Optimal Operative Strategies in Repair of Juxtarenal Abdominal Aortic Aneurysms

In an effort to identify preoperative and perioperative factors impacting outcome in repair of juxtarenal abdominal aortic aneurysm (JRAAA), hospital records and CT scans (for calcification, intraluminal thrombus, and aortic diameter) of all patients undergoing JRAAA repair over the past 10 years were reviewed. The 87 men and 25 women had a mean age of 72, and a mean maximal aortic diameter of 6.2 cm. Renal artery stenosis (RAS) and iliac disease were present in 13 (11%) and 40 patients (35%), respectively. Comorbidities included coronary artery disease (n = 49, 44%), COPD (n = 28, 25%), diabetes mellitus (n = 10, 9%), and preoperative renal insufficiency (PRI; Cr >1.4 mg/dL; n = 14, 12%). A midline incision was used in most of the patients (n = 98,88%). The proximal aortic clamp was placed in the supraceliac (SC) position in 92 (82%) patients, and directly above one or both renal arteries in 20 (18%) patients. The overall mortality was 6% (n = 7). Cardiac complications occurred in 26 patients (23%); pulmonary, in 22 (20%); renal, in 14 (12%); and gastrointestinal, in 10 (9%). No patient experienced mesenteric ischemia. Mean elevation in creatinine was greater in patients with PRI (1.8 mg/dL vs. 0.13 mg/dL, p = 0.04). Mean blood loss (EBL) was 2701 ± 189 cc, and mean LOS was 16.1 ± 1.7 days. Age >70 was associated with increased length of stay (LOS) (12.1 days vs. 18.6 days, p = 0.05) and higher mortality (0 vs. 10%, p = 0.02); otherwise there were no significant relationships between pre- and perioperative parameters and any of the measured outcomes including death, postoperative RI, and LOS. Preferential SC clamping may substantially reduce complications of JRAAA repair (such as mesenteric and renal ischemia) related to proximal cuff disease, but cannot overcome the deleterious affects of advanced age and PRI.