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OBJECTIVES: To compare outcomes between patients who had supra-superior mesenteric artery (SMA) versus supra-celiac clamping, undergoing open aortic reconstruction (OAR) for both aneurysmal and occlusive aortic diseases.
METHODS: A retrospective review from 2001 to 2012 identified 51 patients who underwent OAR with either a supra-celiac (SC) or supra-SMA (SS) aortic cross-clamping (AXC). All patients who had infra-SMA AXC were excluded. An outlier in SS-AXC group (due to young age of 42) was excluded because of inability to match with SC-AXC patients with tolerance. A 1:2 propensity score-based matching between SS-AXC and SC-AXC was performed to adjust for risk factors including sex, age, indication, coronary artery disease, hypertension, diabetes, renal insufficiency and peripheral vascular occlusive disease (PVOD).
RESULTS: Sixteen SS-AXCs were matched with 32 SC-AXCs. Average age was 69.2±93.4 years (range 44.0-87.6), and males constituted 63%. Baseline characteristics were matched, except for the incidence of PVOD (69% vs 25%, p=0.005). Indications for OAR were aneurysm (n=42, 87%) and occlusive disease (n=6, 13%). Intra-operatively, there was no difference in operative times (316 min vs 280 min, p=0.27), but the SS-AXC group did have longer renal ischemia time (41.7 min vs. 27.3 min, p=0.035), compared with SC-AXC group. There were no significant differences in intra-operative blood loss (2.26 L vs. 1.54 L, p=0.296) or blood product transfusion requirements (packed red blood cells: 2.6 units vs. 2.9 units, p= 0.765; Cellsaver: 1.18 L vs. 0.87 L, p=0.42). Overall complication rates were also similar (38% SS-AXC vs 47% SC-AXC, p=0.76), including postoperative coagulopathy (25% vs 28%, p=1) or pancreatitis (0% vs 6%, p= 0.54 ). In-hospital mortality rates did not differ between the 2 groups (0% SS-AXC vs 6.3% SC-AXC, p=0.54). Based on Kaplan-Meier analysis, there were no significant differences of surivival probability at 1 year (0.54, 0.73, p=0.29), or 2 years (0.44, 0.54, p=0.581) between the SS-AXC or SC-AXC groups.
CONCLUSIONS: In patients with suitable anatomy, supra-SMA aortic cross clamping may be a safe and effective alternative to supra-celiac clamping for proximal control in open aortic reconstructive procedures.

Comparison of Post-Operative Complications, Including Mortality

Complication	Supra-SMA AXC (%)	Supra-Celiac AXC (%)	p-value
Rise in Creatinine > 0.5 mg/dL	21	44	0.54
Myocardial Infarction	6	19	0.40
Bowel Ischemia	0	9	0.54
Pulmonary Complication	6	19	0.40
Distal Embolization	13	9	1.0
Pancreatitis	0	6	0.55
Coagulopathy	25	28	1.0
In-hospital Mortality	0	6	0.55