, and results. Acute kidney injury (AKI) was defined as 50% decrease in glomerular filtration rate or two-fold increase in serum creatinine. Multivariate analysis was performed by logistic regression to establish risk factors for renal failure. The influence of preoperative risk factors and deterioration of perioperative renal function on long-term survival was studied using Cox regression model. Descriptive and inferential statistics were used in the analysis.

RESULTS

110 consecutive patients were treated with an average age of 71 years, 82.7% male; 81% hypertensive and 41% active smokers. 46.3% had stage III or higher preoperative chronic kidney disease. Median diameter of the aneurysm was 5.7 cm. Interruption of bilateral renal flow was required in 73 patients (66.4%) and unilateral in 37 (33.6%). The average renal clamping time was 34.5 min. AKI occurred in 9 patients (8.2%). Two patients (1.8%) required postoperative dialysis, one of them permanent. Median hospital stay was 7 days. Thirty-three patients (30%) had at least one complication. Postoperative mortality was 2.7% (3 patients), two of them developed AKI. Multivariate analysis established a longer operative time and need for renal revascularization as independent risk factors for AKI. In the survival analysis, age, cerebrovascular disease, chronic obstructive pulmonary disease, and perioperative AKI were identified as risk factors for long-term mortality.

CONCLUSIONS

JRA open surgical repair can be performed with low morbidity and mortality. Although transient acute renal dysfunction may be relatively frequent, the need for hemodialysis is low. Our study is a reference point to compare with endovascular repair.

Long-term fate of renal function after open surgery for juxtarenal and pararenal aortic aneurysm

BACKGROUND

Although the indications for endovascular aneurysm repair for abdominal aortic aneurysm have been expanding, our primary strategy for pararenal and juxtarenal abdominal aortic aneurysm (P/JRAA) is open surgery (OS). One consequence of OS for P/JRAA is transient renal ischemia owing to renal artery clamping, which can be followed by acute kidney injury (AKI). Prior studies referred to the impact of renal ischemia on AKI, but they have rarely evaluated longer-term renal function. This study focused on a chronic renal decline (CRD) during follow-up.

METHODS

A retrospective review of our series of P/JRAA treated with OS from 2007 to 2015. Patients on hemodialysis at the time of surgery were excluded. Preoperative renal function was estimated using the chronic kidney disease (CKD) staging system. Postoperative AKI was defined by the RIFLE criteria (Risk, Injury, Failure, Loss of function, End-stage renal disease). CRD was defined as progression in CKD stage or estimated glomerular filtration rate (eGFR) decline of >20%.

RESULTS

Among 451 elective OS, 111 underwent repair for P/JRAA. Three patients were excluded because of preoperative hemodialysis. Consequently, 108 patients were enrolled. Preoperatively, 41 patients (38.0%) had CKD stage 3 (eGFR < 60 mL/min/1.73 m²). Eight patients (7.2%) were in stage 4 (eGFR < 30 mL/min/1.73 m²). Proximal clamping was supraceliac (6 patients), suprarenal (34 patients), and inter-renal (68 patients). The median renal ischemic time was 33 minutes. The left renal vein was divided in 24 patients. Fourteen renal arteries in 14 patients were revascularized. Cold renal perfusion was applied in 11 patients. One in-hospital death was excluded from these analyses. AKI was observed in 20 patients (18.7%). One patient required temporary hemodialysis. During a median renal function follow-up for 24.5 months (interquartile range, 3.34-48.4), 17 patients (15.9%) had CRD. One patient required hemodialysis 5 years after surgery. In univariate analysis, CKD stages 3 and 4 were significant predictors for CRD (P = .014 and P < .001, respectively). Cold renal perfusion was associated with a higher risk of CRD (P = .047). On multivariate analysis, preoperative CKD stage 3 (hazard ratio, 4.22; 95% confidence interval, 1.10-16.3; P = .036) and stage 4 (hazard ratio, 59.72; 95% confidence interval, 10.13-352.0; P < .001) were identified as risk factors. In patients with CKD stage ≤2, the estimated freedom from CRD at 5 years was 96.6 ± 3.4%.

CONCLUSIONS

CKD stage ≥3 was a significant risk for CRD after OS for P/JRAA. Renal artery clamping seemed innocuous for patients with a preoperative eGFR of ≥60 mL/min/1.73 m² in terms of CRD. No significant impact of left renal vein division on CRD was confirmed.

Treatment of Abdominal Aortic Pathology

Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.

Results of open pararenal abdominal aortic aneurysm repair: single centre series and pooled analysis of literature

Objectives Endovascular treatment of pararenal abdominal aortic aneurysm has gained terrain over the past decade, despite the substantial need for reinterventions during follow-up. However, open repair is still a well-established treatment option. With the current study we report the results of a consecutive series of elective primary open pararenal abdominal aortic aneurysm repair in a tertiary vascular referral centre, combined with an overview of current literature and pooled data analysis of perioperative mortality of open and endovascular pararenal abdominal aortic aneurysm repair. Methods A retrospective analysis of a prospective database of all elective open pararenal abdominal aortic aneurysm repairs in the St. Antonius Hospital between 2005 and 2014 was performed. Primary endpoint was 30-day mortality. Secondary endpoints were 30-day morbidity, new onset dialysis, reintervention free survival, and overall survival during follow-up. Results Between 2005 and 2014, 214 consecutive patients underwent elective open pararenal abdominal aortic aneurysm repair. Mean age was 69.8 (±7.1) years, 82.7% (177/214) were men, and mean abdominal aortic aneurysm diameter was 62 (±11) mm. Thirty-day mortality was 3.4%. Thirty-day morbidity was 27.1%, which predominantly consisted of pneumonia (18.7% (40/214)), cardiac events (3.3% (7/214)), and new onset dialysis (2.8% (6/214)). Estimated five-year overall survival rate was 74.2%. 0.9% (2/214) of patients required abdominal aortic aneurysm-related reintervention, and an additional 2.3% (5/214) required surgical repair of an incisional hernia. Pooled analysis of literature revealed a 30-day mortality of 3.0% for open pararenal repair and 1.9% for fenestrated endovascular repair. Conclusion Open pararenal abdominal aortic aneurysm repair in the era of increasing endovascular options results in acceptable perioperative morbidity and mortality rates. Mid-term reintervention rate is low compared to fenestrated endovascular aneurysm repair. Expertise with open repair still remains essential for treatment of pararenal abdominal aortic aneurysms in the near future, especially for those patients that are declined for endovascular treatment.

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.

Hypothermic renal perfusion during aortic surgery reduces the presence of lipocalin-2 and preserves renal extraction of dimethylarginines in rats

Cold perfusion through the renal arteries during renal ischemia has been suggested to diminish postoperative renal damage after juxtarenal aortic aneurysm repair. As the kidneys play a key role in dimethylarginine metabolism, which in turn is associated with renal hemodynamics, we hypothesized that the protective effect of cold perfusion is associated with a preserved renal extraction of dimethylarginines. Renal ischemia was induced in three groups of anesthetized Wistar rats ( n = 7/group), which underwent suprarenal aortic clamping (45 min) with no perfusion ( group 1), renal perfusion with 37°C saline ( group 2), or renal perfusion with 4°C saline ( group 3), respectively, followed by 90 min of renal reperfusion in all groups. The sham group had no clamping. In group 3 (renal ischemia with cold perfusion), postoperative serum creatinine levels as well as the presence of luminal lipocalin-2 and its associated brush-border damage were lower compared with groups 1 and 2 ( P < 0.05). Also, renal extraction of asymmetrical (ADMA) and symmetrical (SDMA) dimethylarginine as well as the arginine/ADMA ratio, which defines the bioavailability of nitric oxide, remained intact in group 3 only ( P < 0.04). The arginine/ADMA ratio correlated with cortical flow, lipocalin-2, and creatinine rises. Warm and cold renal perfusion ( groups 2 and 3) during ischemia were similarly effective in lowering protein nitrosylation levels, renal leukocyte accumulation, neutrophil gelatinase-associated lipocalin (NGAL) expression in distal tubules, and urine NGAL ( P < 0.05). These data support the use of cold renal perfusion during renal ischemia in situations where renal ischemia is inevitable, as it reduces tubular damage and preserves renal extraction of dimethylarginines. Renal perfusion with saline per se during renal ischemia is effective in diminishing renal leukocyte accumulation and oxidative stress.

Infrarenal aortic-clamping after renal ischaemia aggravates acute renal failure

BACKGROUND

Renal failure is a frequent complication of juxtarenal abdominal aortic aneurysm (JAA)-repair. During this operation, suprarenal aortic-clamping is followed by infrarenal aortic-clamping (below renal arteries) to restore renal flow, while performing the distal anastomosis. We hypothesized that infrarenal aortic-clamping, despite restoring renal perfusion provokes additional renal damage.

MATERIALS AND METHODS

We studied three groups of rats. After 45min of suprarenal aortic-clamping, group 1 had renal reperfusion for 90min without aortic-clamps (n=7). In group 2, 45min of suprarenal aortic-clamping with a distal clamp on the aortic-bifurcation was followed by 20min of infrarenal aortic-clamping. Renal reperfusion was continued for 70min without aortic-clamps (i.e. 90 min of renal reperfusion; n=8). The sham-group had no clamps (n=7). We measured renal haemodynamics, functional parameters and tissue damage.

RESULTS

On suprarenal aortic-clamp removal, renal artery flow, cortical flow and arterial pressures were higher in group 2 than in group 1. We detected increased tubular brush border damage, luminal lipocalin-2 and 30-60% higher renal protein nitrosylation in group 2 when compared to group 1 (P<0·05). Group 2 showed more release of asymmetrical dimethylarginine (ADMA) from the kidneys in the renal vein, therefore indicating diminished clearing capacity (P<0·001). Arginine/ADMA-ratio, which defines the bio-availability of nitric oxide, tended to be lower in group 2 and correlated with renal flow. Furthermore, there were no significant differences found in creatinine levels and renal leucocyte accumulation between group 1 and 2.

CONCLUSIONS

Additional infrarenal aortic-clamping leads to increased renal damage and oxidative stress, despite adequate perfusion of kidneys after suprarenal aortic-clamping. This study indicates that the clamping sequence used in JAA-repair causes more than simple renal I/R-injury.

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

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.

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.