The Influence of Suprarenal Aortic Cross-clamping on Perioperative and Follow-up Results of Open Repair of Abdominal Aortic Aneurysm

Abstract

The objective was to retrospectively assess the perioperative and long-term outcomes in patients operated on with open repair of abdominal aortic aneurysm (AAA) with or without suprarenal aortic cross-clamping in a single-center experience. From January 2008 to December 2018, 1608 consecutive open and endovascular interventions for AAA were performed. Data concerning these interventions were prospectively recorded; a retrospective analysis of the database was performed and 540 elective open interventions for unruptured AAA were found, in 73 cases with suprarenal aortic cross-clamping (group 1) and in 467 cases with infrarenal aortic cross-clamping (group 2). The two groups were compared in terms of clinical, anatomic, and surgical characteristics and perioperative (<30 days) outcomes with χ2 test; follow-up results were compared with Kaplan-Meier curves and log-rank test. There were no differences between the two groups in terms of demographics, risk factors, and comorbidities, except for a higher percentage of female patients in group 1 than in group 2 (16.2% and 9.1%, respectively; P = .05). Mean preoperative estimated glomerular filtration rate was similar in the two groups as well. Most patients in both groups had a bifurcated aortobi-iliac graft; in group 1, 22 patients had a unilateral or bilateral renal revascularization, whereas in 51 cases, the ostium of one or both renal arteries was included in the proximal anastomosis. The mean time of renal ischemia in group 1 was 16 ± 12 minutes. Patients in group 1 had a longer time of intensive care unit stay than patients in group 2, but the overall length of stay was similar. Perioperative mortality rates were 4.1% in group 1 and 2.7% in group 2 (P = .5); nonfatal major complications occurred in 14 patients in group 1 (19%) and in 69 patients in group 2 (14.5%; P = .3). Follow-up was available in 512 patients (95%), with a median duration of 48 months (range, 1-144 months). Estimated 7-year survival rates were 51.5% in group 1 and 76.5% in group 2 (P < .001; log-rank, 15.3), whereas the corresponding figures in terms of freedom from AAA-related complications were 63.5% and 85.5% (P = .002; log-rank, 9.5). Moreover, patients in group 1 were more likely than patients in group 2 to undergo a reintervention at 7-year follow-up. In patients with complex AAA requiring suprarenal aortic cross-clamping, a significant increase of long term mortality, AAA-related complications, and reintervention was found in comparison with patients undergoing infrarenal aortic clamping.