经股动脉带膜支架腔内搭桥治疗动脉瘤的初步应用

目的 探讨带膜支架腔内治疗动脉瘤的临床意义。方法 应用进口及自制带膜支架,在透视下经股动脉放置在动脉瘤的恰当位置上,实现动脉瘤的腔内搭桥。结果 ４例胸主动脉瘤,１例累及肾动脉、肠系膜上动脉及腹腔动脉的腹主动脉瘤及１例髂动脉瘤应用直筒状带膜支架;５例肾动脉下腹主动脉瘤应用分叉状带膜支架腔内治疗,即刻效果满意。随访３～１９个月,定期ＣＴ及ＭＲＡ检查。５例术后５～８ｄ出现延迟性发热。１例术后３个月发现有     

Endovascular stent grafting in the presence of aortic neck filling defects: early clinical experience

OBJECTIVE: Although endovascular grafts have been increasingly applied to the treatment of abdominal aortic aneurysms, their use in clinical trials is limited by well-defined anatomical exclusion criteria. One such criterion is the presence of thrombus within the infrarenal neck of an aneurysm, which is thought to (1) prevent the creation of a permanent watertight seal between the graft and the vessel wall, resulting in an endoleak; (2) contribute to stent migration; and (3) increase the risk of thromboembolism. This article summarizes our experience with endovascular abdominal aortic aneurysm exclusion in 19 patients with large aortic aneurysms, significant medical comorbidities, and apparent thrombus extending into the pararenal aortic neck. METHODS: Of 268 patients undergoing abdominal aortic aneurysm repair, 19 (7%; 17 men; mean age, 71 years) demonstrated computed tomographic and angiographic evidence of intramural filling defects at the level of the aortic neck. In no instance did these filling defects extend above the renal arteries. Endovascular grafting was performed through use of a balloon-expandable Palmaz stent and an expanded polytetrafluoroethylene graft, delivered and deployed under fluoroscopic guidance. Follow-up at 3, 6, and 12 months and annually thereafter was performed with computed tomography and duplex ultrasound scan. RESULTS: Spiral computed tomography and aortography revealed an irregular flow-limiting defect, occupying up to 75% of the aortic circumference, in every case. The mean aneurysm size, aortic neck diameter, and neck length before the procedure were 6.1, 2.43, and 1.4 cm, respectively; the mean aortic neck diameter after the procedure was 2.61 cm. No primary endoleaks were observed after graft insertion, and no delayed endoleaks have been detected during follow-up, which ranged from 7 to 48 months (mean, 23 months). In one patient, an asymptomatic renal artery embolus was detected on immediate follow-up computed tomography, and in another patient, an asymptomatic posterior tibial embolus occurred. CONCLUSION: No primary endoleaks, endograft migration, or significant distal embolization were observed after endografting in patients with aortic neck thrombus. The deployment of the fenestrated portion of the stent, above the thrombus and across the renal arteries, allows for effective renal perfusion, graft fixation, and exclusion of potential mural thrombus from the circulation. The presence of aortic neck thrombus may not necessarily be a contraindication to endovascular repair in select patients.     

Repair of juxtarenal para-anastomotic aortic aneurysms after previous open repair with fenestrated and branched endovascular stent grafts

Three patients with juxtarenal para-anastomotic aortic aneurysms after previous open abdominal aortic aneurysm repair were treated with custom-designed fenestrated and branched Zenith endovascular stent grafts. Six renal arteries and two superior mesenteric arteries were targeted for incorporation by graft fenestrations and branches. The fenestration/renal ostium interface was secured with balloon-expandable Genesis stents (n = 5) or Jostent stent grafts (n = 1). Completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. During follow-up, one patient developed asymptomatic renal artery occlusion and underwent further endovascular intervention for type I distal endoleak. Computed tomography at 12 months demonstrated complete aneurysm exclusion in all patients with antegrade perfusion in the remaining target vessels. Fenestrated and branched endovascular stent grafts may be an acceptable alternative to conventional open repair in this group of patients.     

Outcome after celiac artery coverage during endovascular thoracic aortic aneurysm repair: preliminary results

BACKGROUND: Endovascular repair of descending thoracic aortic aneurysms has emerged as an alternative to open repair. Coverage of the left subclavian origin has been reported to expand the proximal sealing zone. We report the planned coverage of the celiac artery origin with a thoracic stent graft to achieve an adequate distal sealing zone. METHODS: All patients undergoing endovascular aneurysm repair are prospectively entered into a computerized database. All patients who underwent thoracic endovascular aneurysm repair with coverage of the celiac artery origin were identified and retrospectively analyzed. End points for evaluation included indications for covering the celiac artery, anatomic features of the distal landing zone, demonstration of collateral circulation between the celiac artery and the superior mesenteric artery, technical success of the procedure, and presence of clinical ischemic symptoms after the procedure. RESULTS: Between March 2005 and May 2006, 46 patients underwent endovascular repair of descending thoracic aortic aneurysms. Seven patients had planned celiac artery coverage with a thoracic stent graft to secure an adequate distal sealing zone. Six patients demonstrated collateral circulation through the gastroduodenal artery between the celiac and superior mesenteric arteries before deployment of the stent graft. One patient had a distal type I endoleak at the conclusion of the procedure related to inadequate sealing at the superior mesenteric artery origin. No type II endoleaks were evident at the final intraoperative angiogram or 30-day computed tomography scan. There were no postoperative deaths, no ischemic abdominal complications, and no clinical spinal cord ischemia. Short-term follow-up (1 to 10 months) has demonstrated no additional endoleaks (type I not fully assessed), no aneurysm growth, and no aneurysm ruptures. CONCLUSION: This limited series supports the suitability, in selected patients, of covering the celiac artery origin for a distal landing zone when the distal sealing zone proximal to the celiac artery is inadequate. We recommend the angiographic evaluation of the collateral circulation between the celiac and superior mesenteric arteries when covering the celiac artery origin is being considered.     

Hybrid repair of thoracoabdominal aortic aneurysm in high-risk patients using a quadrifurcated graft

Surgical treatment for thoracoabdominal aortic aneurysm is still challenging and is associated with a high risk of paraplegia. Hybrid repair with stent graft insertion for the thoracoabdominal aorta excluding the branches of the lumbar and visceral arteries and bypass grafting to the visceral branches has been introduced as a less invasive treatment that reduces the risk of paraplegia. For hybrid repair, it is important to have appropriate management of the revascularized grafts to the 4 visceral arteries with sufficient inflow. We have recently adopted a knitted quadrifurcated graft applied inversely from the abdominal aorta or the iliac artery to the 4 visceral arteries; the celiac, superior mesenteric, and bilateral renal arteries. To date, we have used the graft in hybrid repair of thoracoabdominal aortic aneurysm in 2 high-risk elder patients who had disseminated intravascular coagulopathy and severe renal failure, respectively. We found that a knitted quadrifurcated graft was easy to handle and useful for reducing the number of anastomoses, which were expected to shorten the operation time. Postoperative courses were uneventful without paraplegia in either patient. Postoperative computed tomography showed excellent patency of the inversely applied quadrifurcated graft without any endoleak or migration in the thoracoabdominal stent. In conclusion, revascularization of 4 visceral arteries using a quadrifurcated graft should be considered a preferable option in hybrid treatment for thoracoabdominal aortic aneurysm.     

Endovascular repair of abdominal aortic aneurysms: stent-graft fixation across the visceral arteries.

PURPOSE: Recent studies have suggested that transrenal artery fixation of endovascular stent-grafts is safe and may be a desirable means of reducing the risk of type I endoleaks, particularly those with short infrarenal necks. The close proximity of the superior mesenteric and celiac arteries to the renal arteries may commonly result in the placement of the stent struts across all the vessels of the visceral segment of the aorta. The purpose of this study was to determine the incidence and impact of transvisceral artery fixation during aortic stent-graft deployment for the treatment of abdominal aortic aneurysms (AAAs). METHODS: From January 1997 to June 1999, 192 patients (165 men, 27 women; mean age, 82 years) with AAAs were treated with an endovascular graft secured proximally to the aorta with a long (15 mm) uncovered stent segment (60 Parodi/Palmaz, 132 Talent-LPS). Preoperative and postoperative abdominal aortograms and intravenous contrast enhanced spiral computed tomography (CT) scans were performed. Follow-up CT scans were obtained at 3, 6, and 12 months and yearly thereafter as a means of determining stent position and visceral artery patency RESULTS: In 95 patients (49%), the uncovered stent was at or above the level of the superior mesenteric artery. In 23 patients (12%), the stent extended to the level of the celiac axis. In a mean follow-up period of 25 months (range, 6-44 months), serum creatinine levels remained stable, no stenoses or occlusions occurred in the celiac, superior mesenteric, or renal arteries, and no evidence of renal, hepatic, splenic, or intestinal infarction was present on contrast enhanced spiral CT scans. There were no type I endoleaks. CONCLUSION: Transvisceral fixation of the uncovered proximal aortic stent occurs frequently during deployment of devices designed for transrenal fixation and is associated with no early morbidity. Long-term follow-up is necessary to ensure that there are no late sequelae.     

Hybrid endovascular repair with reconstruction of superior mesenteric and celiac arteries for thoracoabdominal and abdominal aortic aneurysms

A 79-year-old woman presented with sustained thoracolumbar back pain. Contrasted computed tomography (CT) showed a thoracoabdominal aortic aneurysm (TAAA: type I of Crawford classification) and an abdominal aortic aneurysm (AAA) that were not ruptured. Considering her age, the placement of an endovascular stent graft was performed for TAAA at the possible sacrifice of the celiac (CA) and superior mesenteric arteries (SMA). In order to prevent ischemic events, it was necessary that blood supply to the CA and SMA was maintained by placing a graft to each artery from the Y-shaped graft for replacement of AAA. Actually, only CA was sacrificed and coil embolization of CA was needed because of type 2 endoleak. The patient was discharged 17 days after surgery. A hybrid technique, endovascular repair with reconstruction of abdominal branches for TAAA and AAA, can be an alternative procedure for such high-risk operation with multiple aortic aneurysms including TAAA.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Thoracoabdominal aortic aneurysm combined with inferior mesenteric artery aneurysm and occlusion of celiac and superior mesenteric arteries

A 56-year-old man with thoracoabdominal aortic aneurysm combined with inferior mesenteric artery aneurysm and occlusion of celiac and superior mesenteric arteries is presented. Contrast-enhanced computed tomography (CT) and aortography revealed thoracoabdominal aortic aneurysm of 6 cm in diameter, accompanied by inferior mesenteric aneurysm of 3 cm in diameter. Severe calcification of the abdominal aorta and occlusion of the celiac and the superior mesenteric arteries were also noted, whose territories were perfused by collateral circulation of the inferior mesenteric artery. At the operation, orifice of the left renal artery was stenosed by severe calcification, which was resected. Because of severe adhesion around the origins of celiac and superior mesenteric arteries, they were left unrevascularized. The thoracoabdominal aortic aneurysm was replaced with an Dacron tube graft, whose side branch was anastomosed to the inferior mesenteric artery after resection of its aneurysm. The postoperative course was uneventful, and no symptoms of intestinal ischemia were noted. As blood supply to the abdominal viscera mostly depends on the inferior mesenteric artery, careful follow-up is necessary.     

Management of pararenal aneurysms of the abdominal aorta

The operative treatment of 77 patients with atherosclerotic aneurysms of the pararenal aorta (54 juxtarenal and 23 suprarenal) is analyzed. Repair of these complex lesions is formidable because of difficult exposure, renal ischemia and myocardial strain as a result of proximal aortic occlusion, and associated renal atherosclerosis with secondary renal functional impairment. Nineteen (25%) patients were normotensive with normal renal function. Sixteen patients (21%) had hypertension alone and 42 (54%) were hypertensive with abnormal renal function. There were multiple renal arteries in 22% of patients. Aortic reconstruction involved infrarenal graft in 27 patients (35%), infrarenal graft plus pararenal aortic endarterectomy (TEA) in 26 (34%), and infra- and pararenal aortic graft in 24 (31%). Twenty-two patients (30%) had normal renal arteries and therefore no renal reconstruction. Of the 55 patients who required combined aortic and renal artery repair, 24 required renal artery repair because of involvement of the renal arteries by the aneurysm and 31 because of atherosclerotic renal artery disease. TEA was the most common technique of renal artery repair (54 of 93 arteries, 58%), followed by reimplantation (18 arteries) and prosthetic graft (13). The perioperative mortality rate was 1.3%. The perioperative morbidity rate was 28% and consisted principally of renal insufficiency (23%). This was usually transient (44%) and (89%) mild. Renal morbidity was adversely affected by renal ischemia status, severity of renal artery disease and extent of renal revascularization. Following reconstruction, hypertension was cured or improved in 77% of patients and abnormal renal function was cured or improved in 46% and stabilized in an additional 39% of patients. These results show that combined aortic aneurysm repair and renal artery reconstruction can be performed with minimal mortality and an acceptable morbidity. Aggressive intraoperative monitoring is necessary to minimize myocardial complications. Careful attention must be paid to the technical details of the reconstruction, especially in minimizing renal ischemia, to reduce the subsequent incidence of renal function deterioration.     

Staged Thoracic and Abdominal Aortic Aneurysm Repair Using Stent Graft Technology and Surgery in a Patient with Acute Renal Failure

2 ) angiography identified a saccular thoracic aortic aneurysm, right renal artery stenosis, left renal artery occlusion, an infrarenal aortic aneurysm, celiac artery, and inferior mesenteric artery (IMA) orificial stenoses. Via an anterior retroperitoneal approach, bilateral renal artery thromboendarterectomy, infrarenal aortic aneurysmectomy, and IMA reimplantation were performed. The patient's tortuous iliac arteries were straightened to permit future passage of a thoracic stent graft by mobilizing the aortic bifurcation and anastomosing it to a Dacron graft within 4 cm of the renal vessels. Two weeks later, a stent graft was placed via a femoral incision utilizing CO₂ angiography, successfully excluding the saccular thoracic aneurysm. Recovery from both procedures was quick, with rapid return of renal function, and alleviation of the hypertension. At 8 months follow-up, his renal arteries and aorta are patent.     

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

Objective

The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications.

Should aortography be used routinely in the elective management of abdominal aortic aneurysm?

Until recently aortography was performed routinely for elective abdominal aortic aneurysm at our institution. A death resulting from this procedure prompted us to evaluate this policy by a retrospective study of 105 elective aneurysm patients. These studies identified 21 renal artery stenoses, 2 renal artery aneurysms, 2 cases of multiple renal arteries, 8 celiac stenoses, 6 superior mesenteric artery stenoses or occlusions, and a number of peripheral occlusive processes and associated iliac aneurysms. However, the impact of these findings on surgical management was limited to six renal artery reconstructions: one for reimplantation of a renal artery arising from the aneurysm, one for serious hypertension, and four in normotensive patients with severe arterial stenosis. No celiac or mesenteric reconstructions were undertaken, and no visceral complications ensued. In only one patient, the one with renal artery reimplantation, was the angiographic information unsuspected and significant for operative management. This did not appear to justify the risk and expense involved in routine preoperative aortography.     

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 renal artery occlusive disease (RAOD), which necessitate repair. To determine the current results of the standard operative treatment of these patterns of pararenal aortic aneurysms, we reviewed the outcome of 257 consecutive patients who underwent operation for JR-AAAs (n = 122), SR-AAAs (n = 58), or RAOD (n = 77). METHODS: The patients with SR-AAAs and RAOD were younger (67.5 +/- 8.8 years) than were the patients with JR-AAAs (70.5 +/- 8.3 years), and more patients 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 disease and in most risk factors for atherosclerosis, except hypertension, which was more common in the RAOD group. Significantly more patients with RAOD had 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 reconstruction. The most common renal reconstruction for SR-AAA was reimplantation (n = 37; 64%) or bypass grafting (n = 12; 21%) and for RAOD was transaortic renal endarterectomy (n = 71; 92%). Mean AAA diameter was 6.7 +/- 2.1 cm 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 complications (bleeding) and postoperative visceral ischemia or infarction but not with aneurysm group or cardiac, pulmonary, or renal complications. Renal 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 loss 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 function and 11 of those patients (4.3%) remained on dialysis. Postoperative loss of renal function correlated (P <.05) with preoperative abnormal renal function and duration of renal ischemia but not with aneurysm type, crossclamp 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 similar, but there was an increased risk of loss of renal function when preoperative renal function was abnormal. These data provide a benchmark for expected treatment outcomes in patients with these patterns of pararenal aortic aneurysmal disease that currently can only be managed with open repair.     

Dissected thoracoabdominal aortic aneurysm repair with modified parallel endografting

A 67-year-old woman with a prior history of aortic dissection was admitted for enlarging the thoracoabdominal aortic aneurysm (TAAA). She has received multiple treatments including Bentall procedure, hemiarch replacement, and subsequent endovascular procedures for the closure of re-entry. Preoperative computed tomography revealed previously implanted thoracic endograft from distal arch to superior mesenteric artery with dissected TAAA measuring up to 70 mm in diameter. Re-entry was observed at bilateral common iliac arteries. The patient was successfully treated by endovascular treatment using a fenestrated stent graft to obtain a landing zone for parallel endograft technique to the iliac arteries for the closure of re-entry.     

Surgical treatment of the thoracoabdominal aortic aneurysms with Marfan's syndrome

We experienced two cases of the thoracoabdominal aortic aneurysms with Marfan's syndrome. Case 1; The 31 year-old-woman was operated upon by Crawford's procedure, which includes reconstruction of renal arteries, superior mesenteric artery, and celiac artery using temporary shunt. Although she had been well for three years after the operation before she developed acute aortic dissection, she could not tolerate the Bentall's procedure on it. Case 2; The 37 year-old woman was operated upon for dissecting aneurysm (DeBakey IIIb). The procedure included replacement of the descending and abdominal aorta by Dacron graft. Four years after the operation, enlargement of residual false lumen had been observed, which caused its dehiscence just proximal to the abdominal aortic anastomosis. The Crawford's procedure, which includes reconstruction of renal arteries, superior mesenteric artery, and celiac artery using temporary shunt was employed for repair of the remaining thoracoabdominal aortic aneurysm. She is well now 5 months after surgery. We conclude that cardiovascular changes in patients with Marfan's syndrome must be observed carefully because of its high recurrent rate after initial surgery. The operation at proper time and a careful observation of cardiovascular changes will improve the prognosis.     

Surgical treatment of pararenal aortic aneurysms in the elderly

AIM: Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature. METHODS: Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery. RESULTS: Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days. CONCLUSION: Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.     

Endovascular Repair of a Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery and the Superior Mesenteric Artery

We present a successful endovascular repair of a thoracoabdominal aortic aneurysm (TAAA) involving the celiac artery and the superior mesenteric artery. After the intentional occlusion of the celiac artery, an Inoue stent graft with a side arm to the superior mesenteric artery was implanted. Management of the visceral arteries in the endovascular repair of TAAA was highlighted.     

Multiple mycotic arterial aneurysms involving the left anterior descending coronary artery following mitral and aortic valve endocarditis: A case report

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.     

Supraceliac aortic occlusion: A safe approach to pararenal aortic aneurysms

Twenty-four patients who underwent surgery for pararenal aortic aneurysms between January 1992 and April 1997 are reviewed. Eighteen patients had primary atherosclerotic aneurysms, three patients had symptomatic infected aneurysms, two patients had an aneurysm proximal to a prior aortic repair, and one patient had a pseudoaneurysm of a proximal aortic graft anastomosis. Thirteen patients underwent elective operation, five had an urgent operation, and six patients underwent an emergency procedure. Five patients had the proximal aortic clamp placed between the renal arteries (Group I), three patients had it placed between the superior mesenteric and the renal arteries (Group II), and 16 patients had it placed in a supraceliac location (Group III). Aneurysm size, age, sex, preoperative blood chemistries (including hemoglobin, hematocrit, liver function studies, and coagulation studies) were similar in all groups. Two patients in Group III were on hemodialysis preoperatively. Preoperative renal function (blood urea nitrogen and creatinine) was the same in all groups. Visceral ischémic time was 43.4 ± 9.37 min to the distal kidney in Group I, 26.6 ± 7.63 min in Group II, and 24.5 ± 6.22 min in Group III. Mean transfusion requirements were similar in all groups. Two patients in Group I required postoperative hemodialysis. No patient in either Group II or III developed renal insufficiency. Mortality was the same in each group but was related to the urgency of operation (elective 7.6%, urgent 40%, emergent 50%). Intrarenal clamping (Group I) was associated with more renal and gastrointestinal complications than either suprarenal or supraceliac clamping. Although suprarenal and supraceliac clamping had similar results, our preference is supraceliac clamping because it is technically easy to achieve and is associated with few end-organ complications.