Outcomes of Concomitant Renal Reconstruction During Open Para-Visceral Aortic Aneurysm Repair
Mathew Wooster, MD, Martin Back, MD, Shivangi Patel, BS, Murray Shames, MD.
University of South Florida, tampa, FL, USA.
Objective: To review outcomes of renal artery revascularizations during open aortic aneurysm repair as a comparative technique to renal stenting during endograft repairs of paravisceral aortic aneurysms.
Methods: Open aneurysm repairs performed from 2010 to 2015 were reviewed, including type IV thoracoabdominal, supra- and juxtarenal aneurysms. Renal reconstruction technique was determined by patient anatomy. Renal loss was defined by artery occlusion or parenchymal length loss >2cm.
Results: 125 patients were included, of which 57 (46%) had 76 renal reconstructions (38 single, 19 bilateral). Interventions included endarterectomy (n = 21), trans-aortic stenting (n =2), reimplantation with (n=25) or without (n=17) endarterectomy, bypass (n=4), and ligation (n=7). Mean aneurysm size was 6.4 cm with 23% (n=29) urgent/emergent operations and 20% (n=25) having had a prior open or endovascular repair. Overall complication rate was 50% with significant increase amongst the renal intervention group, primarily accounted for by a 35% dialysis requirement compared to 16% in patients without renal revascularization (P=.01). Overall 30-day mortality was 9% with no difference between renal (10.5%) and no renal (7%) intervention groups. Urgent/emergent operation (P<.001) was associated with increased 30-day mortality (24% v. 4% elective procedures), but prior infrarenal repair (P=.4) was not. Mean follow up was 26 months. Early renal loss was observed in 13 (23%) patients undergoing renal intervention versus 1 (1.4%) in those who did not (P<.001), with late renal loss observed in 4 (7%) and 2 (3%) respectively (P=.3). Renal intervention (P = .01) and urgent/emergent status (P=.04) were predictive of dialysis requirement, however renal loss was not associated with an increase in dialysis requirement (P=.2). Renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P=.005) and renal loss (P=.04) relative to endarterectomy alone. Mean creatinine on follow up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not significantly different between those undergoing renal intervention and those who did not.
Conclusion: Renal artery reconstruction is associated with an increased complication rate, primarily driven by increased dialysis requirement. However, renal loss does not appear to increase risk of dialysis. Avoidance of left renal reimplantation might be suggested. Current literature reporting renal patency may be overestimated by reliance on glomerular filtration rate or creatinine as a surrogate for directed imaging.
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