Contemporary results of juxtarenal aneurysm repair

AbstractObjective: The increasing use of aortic endografts predictably will add to the complexity of open abdominal aortic aneurysm (AAA) repair and, therefore, the proportion of surgically treated infrarenal AAAs that are juxtarenal in location (JRA) will grow. This study reviews a single-center experience with JRAs. Methods: Between June 1994 and December 2000, 138 patients underwent elective repair of a JRA, comprising 16.1% of 859 consecutive asymptomatic and intact symptomatic nonruptured infrarenal AAAs repaired over the same period. All patients with JRA needed proximal suprarenal clamping (SRC) or supravisceral (SVC) clamping. Patient demographics, selected risk factors, and operative details were recorded. Univariate analyses of selected risk factors for an adverse perioperative event were assessed, and multivariate analyses were performed with linear and logistic regression with backwards selection. Results: SRC was used in 95 patients (69%), and 43 patients (31%) underwent SVC. The mortality rate was 5.1% (7/138) for JRA repair, and 2.8% (20/720) for infrarenal AAA repair (P = .03). The mortality rate was significantly greater for those patients who received SVC compared with SRC (11.6% versus 2.1%; P = .02). Multivariate analysis identified SVC position as the only independent predictor of mortality (odds ratio [OR], 6.1; 95% CI, 1.1 to 32.9; P = .035). Transient renal insufficiency occurred in 39 patients (28.3%), but only eight patients (5.8%) needed dialysis. Patients who had SVC had a significantly greater rate of renal insufficiency than those who received SRC (41.9% versus 22.1%; P = .02). Multivariate analysis showed SVC position (OR, 3.3; 95% CI, 1.4 to 7.8; P = .008), diabetes (OR, 3.7; 95% CI, 1.1 to 12.9; P = .04), and preoperative renal insufficiency (OR, 5.8; 95% CI, 2.2 to 15.4; P < .001) were independent predictors of postoperative renal insufficiency. Renal ischemia during proximal clamping cannot alone explain renal complications because clamp time was shorter in patients with SVC (24.9 ± 2.4 minutes versus 32.2 ± 1.5 minutes; P = .009). Conclusion: JRA repair can be accomplished with a low mortality rate, but a more proximal clamp position may adversely affect outcome in these patients. Postoperative renal insufficiency is related to diabetes, preoperative renal insufficiency, and SVC position. These results suggest SRC is safer than SVC for proximal aortic clamp control of JRAs. Although clamp level must be tailored to patient anatomy, outcome may be improved if the clamp level can be kept distal to the superior mesenteric artery origin. (J Vasc Surg 2002;36:1104-11.