Invited commentary

Abstract

Management of right renal artery reconstruction during complex aortic aneurysm repair, particularly through a flank or thoracoabdominal exposure, can be challenging and may require orificial endarterectomy for stenotic lesions as well as incorporation of the right renal artery into the suture line as a button, most commonly in conjunction with the superior mesenteric and celiac arteries. The use of intraoperative balloon-expandable stents (BESs) in the visceral arteries during open thoracoabdominal aneurysm repair was first described in 2004 by Lemaire et al,1LeMaire S.A. Jamison A.L. Carter S.A. Wen S. Alankar S. Coselli J.S. Deployment of balloon expandable stents during open repair of thoracoabdominal aortic aneurysms: a new strategy for managing renal and mesenteric artery lesions.Eur J Cardiothorac Surg. 2004; 26: 599-607Crossref PubMed Scopus (31) Google Scholar who reported 93 patients. In that study, however, only 9% of the patients had postoperative imaging. In the current study, Patel et al describe their technique and midterm results in 67 patients who underwent BES placement into the right renal artery during open repair of thoracoabdominal, suprarenal, and juxtarenal aortic aneurysms. I congratulate the authors for “thinking outside of the box” by using this creative technique in an attempt to further improve outcomes in this challenging group of patients. With this article, the group from the Massachusetts General Hospital makes yet another important contribution to the technique of open surgical repair of complex aortic aneurysms, once again emphasizing the need for continued outcomes assessment and improvement in surgical technique. Although the results presented in this study are to be applauded, with 4.4% perioperative mortality, 2.9% paraplegia, and 2.9% permanent renal failure rates, this study has some limitations that deserve further scrutiny. The fundamental questions that remain to be answered are whether this new technique of placing BESs into the right renal artery at the time of open aortic reconstruction improves outcomes in terms of renal dysfunction compared with the previously reported techniques of renal artery endarterectomy and patch inclusion,2Conrad M.F. Crawford R.S. Davison J.K. Cambria R.P. Thoracoabdominal aneurysm repair: a 20-year perspective.Ann Thorac Surg. 2007; 83: S856-S861Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar, 3Safi H.J. Harlin S.A. Miller C.C. Iliopoulos D.C. Joshi A. Mohasci T.G. et al.Predictive factors for acute renal failure in thoracic and thoracoabdominal aortic aneurysm surgery.J Vasc Surg. 1996; 24: 338-344Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and what subgroup of patients would benefit most from this new technique. It would be interesting to compare the outcomes of the 67 patients in this study with outcomes of matched control patients undergoing the standard technique for reconstruction. Although this article describes an innovative way to manage the right renal artery during complex open aortic aneurysm repair, it does not definitively support its widespread use. Two-thirds of BESs were deployed because of “concern for impingement” on the orifice of the right renal artery during patch reimplantation. No data are presented to suggest this situation is associated with an increased incidence of right renal artery occlusion. Increased concern with late degeneration in the visceral patch has led more surgeons to move to multiple visceral anastomoses rather than patch inclusion. The authors' technique would not address these concerns. It is unclear in which group of patients this technique is likely to have a clear benefit. A second limitation, acknowledged by the authors, is the lack of complete follow-up. Only two patients experienced new-onset permanent renal failure requiring dialysis postoperatively; however, only 63% of patients at 6 months and 51% of patients at 1 year were available for evaluation. More sensitive indicators of decline in renal function than creatinine levels, such as estimated glomerular filtration rate, were not analyzed in this study. Although renal failure was defined as a creatinine level >1.5 mg/dL, in only 33% of patients was a creatinine level measured >30 days after the procedure. Of the 26 patients who had a clear indication for renal revascularization (ie, renal artery stenosis), only 12 were available for follow-up at 6 months and 10 at 12 months, limiting the strength of the authors' outcome data on postoperative renal dysfunction. Finally, the authors advocate a flank or thoracoabdominal exposure for all complex aortic aneurysms, even for pararenal aneurysms. Juxtarenal or suprarenal aneurysms comprised one-third of the authors' series. There is no doubt that this exposure makes revascularization of the right renal artery more difficult than if approached from an anterior, transabdominal exposure. Although I concur that the flank approach allows superior exposure for thoracoabdominal aortic aneurysm repair, my experience has been that a midline, transabdominal exposure offers more than adequate visualization and control for the treatment of juxtarenal and suprarenal aortic aneurysms and allows for greater flexibility in right renal artery revascularization.4West C.A. Noel A.A. Bower T.C. Cherry K.J. Gloviczki P. Sullivan T.M. et al.Factors affecting outcomes of open surgical repair of pararenal aortic aneurysms; a 10–year experience.J Vasc Surg. 2006; 43: 921-927Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 5Ricotta 2nd, J.J. Duncan A.A. Harbuzariu C. Bower T.C. Oderich G.S. Kalra M. et al.Open surgical repair of pararenal abdominal aortic aneurysms: long term outcomes of renal function.J Vasc Surg. 2009; 49: 13SAbstract Full Text Full Text PDF Google Scholar Patel et al have stimulated us to search for new and better techniques for open complex aortic aneurysm repair in order to allow this procedure to be performed with more alacrity, safety, and effectiveness. Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repairJournal of Vascular SurgeryVol. 51Issue 2PreviewPatients undergoing repair of thoracoabdominal (TAA) or visceral aortic segment aneurysms typically require reconstruction of the renal arteries. The use of balloon expandable stents (BES) has been proposed as an alternative to endarterectomy or bypass for renal artery reconstruction (RAR) during open aortic aneurysm repair. We report technical aspects and long-term patency data for this method of right RAR during complex open aortic aneurysm repair. Full-Text PDF Open Archive