Factors affecting outcomes of open surgical repair of pararenal aortic aneurysms: A 10-year experience

Purpose: Few large series document surgical outcomes for patients with pararenal abdominal aortic aneurysms (PAAAs), defined as aneurysms including the juxtarenal aorta or renal artery origins that require suprarenal aortic clamping. No standard endovascular alternatives presently exist; however, future endovascular branch graft repairs ultimately must be compared with the gold standard of open repair. To this end, we present a 10-year experience. Methods: Between 1993 and 2003, 3058 AAAs were repaired. Perioperative variables, morbidity, and mortality were retrospectively assessed. Renal insufficiency was defined as a rise in the concentration of serum creatinine by >= 0.5 mg/dL. Factors predicting complications were identified by multivariate analyses. Morbidity and 30-day mortality were evaluated with multiple logistic regression analysis. Results: Of a total of 3058 AAA repairs performed, 247 were PAAAs (8%). Mean renal ischemia time was 23 minutes (range, 5 to 60 minutes). Cardiac complications occurred in 32 patients (13%), pulmonary complications in 38 (16%), and renal insufficiency in 54 (22%). Multivariate analysis associated myocardial infarction with advanced age (P =.01) and abnormal preoperative serum creatinine (> 1.5 mg/dL) (P =.08). Pulmonary complications were associated with advanced age (P=.03), renal artery bypass (P =.02), increased mesenteric ischemic time (P=.01), suprarenal aneurysm repair (P <.0008), and left renal vein division (P =.01). Renal insufficiency was associated with increased mesenteric ischemic time (P =.001), supravisceral clamping (P =.04), left renal vein division (P =.04), and renal artery bypass (P =.0002), but not renal artery reimplantation or endarterectomy. New dialysis was required in 3.7% (9/242). Abnormal preoperative serum creatinine (> 1.5 mg/dL) was predictive of the need for postoperative dialysis (10% vs 2%; P =.04). Patients with normal preoperative renal function had improved recovery (93% vs 36%; P =.0002). The 30-day surgical mortality was 2.5% (6/247) but was not predicted by any factors, and in-hospital mortality was 2.8% (7/247). Median intensive care and hospital stays were 3 and 9 days, respectively, and longer stays were associated with age at surgery (P =.007 and P =.0002, respectively) and any postoperative complication. Conclusions: PAAA repair can be performed with low mortality. Renal insufficiency is the most frequent complication, but avoiding renal artery bypass, prolonged mesenteric ischemia time, or left renal vein transection may improve results.