Print this pageSuprarenal aortic cross clamp position: a reappraisal of its effects on outcomes for open abdominal aortic aneurysm (AAA) repair
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Tec Chong, MD, Andres Schanzer, MD, Louis Nguyen, MD, Michael Conte, MD, Michael Belkin, MD.
Brigham and Women's Hospital, Boston, MA, USA.
Objectives:
We hypothesize that when controlling for the need for adjunctive renal revascularization procedures (RRP; renal endarterectomy, aortorenal bypass or renal artery reimplantation) and baseline renal function, aortic cross clamp position per se would have no impact on the outcomes of open AAA repair.
Methods:
All elective open infrarenal and juxtra/suprarenal AAA repairs performed at our institution between 1990 and 2006 were reviewed retrospectively. Univariate comparison and multivariate regression models were used to analyze the effect of clamp position, suprarenal (SR) versus infrarenal (IR), on major adverse cardiovascular events (MACE within 30 days), renal failure, and 5 year survival.
Results:
Analysis of unweighted data (Table 1) show that 30-day mortality and 5 year survival rates were similar between the SR and IR groups. With propensity score models, perioperative MACE was not statistically different. SR was associated with a greater mean EBL and a greater mean length of stay. While new-onset post-operative renal failure was greater in the SR group as a whole when compared to the IR group, no difference was seen when the SR group was limited to those who did not require RRP The rates of new onset post operative hemodialysis were similar between the SR and IR groups.
Table 1
| N | EBL (ml) | 30 day mortality | MACE (Major adverse cardiovascular events) | 5 year survival | Pre operative renal failure | Post operative renal failure | New onset dialysis | LOS (days) | |
| IR | 849 | 1257 | 9 (1.1%) | 79 (9.5%) | 69.1% | 40 (4.7%) | 23 (2.7%) | 7 (0.8%) | 10.7 |
| SR | 171 | 19191 | 3 (1.8%) | 29 (17%)1 | 67.7% | 24 (14.0%)1 | 13 (7.6%)1 | 1 (0.6%) | 12.61 |
| SR (+) RRP | 54 | 2133 | 1 (1.8%) | 14 (25.9%) | 62.6% | 9 (16.7%) | 8 (14.8%) | 1 (1.9%) | 15.8 |
| SR (-) RRP | 117 | 1923 | 2 (1.7%) | 15 (12.8%)3 | 70.7% | 15 (12.8%) | 5 (4.3%)2,3 | 0 (0%) | 11.2 |
| Pre operative renal failure = dialysis dependent or creatinine >2.0mg/dl Post operative renal failure = new onset dialysis or doubling of pre operative creatinine 1p = <0.01 when compared to IR group, other comparisons between SR and IR are p=NS 2p = NS when compared to IR group 3p = <0.05 when compared to SR (+) RRP group | |||||||||
Conclusions:
In AAA repair, SR is well tolerated in patients with juxta/suprarenal AAA. Postoperative renal dysfunction was related to baseline renal status and the use of RRP but not to SR per se. The results from this series are relevant when evaluating future advanced branched and fenestrated endografts.
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