A parallel group observational study of Supra-Renal Aortic aneurysm Repair (SRAR), Juxtarenal Aneurysm Repair (JRAR) and Infrarenal Aortic Aneurysm Repair (IRAR). Does Single Suprarenal Artery clamping alter technical and clinical outcome in Para-Renal Aortic Repair?

Objectives: Approximately 60% of IRAs are suitable for endovascular repair. Consequently relative numbers of open para-renal AAAs are mounting. We aim to equate clinical and technical outcome for open JRAR and SRAR with IRAR.
Methods: Of 110 consecutive open AAA repairs from 2002-2005, 64 were IRAR (34 emergent), 46 para-renal AAA of which 16 SRAR (8 emergent), 30 JRAR (8 emergent). All para-renal AAA had left renal vein division. The proximal aortic clamp placed obliquely, preserving blood supply to the highest renal artery, with no perfusion-shunting. Renal arteries were re-implanted in four cases; the IMA in three cases. Peri-operatively we used N-acetylcysteine, intravenous Saline, 20%Mannitol, antibiotics, Heparin, iloprost and cell-saver-auto-transfusion device.
Results: Groups were matched for age (p=0.766, mean+/-SD: IRAR=73+/-7years, JRAR=73.7+/-8years, SRAR=72.1+/-6years), sex (80%male) and mean aneurysm size (p=0.134, IRAR=6.5 +/-1.6cm, JRAR=7.1 +/-1.6cm, SRAR=7+/-1.9cm). Using multivariate analysis, only Diabetes was associated with adverse outcome (p=0.02, RR=0.35 (95%CI: 0.14-0.84)). Post-operative renal-impairment rates did not vary significantly (IRAR 25%, JRAR=20% SRAR 25%, p=0.863).
Mean hospital stay was similar between groups. (p=0.166, IRAR=20.6+/-20.9 days, JRAR=15.2+/-9.8days, SRAR=26.4+/-25.5days), as was ICU/HDU stay (p=0.373, IRAR=8.3+/-17.5days, JRAR= 5.1+/-5.4days, SRAR=11.1+/-9days)

3-year elective-survival-rate for SRAR was 100%. 3-year-rates for IRAR and JRAR were similar (82.1% v 81.7%, p=0.852, RR=0.87 [95%CI=0.20-3.74]). 3-year emergency-survival-rate for IRAR (52.9%) were similar to JRAR (53.4%, p=0.973, RR=0.98 [95%CI=0.38-2.51]) and SRAR (62.5%, p=0.701, RR=1.27 [95%CI=0.41-3.97])
Conclusions: Outcomes analogous to IRAR are realistic for JRAR and SRAR with single-renal clamping, left renal vein transfixion, minimal visceral-ischaemia time and peri-operative pharmacological manipulation.