A. MEHTA1, T. F. O’Donnell2, R. Schutzer1, E. Trestman1, K. Garg3, J. Mohebali2, J. Siracuse4, M. L. Schermerhorn5, W. D. Clouse6, V. Patel1 2Massachusetts General Hospital,Division Of Vascular And Endovascular Surgery,Boston, MA, USA 3New York University School Of Medicine,Division Of Vascular And Endovascular Surgery,New York, NY, USA 4Boston University,Division Of Vascular And Endovascular Surgery,Boston, MA, USA 5Beth Israel Deaconess Medical Center,Division Of Vascular And Endovascular Surgery,Boston, MA, USA 6University Of Virginia,Division Of Vascular And Endovascular Surgery,Charlottesville, VA, USA 1Columbia University College Of Physicians And Surgeons,Division Of Cardiac, Thoracic, And Vascular Surgery,New York, NY, USA
Introduction: Despite the increasing prevalence of juxtarenal abdominal aortic aneurysms (AAAs), surgical approaches for open repairs continue to vary, especially regarding placement of the proximal aortic clamp. This study assessed whether placing a proximal clamp above both renal arteries versus a single one was associated with worse postoperative renal dysfunction and 30-day mortality.
Methods: We used the 2004-2018 Vascular Quality Initiative, a national, robust, real-world registry, to identify all patients undergoing open repairs of symptomatic or elective juxtarenal AAAs and compared outcomes by clamp site: above one renal artery, above both renal arteries (supra-renal), or above the celiac trunk (supra-celiac). Outcomes included acute kidney injury (AKI, defined as creatinine increase >0.50 mg/dL), new-onset renal failure requiring renal replacement therapy (RRT), and 30-day mortality. We used multilevel logistic regressions, clustered at the hospital level, to adjust for confounding.
Results: We identified 3734 patients (median age 71 years, 70% male, 92% Caucasian), where the median aneurysm diameter was 5.9cm (IQR 5.4-6.8cm). Proximal clamp sites varied: above one renal artery (31%), supra-renal (52%), and supra-celiac (17%). Overall, 30-day mortality was 4.8%, AKI was 20%, and new-onset RRT was 4.0%. Compared to clamping above a single renal artery (Table), supra-renal clamping was associated with increased odds of AKI (OR 1.41 [1.18-1.68]) but not new-onset RRT (OR 1.27 [0.75-2.14]) or 30-day mortality (OR 1.01 [0.69-1.48]). In contrast, supra-celiac clamping was associated with higher odds of both AKI (OR 1.36 [1.01-1.85]) and new-onset RRT (OR 2.00 [1.28-3.12]) and trended towards greater 30-day mortality (OR 1.51 [0.99-2.30]). Every 10-minute increase in intraoperative renal ischemia time raised the odds of all three outcomes: AKI by 7% (3%-11%), new-onset RRT by 11% (5%-17%), and 30-day mortality by 10% (4%-16%).
Conclusion: For patients undergoing open repairs of juxtarenal AAAs, supra-renal clamping relative to clamping above a single renal artery was associated with AKI but not new-onset RRT or 30-day mortality. However, intraoperative renal ischemia time was independently associated with all three postoperative outcomes. Certain patients may benefit from supra-renal clamping versus clamping above a single renal artery if it decreases intraoperative renal ischemia time, for lower rates of new-onset RRT and 30-day mortality.
