Pararenal aortic aneurysms: The future of open aortic aneurysm repair

Purpose: As endovascular stent graft repair of infrarenal abdominal aortic aneurysms (AAAs) becomes more common, an increasing proportion of patients who undergo open operation will have juxtarenal aneurysms (JR-AAAs), which necessitate suprarenal crossclamping, suprarenal aneurysms (SR-AAAs), which necessitate renal artery reconstruction, or aneurysms with associated rena l artery occlusive disease (RAOD), which necessitate repair. To determine t he current results of the standard operative treatment of these patterns of pararenal aortic aneurysms, we reviewed the outcome of 257 consecutive pat ients who underwent operation for JR-AAAs (n = 122), SR-AAAs (n = 58), or R AOD (n = 77). Methods: The patients with SR-AAAs and RAOD were younger (67.5 +/- 8.8 year s) than were the patients with JR-AAAs (70.5 +/- 8.3 years), and more patie nts with RAOD were women (43% vs 21% for JR-AAAs and SR-AAAs). The patient groups were similar in the frequency of coronary artery and pulmonary disea se and in most risk factors for atherosclerosis, except hypertension, which was more common in the RAOD group. Significantly more patients with RAOD h ad reduced renal function before surgery (51% vs 23%). Supravisceral aortic crossclamping (above the superior mesenteric artery or the celiac artery) was needed more often in patients with SR-AAAs (52% vs 39% for RAOD and 17% for JR-AAAs). Seventeen patients (7%) had undergone a prior aortic reconst ruction. The most common renal reconstruction for SR-AAA was reimplantation (n = 37; 64%) or bypass grafting (n = 12; 21%) and for RAOD was transaorti c renal endarterectomy (n = 71; 92%). Mean AAA. diameter n as 6.7 +/- 2.1 c m and was larger in the JR-AAA. (7.1 +/- 2.1 cm) and SR-AAA (6.9 +/- 2.1 cm ) groups as compared with the RAOD group (5.9 +/- 1.7 cm). Results: The overall mortality rate was 5.8% (n = 15) and was the same for all the groups. The mortality rate correlated (P < .05) with hematologic co mplications (bleeding) and postoperative visceral ischemia or infarction bu t not with aneurysm group or cardiac, pulmonary, or renal complications. Re nal ischemia duration averaged 31.6 +/- 21.6 minutes and was longer in the SR-AAA group (43.6 +/- 38.9 minutes). Some postoperative renal function los s occurred in 104 patients (40.5%), of whom 18 (7.0%) required dialysis. At discharge or death, 24 patients (9.3%) still had no improvement in renal f unction and 11 of those patients (4.3%) remained on dialysis. Postoperative loss of renal function correlated (P < .05) with preoperative abnormal ren al function and duration of renal ischemia but not with aneurysm type, cros sclamp level, or type of renal reconstruction. Conclusion: These results showed that pararenal AAA repair can be performed safely and effectively. The outcomes for all three aneurysm types were sim ilar, but there was an increased risk of loss of renal function when preope rative renal function was abnormal. These data provide a benchmark for expe cted treatment outcomes in patients with these patterns of pararenal aortic aneurysmal disease that currently can only be managed with open repair.