Society For Clinical Vascular Surgery

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Cross Clamp Location and Perioperative Outcomes after Open Abdominal Aortic Aneurysm Surgery
Ali Rteil, MD, Ziad Al Adas, MD, Ali Amro, MD, Loay S. Kabbani, MD, Timothy J. Nypaver, MD, Mitchell R. Weaver, MD, Jens Eldrup-Jorgenson, MD, Alexander D. Shepard, MD.
Henry Ford Hospital, Detroit, MI, USA.

Introduction
Suprarenal aortic clamping during abdominal aortic aneurysm (AAA) repair has traditionally been associated with an increased risk of post-operative renal and cardiac morbidity and mortality. Studies comparing suprarenal vs infrarenal aortic clamping, however, are limited by small sample sizes. By analyzing national VQI data for patients undergoing open infrarenal AAA repair, we sought to better characterize the effects of suprarenal clamping on post-operative outcomes.
Methods
We performed a retrospective analysis of the prospectively collected national Vascular Quality Initiative (VQI)® database for all open infrarenal AAA repairs performed between 2003 and 2017. All operations performed on symptomatic or ruptured AAAs were excluded. AAA repairs were divided into four groups based on the aortic clamp position: infrarenal, above one renal, above two renals, and supraceliac. The groups were univariately compared, followed by multivariate logistic regression for four primary outcomes: acute kidney injury (AKI, defined by the VQI as creatinine increase ≥0.5 mg/dl), post-operative dialysis, cardiac complications (post-operative myocardial infarction, heart failure, or arrhythmia), and 30-day mortality
Results
During the study period, 9068 open AAA repairs were recorded in the VQI; 6422 were elective. Aortic clamp level was infrarenal in 58%, above one-renal in 14%, above two-renals in 21%, and supraceliac in 7%. Multivariate analysis for AKI revealed the following risk factors: suprarenal cross-clamping (all three positions) and clamp time. Post-operative dialysis was associated with supraceliac clamping only. Cardiac complications were associated with supraceliac clamping only, and were not correlated with clamp time. And finally, 30-day mortality was associated with increasing clamp time, but not clamp position.
Conclusions
Although suprarenal clamping, at any level, was associated with an increased risk of AKI, only supraceliac clamping was associated with increased dialysis requirement and cardiac morbidity. Perioperative mortality was unaffected by clamp level.


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