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Objective: To review the outcomes of direct renal artery revascularizations during open aortic aneurysm repair as a potential comparative technique to renal artery endoprostheses placed during branched, fenestrated and parallel endograft repairs of para-visceral aortic aneurysms.
Methods: Open abdominal aneurysm repairs performed from 2010 to 2015 at a single institution were reviewed, including type IV thoracoabdominal, supra- and juxtarenal aneurysms. Infrarenal aneurysms, type 1-3 thoracoabdominal, and infectious aneurysms were excluded, as were patients with preoperative end stage renal disease. Direct renal reconstruction techniques included eversion endarterectomy, bypass, and vessel reimplantation based on patient anatomy. Renal loss was defined by artery occlusion or parenchymal atrophy / length loss >2cm. Student t-test was used for comparison of continuous variables and chi-squared analysis was performed for categorical variables.
Results: 125 patients were included, of which 57 patients (46%) had 76 renal reconstructions (38 single, 19 bilateral) performed during aortic operations. Interventions included endarterectomy (n = 21), trans-aortic stenting (n =2), reimplantation with (n=25) or without (n=17) endarterectomy, bypass (n=4), and ligation (n=7). Mean aneurysm size was 6.4 cm with 23% (n=29) urgent/emergent operations and 20% (n=25) having had a prior infrarenal open or endovascular repair. Overall major complication rate was 50% with significant increase amongst the group requiring renal intervention, primarily accounted for by a 35% early or late dialysis requirement compared to 16% in no renal revascularization patients (P=.01). Overall 30-day mortality was 9% with no difference between renal (10.5%) and no renal (7%) intervention groups. Urgent/emergent operation (P<.001) was associated with increased 30-day mortality (24% v. 4% elective procedures), but prior open or endovascular repair (P=.4) was not. Mean follow up was 26 months with directed imaging out to a mean of 18 months. Early renal loss was observed in 13 (23%) patients undergoing renal intervention versus 1 (1.4%) in those who did not (P<.001), with late renal loss observed in 4 (7%) and 2 (3%) respectively (P=.3). Renal intervention (P = .01) and urgent/emergent status (P=.04) were predictive of dialysis requirement, however amongst those undergoing intervention, renal loss was not associated with an increase in dialysis requirement (P=.2). Of the directed intervention techniques, renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P=.005) and renal loss (P=.04) relative to endarterectomy alone. Mean creatinine on late follow up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not statistically significantly different between those undergoing renal intervention (1.5 mg/dL) and those who did not (1.4 mg/dL).
Conclusion: Renal artery reconstruction at the time of open repair of para-visceral aneurysms is associated with an increased complication rate, primarily driven by occlusion of reimplanted vessels and increased dialysis requirement. However, renal loss does not appear to increase risk of dialysis. Outcomes after elective aortic repair requiring renal reconstruction were respectable but avoidance of left renal reimplantation might be suggested. Current literature reporting renal patency may be overestimated by reliance on glomerular filtration rate or creatinine as a surrogate for directed imaging.