Circumferential Aortic Endarterectomy Followed with Immediate Infrarenal Clamping Obviates Suprarenal Clamping for Juxtarenal Aortoiliac Occlusion

Abstract

Traditional open surgery for juxtarenal aortoiliac occlusive disease (AIOD) requires suprarenal aortic cross-clamping (SRCC), which is associated with high incidence of acute kidney injury (AKI). This study was to compare the outcomes of circumferential aortic endarterectomy followed by immediate infrarenal cross-clamping (IRCC) with the traditional approach of SRCC during surgery for juxtarenal AIOD. A 10-year retrospective review of 87 patients who underwent open surgery for AIOD at our University Medical Center was performed. There were 52 males and 35 females (mean age of 52years). Multivariate analysis was performed to assess operative time, blood loss, incidence of AKI, 30-day mortality, and recurrent aneurysm/pseudoaneurysm. Thirty-seven patients were found to have juxtarenal AIOD, which were divided into SRCC (n=25) and IRCC (n=12). Ten patients from the SRCC developed AKI versus 1 from the IRCC (30% vs. 8.3%, P=0.04). SRCC demonstrated increased blood loss (1,681 vs. 591mL, P=0.004). Mean operative time was less in the IRCC group (5 vs. 7hr, P=0.0001). Thirty-day mortality in the SRCC group was 1 and 0 in the IRCC group, respectively. Recurrent aneurysm or pseudoaneurysm was not identified in endarterectomized aorta up to 4-year follow-up. Circumferential aortic endarterectomy followed with immediate IRCC is a feasible, safe, and effective approach for juxtarenal AIOD in properly selected patients. It may be associated with lower rates of AKI, intraoperative bleeding, operating room time, and length of hospital stay, when compared with the traditional SRCC.