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Editor's Choice – Durability of Open Repair of Juxtarenal Abdominal Aortic Aneurysms: A Multicentre Retrospective Study in Five French Academic Centres

Open ArchivePublished:September 14, 2019DOI:https://doi.org/10.1016/j.ejvs.2019.05.010

      Objectives

      With a focus on renal function, the goal of this multicentre study was to assess peri-operative complications and late mortality of open surgical repair (OSR) of juxtarenal abdominal aortic aneurysms (JRAAA).

      Methods

      From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a JRAAA in five French academic centres were evaluated retrospectively. The definition of JRAAA was an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck <10 mm. End points included post-operative death; acute kidney injury (AKI) defined by the RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease) criteria; and long term follow-up with freedom from chronic renal decline (CRD) and any graft related complications. Factors predictive of renal insufficiency were determined by multivariable analysis.

      Results

      Of 315 patients, 292 (92.6%) were men (mean age 68 ± 8 years), and 73 (23.2%) had baseline chronic kidney disease (CKD) with an estimated glomerular filtration rate of <60 mL/min/1.73 m2. The level of aortic clamping was supracoeliac (n = 11), suprarenal (n = 235), or inter-renal above one renal artery (n = 69). The mean duration of renal artery clamping was 24 ± 7 min (range 10–55 min). Eleven patients (3.5%) presented with a renal artery stenosis that was treated conservatively. Perfusion of the renal arteries with a chilled Ringer's solution was used selectively in seven patients (2.2%). The overall 30 day mortality was 0.9% (three patients). AKI occurred in 53 patients (16.8%). Nine patients (2.9%) required temporary dialysis and one patient required chronic dialysis. Predictors of AKI were pre-existing CKD (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.13–4.48; p = .021], diabetes (OR 3.15, 95% CI 1.48–6.71; p = .003), hypertension (OR 3.38, 95% CI 1.33–8.57; p = .01), and age (OR 1.05, 95% CI 1.01–1.10; p = .014). The level of aortic clamping and duration of renal artery clamping were not associated with an increased risk of AKI. The Kaplan–Meier survival estimate was 71% ± 5% at five years. Predictors of CRD during follow up were AKI (hazard ratio [HR] 15.81, 95% CI 5.26–47.54; p = .001), diabetes (HR 4.56, 95% CI 1.57–13.17; p = .005), and pre-existing CKD (HR 2.93, 95% CI 1.19–7.20; p = .019), with freedom from CRD of 89% ± 3% at five years. Surveillance imaging was obtained by computed tomography angiography in 290 patients (92.6%) at a mean follow up of 4.3 ± 2.4 years. Renal artery occlusion occurred in two patients (0.7% of imaged renal arteries). One patient (1.9%) had an aneurysm of the visceral aorta and eight patients had a descending thoracic aneurysm.

      Conclusions

      This multicentre study suggests that in fit patients, open JRAAA repair can be performed with acceptable operative risk with durable results in terms of both graft integrity and preservation of renal function.

      Keywords

      This multicentre study suggests that in fit patients, open juxtarenal abdominal aneurysm repair can be performed with acceptable operative risk and with durable results in terms of both graft integrity and preservation of renal function. Predictors of acute kidney injury (AKI) were pre-existing chronic kidney disease, diabetes, hypertension, and age. The level and duration of renal artery clamping (24 ± 7 min, range 10–55 min) were not associated with an increased risk of AKI in this group of fit patients.

      Introduction

      Since its introduction 20 years ago, endovascular aortic aneurysm repair (EVAR) has gradually replaced open abdominal aortic aneurysm (AAA) repair in patients with suitable anatomy.
      • Lederle F.A.
      • Stroupe K.T.
      • Kyriakides T.C.
      • Ge L.
      • Freischlag J.A.
      Open vs endovascular repair (over) veterans affairs cooperative study group. Long-term cost-effectiveness in the veterans affairs open vs endovascular repair study of aortic abdominal aneurysm: a randomized clinical trial.
      • Burgers L.T.
      • Vahl A.C.
      • Severens J.L.
      • Wiersema A.M.
      • Cuypers P.W.
      • Verhagen H.J.
      • et al.
      Cost-effectiveness of elective endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysms.
      Open repair is now mostly performed in patients with complex aortic anatomy, including those with aneurysms in close proximity to the renal arteries.
      British Society for Endovascular Therapy and the Global Collaborators on advanced stent graft techniques for aneurysm repair (Globalstar) registry. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom.
      • Rao R.
      • Lane T.R.
      • Franklin I.J.
      • Davies A.H.
      Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
      The aim of the study was to assess the outcomes of open surgical repair (OSR), including preservation of renal function and durability of the aortic reconstruction. Considering the increasing use of fenestrated endovascular repair (FEVAR) or parallel graft chimney technique (CH-EVAR) for juxtarenal aneurysms, the present results could provide a benchmark for OSR in fit patients.

      Materials and methods

      From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a juxtarenal abdominal aortic aneurysm (JRAAA) in five French academic centres were evaluated retrospectively (Table 1). A JRAAA was defined as an aortic aneurysm extending up to but not involving the renal arteries (Fig. 1), i.e., with a short neck (<10 mm) necessitating suprarenal or inter-renal aortic clamping.
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
      Patients with suprarenal aortic aneurysm or type IV thoraco-abdominal aneurysm (TAAA) were excluded, as were patients with ruptured, dissected, or connective tissue disorder aneurysm and primary infected aneurysm. Patients with an inflammatory aneurysm (n = 18; 5.7%) were not excluded. During the inclusion period, both open repair and FEVAR/CH-EVAR were available in most of the participating centres, and 58 patients considered unfit for OSR were treated by FEVAR or, in an emergency, by means of a parallel graft in a chimney configuration (CH-EVAR). Unfit patients excluded from the study were those with severe respiratory disease (forced expiratory volume in 1 s [FEV1] < 1 L), recent myocardial infection, cardiac failure with left ventricular ejection fraction (LVEF) < 40%, and patients on chronic haemodialysis. As both open and endovascular repair were available in the five participating centres, patients considered unfit for OSR received endovascular repair. No comparison was attempted between these two groups (OSR and endovascular repair) as age, cardiovascular, and respiratory risk factors were so different that even a propensity method was not applicable.
      Table 1Number of patients undergoing elective open surgical repair of a juxtarenal aortic aneurysm
      Vascular centresPatients

      n = 315
      Toulouse88 (27.9)
      Marseille77 (24.4)
      Poitiers54 (17.1)
      Saint Etienne50 (15.9)
      Clermont-Ferrand46 (14.6)
      Data are provided as n (%).
      Figure 1
      Figure 1A juxtarenal aortic aneurysm was defined as an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck <10 mm (A), necessitating inter-renal (B), suprarenal below the superior mesenteric artery (C), or coeliac (D) clamping.
      Demographic, pre-, intra-, and post-operative data, including clinical presentation, aneurysm extent, operative management, complications, follow up with computed tomography angiography (CTA) imaging, and estimated glomerular filtration rate (eGFR) for renal function, were collected from a review of the electronic medical records by two authors (X.C., J.B.R.).
      The study protocol was approved by the Institutional Review Board of the University Hospital of Toulouse. All patients provided consent for the operation. Once completed and audited, the database was de-identified, and individual consent for the use of the database was waived by the institutional ethics committee.
      Open JRAAA repair was performed under general anaesthesia, with additional epidural anaesthesia according to the anaesthetist's experience. The choice of a transperitoneal or a retroperitoneal approach was decided after reviewing the fine cut (1 mm slices) CTA images of the aorta with three dimensional (3D) reconstructions to select the best location for aortic clamping. The retroperitoneal retrorenal approach was preferred to allow easy clamping of the suprarenal aorta without the obstacles represented by the left renal vein and by the pancreas. The transperitoneal approach was preferred for cases with a right iliac aneurysm or retro-aortic left renal vein. All proximal anastomoses were sewn to the infrarenal aortic cuff just below the renal arteries. For the transperitoneal approach, the left renal vein was divided when necessary, to improve access to the juxtarenal aorta and was re-anastomosed whenever possible, either directly or through a short prosthetic graft at the end of the procedure. The aneurysm was repaired using a straight or a bifurcated knitted polyester graft. During the procedure, an infusion of chilled Ringer solution into the renal arteries was used in seven patients (2.3%).

      Definition and analysis of renal function

      Baseline renal function was stratified according to the Kidney Disease Outcomes Quality Initiative staging for chronic kidney disease (CKD) as normal (stages 1 and 2, with an eGFR > 60 mL/min/1.73 m2) and abnormal (CKD ≥ 3, with an eGFR < 60 mL/min/1.73 m2).
      Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
      KDIGO clinical practice guideline for acute kidney injury.
      Patients in stage 5 or on renal replacement therapy were excluded from the study.

      Acute kidney injury

      Post-operative renal function during hospital stay was estimated using the Risk, Injury, Failure, Loss of function, End stage renal disease (RIFLE) criteria (Table 2).
      • Singbartl K.
      • Kellum J.A.
      AKI in the ICU: definition, epidemiology, risk stratification, and outcomes.
      According to the RIFLE criteria, acute kidney injury (AKI) was defined as a two-fold increase of serum creatinine within one week of aneurysm repair. If the serum creatinine level became less than twice the basal level, the patient was considered to have recovered from AKI.
      Table 2Risk, Injury, Failure, Loss of function, End-stage renal disease (RIFLE) and Acute Kidney Injury Network (AKIN) criteria for acute renal dysfunction
      AKIN criteriaRIFLE criteriaDefinition
      Risk1.5-fold increase in Screat
      Stage 1InjuryTwo-fold increase in Screat
      Stage 2FailureThree-fold increase in Screat
      Stage 3LossComplete loss of kidney function in >4 weeks. All patients receiving temporary renal replacement therapy are considered to have met AKIN “stage 3” and RIFLE “Loss” criteria
      From Singbartl et al.
      • Singbartl K.
      • Kellum J.A.
      AKI in the ICU: definition, epidemiology, risk stratification, and outcomes.
      • Singbartl K.
      • Kellum J.A.
      The Kidney Disease Improving Global Outcomes (KDIGO)Working Group. Acute kidney injury guideline.
      and Bellomo et al.
      • Bellomo R.
      • Kellum J.A.
      • Ronco C.
      Acute kidney injury.
      AKIN = Acute Kidney Injury Network; RIFLE = Risk, Injury, Failure, Loss of function, End-stage renal disease. Screat = serum creatinine concentration.
      Chronic renal decline (CRD) was investigated during follow up. CRD was defined in patients with pre-operative normal renal function (CKD stages 1 and 2) as a sustained drop in eGFR to < 60 mL/min/1.73 m2. In patients with pre-existing CKD (stages 3 and 4) at study entry, renal function decline was defined as an eGFR reduction of >20% or the need for permanent haemodialysis. The eGFR was calculated pre-operatively, at discharge, and repeatedly during follow up.
      • Mills Sr., J.L.
      • Duong S.T.
      • Leon Jr., L.R.
      • Goshima K.R.
      • Ihnat D.M.
      • Wendel C.S.
      • et al.
      Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate.

      End points

      Primary end points included 30 day mortality or any death beyond 30 days during hospitalisation, acute kidney failure, and chronic renal decline. Secondary end points included any respiratory or cardiac complications, any secondary intervention related to the aneurysm repair, or any death due to aneurysm rupture.

      Complications and surveillance

      Assessment of pulmonary risk was made by spirometry in all patients with measurement of FEV1. Respiratory complications included any prolonged intubation (>48 h), re-intubation, and pneumonia.
      All patients underwent cardiac risk stratification before elective open repair. In this study, the designation of coronary artery disease was restricted to a positive history of myocardial infarction or coronary stenting. Myocardial infarction was diagnosed by electrocardiography and biomarker changes (troponins T and I). Cardiac failure was defined by measurement of a LVEF of <40%.
      Surveillance imaging by CTA was obtained in 290 patients (92.6% of survivors) with a mean follow up of 4.3 ± 2.4 years. These patients received two to three CTAs during follow up, and 22 patients (7%) were lost to follow up. All CTAs were performed with fine cuts and included the abdomen and pelvis. The chest was included when possible. All investigators review the CTA as part of routine patient care. They look for any abnormality of and around the prosthesis, patency of the visceral and renal arteries, and any other aneurysm (thoracic aorta or peripheral). In this series, 25 patients (8.6%) underwent non-contrast CT because of renal insufficiency or contrast allergy completed by duplex ultrasonography (DUS), which was also used to check the femoral anastomosis in case of aortofemoral bypass and the popliteal arteries in all patients.
      An aneurysm involving a remote arterial segment was based on the following criteria: thoracic or visceral aorta (≥4 cm); iliac arteries (≥3 cm); and femoral and popliteal arteries (≥2 cm). The last biological samples (serum creatinine, eGFR) were obtained at a mean follow up of 4.1 ± 0.5 years in 301 patients (96% of survivors).

      Statistical analysis

      The set of covariates included in the analyses are shown in Table 3, Table 4. Univariable analysis was performed using the chi square test, and Fisher's exact test was used for categorical data. The t test was used for continuous data with normal distribution and the Mann–Whitney test for continuous data with non-normal distribution. Multivariable analysis of risk factors for AKI was performed by binary logistic regression analysis with the RIFLE criteria as the dependent variable recoded as a binary variable (RIFLE 0–1 vs. RIFLE 2–4). All independent variables were tested for inter-collinearity. Results are reported as the odds ratio (OR) with a 95% confidence interval (CI).
      Table 3Pre-operative characteristics of the studied 315 patients with open surgical repair of juxta-renal aortic aneurysm
      CharacteristicsPatients

      n = 315
      Age – years68 ± 8
      Male gender292 (92.6)
      Smoking264 (83.8)
      ASA category 3–4197 (62.5)
      Hypertension235 (74.6)
      Coronary artery disease47 (14.9)
      Mean LVEF < 40%20 (6.3)
      Chronic obstructive pulmonary disease96 (30.4)
      Diabetes51 (16.2)
      Cerebrovascular disease30 (9.5)
      Hypercholesterolaemia213 (67.6)
      Renal artery stenosis11 (3.5)
      Pre-operative creatinine – μmol/L95 ± 30
      Pre-operative GFR – mL/min/1.73 m274 ± 19
       GFR 15–29
      Severe chronic kidney disease, CKD Working Group (2013).
      5 (1.6)
       GFR 30–59
      Moderate to mild chronic kidney disease.
      68 (21.6)
       GFR ≥ 60
      Normal kidney function.
      242 (76.8)
      Betablockers123 (39.0)
      Statins225 (71.4)
      Antiplatelet agents251 (79.7)
      Data are n (%) or mean ± standard deviation (SD) unless otherwise indicated.
      ASA = American Society of Anesthesiologists; LVEF = left ventricular ejection fraction; GFR = glomerular filtration rate; CKD = chronic kidney disease.
      a Severe chronic kidney disease, CKD Working Group (2013).
      b Moderate to mild chronic kidney disease.
      c Normal kidney function.
      Table 4Operative data of the studied 315 patients with open surgical repair of juxta-renal aortic aneurysm
      CharacteristicsPatients

      n = 315
      Aneurysm diameter (range) – mm59.7 ± 12 (50–130)
      Aortic clamp position
       Above one renal artery69 (21.9)
       Above both renal arteries, below SMA235 (74.6)
       Supracoeliac11 (3.5)
      Incision for aortic approach
       Lumbotomy retroperitoneal164 (52.1)
       Median laparotomy103 (32.7)
       Thoracolombotomy retroperitoneal48 (15.2)
      Total operative time – min194 ± 45
      Clamp time of renal arteries – min24 ± 7
      Clamp time of coeliac aorta – min
      Clamp time of the coeliac aorta in 33 patients with supracoeliac aortic clamping.
      23 ± 6
      Left renal vein division39 (12.4)
      Adjunctive renal artery procedure
      Accessory renal artery re-implantation (n = 4).
      4 (1.3)
      Renal perfusion during clamping7 (2.3)
      IMA re-implantation18 (5.7)
      Blood loss – mL1 100 (225–3 900)
      Type of polyester prosthesis
       Straight
      Straight graft, including three patients with a false aortic anastomotic aneurysm on a previous aortic graft.
      159 (50.5)
       Bifurcated
      Bifurcated graft, including bi-iliac grafts (n = 99) and bifemoral grafts (n = 57).
      156 (49.5)
      Data are n (%) or mean ± standard deviation (SD) or median (interquartile range [IQR]) unless otherwise indicated.
      SMA = superior mesenteric artery; IMA = inferior mesenteric artery.
      a Clamp time of the coeliac aorta in 33 patients with supracoeliac aortic clamping.
      b Accessory renal artery re-implantation (n = 4).
      c Straight graft, including three patients with a false aortic anastomotic aneurysm on a previous aortic graft.
      d Bifurcated graft, including bi-iliac grafts (n = 99) and bifemoral grafts (n = 57).
      Overall survival and freedom from CRD were analysed by the Kaplan–Meier method. Regarding CRD, the log rank test was used to compare the CKD and RIFLE groups. To adjust for the analysis of risk factors for CRD, a Cox regression model was run after checking the proportional hazards assumptions. Results are reported as the hazard ratio (HR) with a 95% CI. For all statistical analyses, p < .05 was considered significant. SPSS 25 (IBM, Armonk, NY, USA) was used for the analysis.

      Results

      Demographic data

      Demographic and clinical data are summarised in Table 3. The mean age at operation was 68 ± 8 years (range 45–86 years). In this series, 242 patients (76.8%) had normal pre-operative kidney function (CKD class 1–2, eGFR ≥ 60 mL/min/1.73 m2), 68 patients (21.6%) presented with moderate to mild CKD (class 3, eGFR 30–59 mL/min/1.73 m2), and five patients (1.6%) had severe CKD (class 4, eGFR 15–29 mL/min/1.73 m2). No patient was on haemodialysis. Twenty patients (6.3%) had an LVEF ≤ 40%, with an average value for LVEF of 55% ± 6%.

      Aneurysms

      In this series, 294 AAAs (93.3%) were degenerative, 18 AAAs (5.7%) were inflammatory, and three were anastomotic aneurysms occurring on a previous aortic graft (1.0%). Ten inflammatory aneurysms were painful and tender on palpation. All other aneurysms were asymptomatic. Mean AAA diameter was 59.7 ± 12 mm (range 50–130 mm). Of the five AAAs with a diameter between 50 and 55 mm, three were inflammatory and tender on palpation and two were anastomotic aneurysms on a previous aortic prosthesis.

      Operative data

      Operative data are reported in Table 4. Mean total operating time was 194 ± 45 min.
      A retroperitoneal approach was most commonly performed (n = 212 [67.3%]) using a left lumbotomy (n = 164 [52.1%]) or a short thoracophrenolumbotomy (n = 48 [15.2%]). A transperitoneal approach by a midline laparotomy was used in 103 patients (32.7%).
      Proximal clamping was carried out at the level of the inter-renal aorta, above one renal artery, in 69 patients (21.9%), above both renal arteries and below the superior mesenteric artery in 235 patients (74.6%), and at the level of the supracoeliac aorta in 11 patients (3.5%). The mean renal artery clamping time was 24 ± 7 min (range 18–55 min). In the 33 patients with supracoeliac clamping, the median visceral ischaemic time was 23 ± 6 min (range 18–40 min). Renal perfusion of cold Ringer's solution was used in seven patients (2.2%). The left renal vein was divided in 39 patients (12.4%) and re-anastomosed at the end of the procedure in 31 patients.
      Four patients (1.3%) underwent re-implantation of a large accessory renal artery in the prosthetic graft. In this series, 11 patients (3.5%) presented with a >50% stenosis of one renal artery. No renal artery bypass was attempted in these patients.
      A straight knitted polyester prosthesis was used in 159 patients (50.5%), and a bifurcated prosthesis in 156 patients (49.5%) with an iliac artery aneurysm (n = 99) or with occlusive external iliac artery disease (n = 57). The inferior mesenteric artery was implanted in the aortic prosthesis in 18 patients (5.7%).

      Hospitalisation

      The median post-operative hospital stay was eight days (interquartile range [IQR] 5–24 days) with a median intensive care unit stay of 1.6 days (IQR 0–3 days). There were three in hospital deaths (0.9%) related to colon ischaemia (n = 2) and myocardial infarction (n = 1). Other post-operative complications are reported in Table 5. In all, 46 patients (14.6%) presented with 67 complications. Respiratory complications were the most frequent (n = 44) with artificial ventilation of more than 48 h in 21 patients, 18 of them with a pre-operative FEV1 <70% of the expected value.
      Table 5Postoperative complications in the studied 315 patients with open surgical repair of juxta-renal aortic aneurysm
      VariablePatients

      n = 315
      Deaths
      Patients with a postoperative complication
      Sixty-seven complications occurred in 46 patients, 21 patients had two complications.
      46 (14.6)
      General complications
       Respiratory
      Pneumonia (n = 42), pulmonary embolism (n = 2).
      44 (13.9)
       Myocardial infarction4 (1.3)1 (0.3)
       Stroke3 (0.9)
      Surgical complications
       Colon necrosis2 (0.6)2 (0.6)
       Acute leg ischaemia
      One patient with leg amputation.
      2 (0.6)
       Postoperative haematoma
      Postoperative haematoma requiring surgical drainage.
      4 (1.3)
       Ureteral trauma1 (0.3)
       Evisceration (laparotomy)3 (0.9)
       Lymphocoele scarpa4 (1.3)
      Data are provided as n (%).
      a Sixty-seven complications occurred in 46 patients, 21 patients had two complications.
      b Pneumonia (n = 42), pulmonary embolism (n = 2).
      c One patient with leg amputation.
      d Postoperative haematoma requiring surgical drainage.

      Follow-up

      During a mean follow-up of 4.3 ± 2.4 years (Table 6), 53 patients died (16.8%) from cardiovascular complications (n = 18), stroke (n = 10), and cancer (n = 22), and 22 patients (7%) were lost to follow up. The three year survival rate was 93% ± 2% and the five year survival rate was 71% ± 5%. There has been no aneurysm related death. An incisional hernia (IH) was identified in 30 patients (9.5%), whether by CTA showing a small discontinuity in the fascia layer (n = 17) or as clinical evidence of ventral IH in 13 patients. But as the search for IH was not systematically sought by CTA, it is possible that small IH may have been missed. In this series, three patients required IH repair. No patient developed IH incarceration or intestinal obstruction. Vascular re-intervention was performed in six patients (1.9%), including one patient with removal of an infected prosthetic graft and insertion of an aortic homograft, one patient with renal artery stenting and four patients with iliac artery stenting. The Kaplan–Meier three and five year freedom rates for combined re-intervention/graft or renal artery occlusion were 98% ± 2% and 95% ± 5%, respectively.
      Table 6Late deaths, complications, and re-interventions of 315 patients with open surgical repair of juxta-renal aortic aneurysm during mean follow up of 4.3 years
      VariablesPatients with complications after initial hospitalization

      n = 312
      Deaths occurring in 312 patients surviving after the initial hospitalisation and during a mean follow up of 4.3 years.
      Deaths
      General complications during follow up79 (25.3)53 (16.8)
       Congestive heart failure and myocardial infarction27 (8.6)18
       Stroke16 (5.1)10
       Cancer31 (9.9)22
       Other causes
      Chronic pulmonary occlusive disease (n = 4) and trauma (n = 1).
      5 (1.6)3
      Wound complications30 (9.6)0
       Midline hernia11 (3.5)0
       Lumbotomy hernia18 (5.7)0
      Re-interventions (vascular)6 (1.9)0
       Prosthetic graft infection
      Re-intervention. Replacement of the polyester graft with an aortic homograft.
      1 (0.3)0
       Renal artery stenting1 (0.3)0
       Iliac artery stenting4 (1.3)0
      Data are provided as n (%)
      a Deaths occurring in 312 patients surviving after the initial hospitalisation and during a mean follow up of 4.3 years.
      b Chronic pulmonary occlusive disease (n = 4) and trauma (n = 1).
      c Re-intervention. Replacement of the polyester graft with an aortic homograft.

      Renal outcomes

      Post-operative renal outcomes

      Post-operative renal function was assessed in all patients (Table 7). In this series, 53 patients (16.8%) developed a post-operative AKI according to the RIFLE criteria, with “injury” in 38 patients (12.1%), “failure” in six (1.9%), and “loss” in nine (2.9%) who required temporary renal replacement therapy in the immediate post-operative period. Of these, one patient (0.3%) required permanent haemodialysis.
      Table 7Postoperative acute kidney injury and late renal outcomes in the studied 315 patients with open surgical repair of juxta-renal aortic aneurysm
      VariablePatients

      n = 315
      Early outcomes (hospitalisation)
       Pre-operative eGFR – mL/min/1.73 m274 ± 19
       Pre-operative serum creatinine – μmol/L95 ± 30
       Postoperative peak serum creatinine – μmol/L143 ± 89
      RIFLE criteria
       No risk220 (69.8)
       Risk42 (13.3)
       Injury38 (12.1)
       Failure6 (1.9)
       Loss – temporary renal replacement therapy9 (2.9)
      AKIN criteria
       Stage 138 (12.1)
       Stage 26 (1.9)
       Stage 39 (2.9)
      Late renal outcomes
       Length of follow up – y4.3 ± 2.4
       Chronic renal decline during follow up
      Chronic renal decline: follow up eGFR <60 mL/min/1.73 m2 in patients with pre-operative CKD 1–2 and follow up eGFR reduction >20% or permanent haemodialysis in patients with pre-operative CKD 3–4.
      25 (7.9)
       Permanent haemodialysis1 (0.3)
      Data are provided as n (%) or mean ± standard deviation (SD).
      eGFR = estimated glomerular filtration rate; RIFLE = Risk, Injury, Failure, Loss of function, End-stage renal disease; AKIN = Acute Kidney Injury Network.
      a Chronic renal decline: follow up eGFR <60 mL/min/1.73 m2 in patients with pre-operative CKD 1–2 and follow up eGFR reduction >20% or permanent haemodialysis in patients with pre-operative CKD 3–4.
      Risk factors for post-operative AKI were analysed (Table 8). Of all the variables studied, univariable analysis suggested that pre-existing CKD with eGFR <60 mL/min/1.73 m2, age, diabetes, and hypertension were significantly associated with the risk of post-operative AKI. These four variables were entered in a logistic regression model and all were confirmed as risk factors for AKI.
      Table 8Risk factors for postoperative acute kidney injury (AKI) in 315 patients with open surgical repair of juxta-renal aortic aneurysm
      CharacteristicsRIFLE 0–1 (n = 262)RIFLE 2–4 (n = 53)Univariate analysis

      p value
      Comparison of patients with RIFLE criteria 0–1 with patients presenting an acute kidney injury (AKI) defined as RIFLE criteria 2–4.
      Multivariate analysis
      OR (95% CI)p value
      Diabetes36 (13.7)15 (28.3).0163.15 (1.48–6.71).003
      Hypertension188 (71.8)47 (88.7).0163.38 (1.33–8.57).010
      Age – y67.4 ± 7.871.3 ± 6.9.0011.05 (1.01–1.10).014
      CKD with eGFR <60 mL/min/1.73 m2
      CKD stages 3–4 (eGFR < 60 mL/min/1.73 m2) vs stages 1–2 (eGFR ≥ 60 mL/min/1.73 m2).
      52 (19.8)21 (39.6).0042.25 (1.13–4.48).021
      Beta blockers100 (48.2)23 (43.4).57
      Statins187 (71.4)38 (71.7).97
      Antiplatelet agents209 (79.7)42 (79.2).86
      ASA 3–4160 (61.1)37 (69.8).29
      LVEF < 40%14 (5.3)6 (11.3).12
      AAA diameter – mm62 ± 1159 ± 7.08
      Clamp time – min
      Clamp time of the renal arteries.
      24 ± 726 ± 6.24
      LRVD33 (12.2)6 (13.3).60
      Position of clamps on the aorta.89
       Above one renal artery59 (22.5)10 (18.9)
       Above both renal arteries194 (74.0)41 (77.3)
       Coeliac aorta9 (3.4)2 (3.8)
      Blood loss – mL1337 ± 10571344 ± 1119.96
      Data are n (%) or mean ± standard deviation (SD) unless otherwise stated. Direct logistic regression was performed to assess the impact of a number of covariates on the likelihood that patients will present postoperative AKI. After multicollinearity diagnostics the omnibus tests of model coefficients, containing all predictors, was statistically significant (chi square 31.11 with 5° of freedom, p < .001). The model correctly classified 82.5% of cases. The chi square value for the Hosmer and Lemeshow test was 6.86, with 8° of freedom and a significance level of .551, indicating full support for the model. As shown in the table, four independent variables made a unique statistically significant contribution to the model with a significant OR. The strongest predictors of AKI were hypertension and diabetes with a threefold increase of the risk, followed by age and pre-operative CKD.
      RIFLE = Risk, Injury, Failure, Loss of function, End-stage renal disease; OR = odds ratio; CI = confidence interval; CKD = chronic kidney disease; eGFR = estimated glomerular filtration rate; ASA = American Society of Anesthesiologists; LVEF = left ventricular ejection fraction; AAA = abdominal aortic aneurysm; LRVD = left renal vein division.
      a Comparison of patients with RIFLE criteria 0–1 with patients presenting an acute kidney injury (AKI) defined as RIFLE criteria 2–4.
      b CKD stages 3–4 (eGFR < 60 mL/min/1.73 m2) vs stages 1–2 (eGFR ≥ 60 mL/min/1.73 m2).
      c Clamp time of the renal arteries.
      In this series, renal ischaemic time, renal perfusion during aortic clamping, level of proximal clamp sites, and left renal vein division were not associated with an increased risk of AKI as renal clamp time was short in these patients (24 ± 7 min), never exceeding 55 min.

      Risk analysis for CRD

      During a mean follow up of 4.3 ± 2.4 years, CRD was found in 25 patients (7.9%). Thirty-five patients (11.1%) were lost to follow up after four years. The Kaplan–Meier method demonstrated significantly higher freedom from CRD at three years (97% ± 2%) and at five years (96% ± 3%) in patients with pre-operative normal renal function, CKD stages 1 and 2 (eGFR ≥ 60 mL/min/1.73 m2) compared with patients with CKD stages 3 and 4 (eGFR < 60 mL/min/1.73 m2): 93% ± 3% and 81 ± 6%, respectively (log rank 14.7, p = .005) (Fig. 2).
      Figure 2
      Figure 2Cumulative Kaplan-Meier survival of patients without chronic renal decline showing higher freedom from chronic renal decline at three years (97% ± 2%) and at five years (96% ± 3%) in patients with normal pre-operative renal function, chronic kidney disease (CKD) stages 1–2 (estimated glomerular filtration rate [eGFR] ≥ 60 mL/min/1.73 m2) (blue line) vs. Patients with CKD stages 3–4 (eGFR < 60 mL/min/1.73 m2) (red line): 93% ± 3% and 81 ± 6%, respectively.
      Likewise, the Kaplan–Meier method demonstrated that patients without post-operative AKI (RIFLE categories 0–1), have significantly higher freedom from CRD at three years (99% ± 5%) and five years (98% ± 9%) compared with patients with post-operative AKI (RIFLE stages 2–4): 81% ± 6% and 73% ± 7%, respectively (log rank 78.52, p < .001) (Fig. 3). In univariable analysis, in addition to CKD and AKI, age, and diabetes were also significantly associated with risk of CRD. In multivariable analysis, using the Cox proportional hazards method, AKI, CKD and diabetes remained significant predictors of the time dependent risk of CRD that occurred in 25 patients (7.9%) (Table 9). Only one patient needed permanent dialysis (0.3%).
      Figure 3
      Figure 3Kaplan–Meier method showing that patients without post-operative acute kidney injury (AKI) (Risk, Injury, Failure, Loss of function, End stage renal disease [RIFLE] categories 0–1) have significantly higher freedom from chronic renal decline at three years (99% ± 5%) and five years (98% ± 9%) (blue line) compared with patients with post-operative AKI (RIFLE stages 2–4) (red line): 81% ± 6% and 73% ± 7%, respectively.
      Table 9Risk factors for chronic renal decline (CRD) during a mean follow up of 4.3 years in 315 patients with open surgical repair of juxta-renal aortic aneurysm
      CharacteristicsNo CRD

      n = 290
      CRD

      n = 25
      Univariate p valueCox regression
      HR (95% CI)
      A Cox proportional hazards model was run in SPSS (IBM, Armonk, NY, USA) to investigate the relationship between occurrence of CRD and four possible explanatory variables that appear significant on univariate analysis. The full model containing all predictors was statistically significant (chi square 63.74, with 4° of freedom; p < .001). As shown in the table, only three of the independent variables made a unique statistically significant contribution to the model with a significant HR. The strongest predictor of CRD was the occurrence of an acute postoperative kidney insufficiency, followed by diabetes and pre-operative CKD.
      p value
      CKD with eGFR < 60 mL/min/1.73 m2
      CKD stages 3–4 eGFR <60 mL/min/1.73 m2 vs stages 1–2 eGFR ≥60 mL/min/1.73 m2.
      58 (20.0)15 (60.0).0012.93 (1.19–7.20).019
      RIFLE category 2–4 AKI
      RIFLE category 2–4 (AKI) vs RIFLE category 0–1.
      32 (11.0)21 (84.0).00115.81 (5.26–47.54).001
      Diabetes
      Diabetes vs no diabetes.
      42 (14.5)9 (46.0).0144.56 (1.57–13.17).005
      Age at last follow up – y71.7 ± 8.075.7 ± 6.9.0031.64 (0.59–4.59).34
      Hypertension214 (73.8)21 (84.0).34
      Beta blockers114 (39.3)9 (36.0).83
      Statins208 (71.7)17 (68.0).65
      Antiplatelet agents231 (79.7)20 (80.0).99
      Data are n (%) or mean ± standard deviation (SD) unless stated otherwise. CRD = chronic renal decline; HR = hazard ratio; CI = confidence interval; CKD = chronic kidney disease; eGFR = estimated glomerular filtration rate; RIFLE = Risk, Injury, Failure, Loss of function, End-stage renal disease.
      a A Cox proportional hazards model was run in SPSS (IBM, Armonk, NY, USA) to investigate the relationship between occurrence of CRD and four possible explanatory variables that appear significant on univariate analysis. The full model containing all predictors was statistically significant (chi square 63.74, with 4° of freedom; p < .001). As shown in the table, only three of the independent variables made a unique statistically significant contribution to the model with a significant HR. The strongest predictor of CRD was the occurrence of an acute postoperative kidney insufficiency, followed by diabetes and pre-operative CKD.
      b CKD stages 3–4 eGFR <60 mL/min/1.73 m2 vs stages 1–2 eGFR ≥60 mL/min/1.73 m2.
      c RIFLE category 2–4 (AKI) vs RIFLE category 0–1.
      d Diabetes vs no diabetes.

      Surveillance imaging

      Surveillance imaging was obtained in 290 patients (92.6% of survivors) during follow up. CTA imaging revealed one 4 cm aortic aneurysm above the level of the renal arteries and eight aneurysms of the thoracic aorta. Of these, four patients underwent subsequent TEVAR. Two native renal arteries were thrombosed (0.7%). One patient presented with an infected aortic graft and received a cryopreserved aortic homograft. One hypertensive patient with renal artery stenosis and four patients with an iliac stenosis underwent subsequent stenting. There were no anastomotic pseudo-aneurysms identified on follow up imaging. DUS revealed a popliteal aneurysm >25 mm in eight patients. These eight popliteal aneurysms were treated by conventional surgery and eight saphenous vein bypass grafts were performed.

      Discussion

      In this study, the early and long term outcomes of 315 consecutive patients with a JRAAA who received OSR were reviewed. This series reflects the practice of five high volume vascular centres. Contrary to many contemporary studies hindered by an inconsistent definition of JRAAA and meta-analyses mixing JRAAA, pararenal, or type IV TAAA aneurysm in one entity, which is perhaps appropriate for an endovascular repair but not adapted to OSR insofar as these aortic locations have a very different operating risk,
      • Rao R.
      • Lane T.R.
      • Franklin I.J.
      • Davies A.H.
      Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
      Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
      KDIGO clinical practice guideline for acute kidney injury.
      • Singbartl K.
      • Kellum J.A.
      AKI in the ICU: definition, epidemiology, risk stratification, and outcomes.
      • Mills Sr., J.L.
      • Duong S.T.
      • Leon Jr., L.R.
      • Goshima K.R.
      • Ihnat D.M.
      • Wendel C.S.
      • et al.
      Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate.
      • Tinelli G.
      • Crea M.A.
      • de Waure C.
      • Di Tarna G.L.
      • Becquemin J.P.
      • Sobocinski J.
      • et al.
      A propensity matched comparison of fenestrated endovascular aneurysm repair and open surgical repair of pararenal and paravisceral aortic aneurysms.
      this series was limited to patients presenting with a JRAAA extending up to but not involving the renal arteries.
      In the authors’ practice and according to the above definition, JRAAAs account for almost 10% of the AAAs treated. Nowadays, complex endografting is currently recommended for JRAAA, but despite almost constant immediate technical success, FEVAR and CH-EVAR are not devoid of risk, with a post-operative mortality rate of 4% in a series of the highest quality,
      • Rao R.
      • Lane T.R.
      • Franklin I.J.
      • Davies A.H.
      Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
      and freedom from secondary interventions of 70% three years post-operatively.
      British Society for Endovascular Therapy and the Global Collaborators on advanced stent graft techniques for aneurysm repair (Globalstar) registry. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom.
      The present series compares favourably with a low post-operative mortality and a freedom from secondary interventions of 95% ± 5% at five years. These results reinforced the preference for OSR in fit patients with a short aneurysm neck (<10 mm). However, the results should be interpreted bearing in mind the very low proportion of supracoeliac aortic clamping and the relatively short aortic and renal artery clamping times in the entire series.
      The mortality of the current series was low (0.9%), which is in agreement with the findings of Jongkind et al.,
      • Jongkind V.
      • Yeung K.K.
      • Akkersdijk G.J.
      • Heidsieck D.
      • Reitsma J.B.
      • Tangelder G.J.
      • et al.
      Juxtarenal aortic aneurysm repair.
      who found in a review of OSR for JRAAA a rate of post-operative mortality ranging from 0.8% to 6.3%, and long term durability. Open repair for JRAAA, when compared with infrarenal AAA repair, has been shown to have comparable mortality.
      • Landry G.
      • Lau I.
      • Liem T.
      • Mitchell E.
      • Moneta G.
      Open abdominal aortic aneurysm repair in the endovascular era: effect of clamp site on outcomes.
      The most important message that can be drawn from this series is that there is no rationale to propose complex endovascular treatment in fit patients with a JRAAA. The surgical ability in choosing between OSR and endovascular repair according to the risk factors and aneurysm anatomy allowed for improvement of the OSR results. Following the present results and the recommendation made by the European Society for Vascular Surgery,
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
      it is suggested that centralisation to specialised high volume centres with a multidisciplinary team that can offer both complex open and endovascular repair for the treatment of JRAAA is to be recommended.
      However, in this series post-operative complications were not uncommon, particularly respiratory complications (13.9%), which are inevitable after OSR in this elderly population with 83.8% of active smokers.
      In this series, technical surgical details are important: 67% of the operations were performed via a left retroperitoneal approach by an extended lumbotomy and by a short thoracolumbotomy according to the morphology of the patient and the state of the aorta above the renal arteries. In the authors’ view, careful analysis of CTA images with 3D reconstruction of the aorta is of paramount importance in deciding where to clamp the aorta in patients with a JRAAA.
      If the suprarenal aorta was hostile, or the patient obese, the retroperitoneal retrorenal approach was preferred because it provides optimal exposure of the abdominal aorta above the renal arteries and facilitates placement of the proximal aortic clamp above the renal arteries (74.6%), or even above the coeliac trunk (3.5%). Inter-renal clamping, leaving one renal artery open, was done in only 69 (21.9%) patients with a healthy inter- and suprarenal aorta. The left retroperitoneal retrorenal approach also presented the advantage of being free of the left renal vein and of the pancreas. The transperitoneal approach was preferred in the case of a right iliac aneurysm or retro-aortic left renal vein.
      In this series, the aortic anastomosis was not always easy to carry out in patients with inter-renal clamping, with the risk of leakage on the posterior aspect of the aortic anastomosis. In addition, an inter-renal aortic clamp too close to the ostia of the unclamped renal artery can distort and compress this artery. The inter-renal aortic clamp also increases the risk of renal embolism in case of hostile JRAAA neck with ulceration and thrombus.
      It is acknowledged that the published literature is not universal regarding the level of aortic clamping in patients with a JRAAA. Indeed, there is a risk of visceral ischaemia in patients with supracoeliac aortic clamping,
      • Nypaver T.J.
      • Shepard A.D.
      • Reddy D.J.
      • Elliott Jr., J.P.
      • Ernst C.B.
      Supraceliac aortic cross-clamping: determinants of outcome in elective abdominal aortic reconstruction.
      • Chiesa R.
      • Tshomba Y.
      • Mascia D.
      • Rinaldi E.
      • Logaldo D.
      • Civilini E.
      Open repair for juxtarenal aortic aneurysms.
      but this series shows that this risk does not apply to JRAAA with a short clamp time of 24 ± 7 min. In addition, the level of aortic clamp was not associated with an increased risk of AKI. As the renal clamp time was short, there was no reason to suggest systematic perfusion of the renal arteries, as recommended by others.
      • Sugimoto M.
      • Takahashi N.
      • Niimi K.
      • Kodama A.
      • Banno H.
      • Komori K.
      Long-term fate of renal function after open surgery for juxtarenal and pararenal aortic aneurysm.
      In patients in whom a transperitoneal approach was used, the left renal vein was divided in 39 patients (12.4%), and as previously shown,
      • Sugimoto M.
      • Takahashi N.
      • Niimi K.
      • Kodama A.
      • Banno H.
      • Komori K.
      Long-term fate of renal function after open surgery for juxtarenal and pararenal aortic aneurysm.
      it had no impact on post-operative renal function.
      Considering renal function, the standard definitions of CKD, AKI, and CRD recommended by the National Kidney Foundation were used.
      Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group
      KDIGO clinical practice guideline for acute kidney injury.
      The disparity of pre-operative eGFR explains why comparisons of the evolution of the mean value of the eGFR or serum creatinine is of little help in these patients. Instead, the RIFLE criteria were used, as recommended by Singbartl et al.,
      • Singbartl K.
      • Kellum J.A.
      AKI in the ICU: definition, epidemiology, risk stratification, and outcomes.
      who have shown that in patients with CKD, even small changes in serum creatinine concentrations could be associated with an increased risk of CRD. In this series, 53 patients (16.8%) presented with an AKI, which is comparable to the 20% found by Deery et al. in a large series of 443 open JRAAA repairs.
      • Deery S.E.
      • Lancaster R.T.
      • Baril D.T.
      • Indes J.E.
      • Bertges D.J.
      • Conrad M.F.
      • et al.
      Contemporary outcomes of open complex aortic aneurysm repair.
      In the present series, logistic regression analysis showed that pre-existing CKD, increased age, hypertension, and diabetes were significant independent predictors of AKI with a twofold risk in patients with CKD and a threefold risk in patients with diabetes or hypertension. Of note, surgical covariates such as the level of the clamp on the aorta, duration of renal clamping, blood loss, and left renal vein division had no impact on the risk of AKI.
      Risk factors for CRD, defined by the same method as other studies,
      • Mills Sr., J.L.
      • Duong S.T.
      • Leon Jr., L.R.
      • Goshima K.R.
      • Ihnat D.M.
      • Wendel C.S.
      • et al.
      Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate.
      • Tran K.
      • Fajardo A.
      • Ullery B.W.
      • Goltz C.
      • Lee J.T.
      Renal function changes after fenestrated endovascular aneurysm repair.
      were analysed with a mean follow up of 4.2 ± 2.4 years. A Cox proportional hazards model demonstrated that AKI (RIFLE categories 3–4) was the strongest predictor of CRD, followed by diabetes and CKD. These results confirm those published by Komshian et al.
      • Komshian S.
      • Farber A.
      • Patel V.I.
      • Goodney P.P.
      • Schermerhorn M.L.
      • Blazick E.A.
      • et al.
      Patients with end-stage renal disease have poor outcomes after endovascular abdominal aortic aneurysm repair.
      It is acknowledged that even with an appropriate open surgical technique, surgeons cannot escape the risk of AKI (16.8%) in such a population with pre-existing hypertension (75%), CKD (23%), and diabetes (16%). Loss of renal function occurred in nine patients (2.9%), among whom, only one required permanent dialysis. In the long term, CRD was observed in 25 of the survivors (8%) with freedom from CRD of 89% ± 3% at five years.
      When interpreting the results, the reader should take into account that this series is limited to JRAAA, for which a large number of authors recommend FEVAR or CH-EVAR, claiming a too high risk of open surgery with subsequent renal dysfunction. Herein, it has been demonstrated, after others, that this is not the case.
      • Tsai S.
      • Conrad M.F.
      • Patel V.I.
      • Kwolek C.J.
      • LaMuraglia G.M.
      • Brewster D.C.
      • et al.
      Durability of open repair of juxtarenal abdominal aortic aneurysms.
      Following two large negative randomised controlled trials,
      The ASTRAL Investigators
      Revascularization versus medical therapy for renal-artery stenosis.
      The CORAL Investigators
      Stenting and medical therapy for atherosclerotic renal-artery stenosis.
      a very conservative attitude was adopted regarding renal artery stenosis with favourable long term results as only one late renal artery stenting was deemed necessary in a patient with worsening hypertension.
      The limitations of this study are related to its retrospective design. Thirty-five patients (11.2%) were lost to follow up, but all causes of death were identified and were not related to surgery (Table 6).
      In conclusion, this multicentre study suggests that open JRAAA repair can be performed with an acceptable operative risk and durable results in terms of both graft integrity and preservation of renal function. In the authors’ opinion, these results can be easily duplicated in all vascular surgery centres with a practice in aortic surgery large enough to maintain their expertise.

      Conflict of interest

      None.

      Funding

      None.

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