The removal of all proximal aneurysmal aortic tissue does not affect anastomotic degeneration after open juxtarenal aortic aneurysm repair

Abstract

ObjectiveFor the open treatment of juxtarenal aortic aneurysms (JRAAs), some argue for the removal of all proximal aneurysmal aortic tissue to prevent future degeneration, whereas others deem it unnecessary. This study sought to compare perioperative and long-term outcomes of two different approaches to treatment of JRAAs. MethodsPatients who underwent open JRAA repair from 2007 to 2015 at our institution were reviewed and stratified by operative technique: plication of the aneurysm cuff with graft sewn up to the renal arteries (PLI) vs a beveled anastomosis with left renal artery bypass (LRB). Patients who underwent additional mesenteric bypasses were excluded. Primary outcomes included death, anastomotic degeneration, and decline in renal function. Univariate and Kaplan-Meier analyses were performed. ResultsThere were 199 patients identified, 56% PLI (n = 112) and 44% LRB (n = 87). The majority were male (68%), white (89%), and smokers (58%). Mean age was 71.5 ± 8.5 years. LRB patients were more likely to have chronic kidney disease (29% vs 13%; P = .01) and larger juxtarenal diameters (median, 25 mm vs 28 mm; P = .001). LRB patients had longer postoperative length of stay (median, 8 days vs 7 days; P = .003) and longer operative times (median, 4.7 hours vs 3.7 hours; P < .001). Overall 30-day mortality was 2% (n = 4), with no difference between cohorts. There were no differences in perioperative complications except for the development of acute kidney injury, which was more common in LRB patients (47% vs 23%; P < .001). During 3-year follow-up, there was no difference in anastomotic aneurysmal degeneration or sac growth. In the long term, LRB patients were more likely to develop an occluded left renal artery (20% vs 0%; P = .004) and right renal artery stenosis (29% vs 3%; P = .002). However, neither group was more likely to have a decline in renal function (PLI, 23%; LRB, 25%; P = .84). There was no difference in 5-year mortality (P = .72). ConclusionsThe more complex technique involving LRB was not protective against long-term anastomotic degeneration, decline in renal function, or mortality. In addition, LRB led to longer length of stay and operative times, with increased risk of perioperative acute kidney injury. In an era when fewer open aortic repairs are being performed, it is reasonable to consider the PLI technique in the treatment of JRAAs, particularly in patients with baseline chronic kidney disease.