- This retrospective study of 199 patients undergoing open repair of juxtarenal aortic aneurysms (JRAAs) compared two techniques for creating the proximal anastomosis
- Removal of all proximal aneurysmal tissue through a beveled anastomosis, with a bypass to the left renal artery, was not associated with lower rates of anastomotic degeneration compared with leaving a small cuff of aneurysmal tissue
- The two techniques did not differ with respect to rates of long-term renal decline or five-year mortality
An unsettled issue in vascular surgery is whether all proximal aneurysmal aortic tissue should be removed during open treatment of juxtarenal aortic aneurysms (JRAAs). The traditional teaching has been to remove all tissue in the hopes of preventing recurrence and the risk of future rupture. However, there are little data about whether surgical technique influences juxta-anastomotic aneurysmal degeneration after open repair.
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Linda J. Wang, MD, MBA, surgical resident, Mark F. Conrad, MD, MMSc, director of Clinical Research in the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital, and colleagues retrospectively compared two techniques for creating the proximal anastomosis during open repair of JRAAs:
- Left renal artery bypass (LRB): removal of all proximal aneurysmal tissue through a beveled anastomosis with a bypass to the left renal artery aneurysm at the level of the renal arteries
- Plication (PLI) of the aneurysm cuff with proximal graft anastomosis sewn up to the renal arteries
The researchers report in the Journal of Vascular Surgery that the more complex LRB technique did not protect against long-term anastomotic degeneration, a decline in renal function or mortality.
The researchers studied 199 patients who underwent elective open JRAA repair at Mass General between January 2007 and March 2015. Patients were eligible for the study if the repair required a proximal aortic clamp that was suprarenal or higher. Exclusion criteria were a ruptured or infected aneurysm or the requirement for an additional mesenteric bypass.
112 (56%) of the patients underwent PLI and 87 (44%) underwent LRB. Their outcomes were assessed through March 2018.
The overall 30-day complication rate was significantly higher in the LRB group than in the PLI group (67% vs. 38%, P < .001). The most common complication was acute kidney injury (AKI; 34% of patients). The rate of AKI was significantly higher after LRB than PLI (47% vs. 23%, P < .001), probably because of the longer renal ischemia time involved in the LRB procedure.
Three patients in the LRB group and one patient in the PLI group died (P = NS).
Of the 96 patients who had both preoperative and postoperative renal function assessments, 24% had a decline in renal function within three years, with no significant difference between the LRB and PLI groups.
Among the 68 patients who had both preoperative and postoperative imaging, the LRB group was significantly more likely than the PLI group to develop right renal artery stenosis or occlusion (30% vs. 3%; P = .002) and left renal artery or bypass occlusion (20% vs. 0%; P = .004). Four of the nine LRB patients who developed right renal artery stenosis or occlusion had significant right renal artery stenosis before the procedure. 15% of patients had anastomotic degeneration (defined as ≥5 mm growth), with no significant difference between the LRB and PLI groups.
Five patients, all in the LRB group, required late intervention for renal stenosis or occlusion.
Five-year follow-up imaging was available on 18 patients in the LRB group and 20 in the PLI group. It was found that:
- Four patients (11%) had anastomotic degeneration, two each in the LRB and PLI groups
- 15 patients (39%) required intervention for a remote aneurysm (LRB, n=5; PLI, n=10)
- 13 of these interventions occurred more than three years after the original surgery
- Five-year survival was 73% in the LRB group and 77% in the PLI group (P = NS)
The approach to open repair of JRAA should be chosen with the goal of preventing the degeneration of the anastomosis. It is reasonable to consider leaving a small cuff of aneurysmal tissue during open repair of JRAAs, particularly in patients with baseline chronic kidney disease.
The LRB technique of sewing into the right renal artery ostium may predispose the patient to right renal artery stenosis. Particular care must be taken not to narrow the right renal artery origin.
Given the 39% incidence of remote aneurysms after repair and the 15% incidence of anastomotic degeneration, interval surveillance is prudent after open JRAA repair, as the Society of Vascular Surgery recommends.
Learn more about the Division of Vascular and Endovascular Surgery
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