Suprarenal Abdominal Aortic Aneurysm Research Articles

Invited commentary

The high-risk patient has been haunting us for years. Before the endovascular era, very few patients were actually denied open aneurysm repair on account of extensive cardiovascular comorbidity and the increased mortality this type of surgery would be associated with. With the advent of endovascular aneurysm repair (EVAR), things changed. Because this therapy was initially considered most appropriate for patients who had a prohibitive risk for open surgery, an epidemic of high-risk patients seemed to ensue. In the subsequent years, many efforts were made to define “high risk,” but a widely accepted definition could not be accomplished. Recently, the EVAR-2 trial generated renewed interest in the preoperative risk profile of abdominal aortic aneurysm (AAA) patients, as it concluded that EVAR offers no benefit for high-risk patients compared with best medical treatment. Unfortunately, the EVAR-2 trialists had also failed to agree upon a clear definition of their high-risk patients. The Glasgow Aneurysm Scale (GAS) is a simple score that can be calculated in the office without complex formulas. It provides a numerical score representing the preoperative risk profile of an AAA patient. In a retrospective study, Hirzalla et al aimed at an external validation of the GAS score as a predictor for postoperative mortality and major morbidity after elective open AAA repair. They conclude that the GAS is a valid predictor for postoperative mortality and morbidity, but that it should merely be used to identify low-risk patients and not to identify high-risk patients. Apart from this being a bit of a disappointment in itself (we are really after a score that defines high-risk), a few methodologic issues of this study and some other limitations of the GAS score need to be highlighted. The study population that was used to validate the GAS score consisted of patients who were all considered suitable for open repair between 1994 and 2003. It is very likely that in the same period, patients who were considered at high risk for open repair (by whatever criteria) were treated by EVAR in this institution. As a result, young, low-risk patients are probably over-represented in the current study population. Unfortunately, the authors also included juxtarenal and suprarenal AAA repairs. As this subgroup is responsible for three of the total five deaths, it obviously plays a major role in the study outcome. With only two deaths in the remaining 193 infrarenal AAA repairs, one thing is clear for these authors: they really do not need a scoring system to predict deaths, as their mortality rate of open AAA-repair is exceptionally good. The reader is left with the conclusion that GAS may be helpful in identifying low-risk patients for this infrarenal AAA population, while this seems to be based upon a study population void of high-risk patients. Furthermore, it is important to realize that age is a major driver of the GAS score. The typical median of AAA patients at the time of surgery is between 70 and 75, which means that almost half of all AAA patients considered for repair already fall into the high-risk GAS-category (>77 points) on account of their age alone. With a history cerebrovascular or renal disease, it becomes almost impossible for a patient to qualify as low risk. Fortunately, these risk factors are uncommon (13% and 6%, respectively, in the current study). Patients with myocardial disease can only qualify as low risk if they are in their 60s. It therefore must be questioned if GAS really offers a lot more predictive power than age alone. Not to mention the issue of corrected or improved cardiac disease not being accounted for in the GAS score, as appropriately addressed by the authors. In conclusion, the authors are to be commended for tackling a vital issue in current AAA practice. The GAS score is a clever and simple test that deserves further evaluation; however, it needs application in larger studies with a higher proportion of patients with significant risk factors.

Combined Treatment with Open and Endovascular Surgery of a Mycotic Abdominal Aortic Aneurysm

We report the treatment of a 67-year-old male patient with a suprarenal mycotic aortic aneurysm. A 67-year-old male developed renal failure during the treatment of a urine infection and a paracervical abscess. Further investigations revealed a 5.6cm saccular suprarenal abdominal aortic aneurysm. A successful combined treatment was carried out with endovascular techniques and open surgery, realizing a retrograde aorto-superior mesenteric bypass. Postoperative follow up scans showed exclusion and thrombosis of the aneurysm. Treatment of mycotic aneurysms is mainly surgical, but endovascular therapy helps to avoid highly complicated surgery and reduces mortality.

Combined Treatment with Open and Endovascular Surgery of a Mycotic Abdominal Aortic Aneurysm

We report the treatment of a 67-year-old male patient with a suprarenal mycotic aortic aneurysm. A 67-year-old male developed renal failure during the treatment of a urine infection and a paracervical abscess. Further investigations revealed a 5.6 cm saccular suprarenal abdominal aortic aneurysm. A successful combined treatment was carried out with endovascular techniques and open surgery, realizing a retrograde aorto-superior mesenteric bypass. Postoperative follow up scans showed exclusion and thrombosis of the aneurysm. Treatment of mycotic aneurysms is mainly surgical, but endovascular therapy helps to avoid highly complicated surgery and reduces mortality.

Aorto-Left Renal Artery Bypass as an Adjunct to Suprarenal Abdominal Aortic Aneurysm Repair

Renal ischemia remains a vexing issue in the repair of suprarenal abdominal aortic aneurysms (SR-AAAs). Multiple reconstruction methods have been described, including fish-mouth anastomoses, renal artery reimplantation, and aortorenal interposition grafts. We present an alternative method of SR-AAA repair that minimizes renal ischemia time. We describe our approach in two patients with SR-AAAs. Both patients had normal preoperative renal function. Maximal aneurysm diameters were 6.0 and 7.4 cm. In each case, the abdominal aorta was exposed via the retroperitoneal approach and the supraceliac aorta was dissected from the surrounding tissue. A partially occluding side-biting aortic clamp was placed at this level to facilitate placement of a synthetic 6 mm interposition graft that was sewn in an end-to-side fashion to the suprarenal aorta first. These grafts were then sewn end-to-end to the left renal artery, completing the aorto-left renal bypass. Left renal ischemia times were 12 and 14 min. The aneurysm was then repaired with a beveled proximal anastomosis, accommodating the right renal artery orifice. Both patients had minimal postoperative renal dysfunction, with peak creatinine levels of 1.9 and 1.4 mg/dl. At discharge, both patients had a creatinine level of 1.1 mg/dl. Urinary output remained normal throughout the hospital stays, and neither patient required dialysis. Retroperitoneal aortic exposure with preliminary aorto-left renal artery bypass is an effective method of treating SR-AAAs. Proximal anastomosis can be done with less urgency and minimal right renal ischemia, by revascularizing the left kidney first.

Endografting Increases Total Volume of AAA Repairs but Not at the Expense of Open Surgery: Experience in More Than 1000 Patients

To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeon's discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001-2002 after the introduction of "high-risk" screening criteria (age > or = 72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p > 0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p = 0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p = 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p > 0.05) and fell still further to 1.2% in the most recent period (p = 0.021 versus pre EVAR). The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.

Acalculous Gangrenous Cholecystitis Coexisting with a Mycotic Suprarenal Aortic Aneurysm

Mycotic suprarenal aortic aneurysms are rare, and most often caused by bacteraemic spread. Acalculous cholecystitis is usually associated with major surgery and trauma. An association between acalculous gangrenous cholecystitis and a mycotic suprarenal aortic aneurysm has not been described. We present a case of a perforated gangrenous cholecystitis with an adjacent suprarenal abdominal aortic mycotic aneurysm, presenting a challenging surgical case.

Acalculous Gangrenous Cholecystitis Coexisting with a Mycotic Suprarenal Aortic Aneurysm

Mycotic suprarenal aortic aneurysms are rare, and most often caused by bacteraemic spread. Acalculous cholecystitis is usually associated with major surgery and trauma. An association between acalculous gangrenous cholecystitis and a mycotic suprarenal aortic aneurysm has not been described. We present a case of a perforated gangrenous cholecystitis with an adjacent suprarenal abdominal aortic mycotic aneurysm, presenting a challenging surgical case.

Superior mesenteric arteriovenous fistula causing massive hematemesis

Surgery 2003;134:102-4.

The use of recombinant activated factor VII to control bleeding during repair of a suprarenal abdominal aortic aneurysm

Recombinant activated factor VII (rFVIIa) was first used to control bleeding in haemophilia patients. More recently, it has been used to prevent severe bleeding in patients without pre-existing coagulopathy. We report a case where rFVIIa was used to successfully control postoperative bleeding in a patient undergoing suprarenal abdominal aortic aneurysm (AAA) repair.Eur J Vasc Endovasc Surg 26, 221-222 (2003)

Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries.

In this retrospective review, we report the surgical results of infected aortic aneurysms treated at a single center over 5 years. From October 1996 to October 2001, 19 patients with infected aortic aneurysm were treated with surgery, nine with suprarenal infections (four proximal descending thoracic aortic aneurysms, two distal descending thoracic aortic aneurysms, and three suprarenal abdominal aortic aneurysms) and 10 with infrarenal infections (eight infrarenal abdominal aortic aneurysms and two iliac artery aneurysms). All had a positive blood or tissue culture; 89% were febrile, 89% had leukocytosis, and 32% were hemodynamically unstable. The most common responsible pathogens were Salmonella organisms (74%) followed by Streptococcus species (11%). Nine of 10 infrarenal infections were caused by Salmonella organisms. Both infrarenal and suprarenal infections were treated with wide débridement of infected aorta, in situ prosthetic graft or patch repair, and prolonged intravenous antibiotics. Hospital survival rate was 95%: 100% for infrarenal and 89% for suprarenal infections. There was no perioperative intestinal ischemia or perioperative limb loss. Acute renal failure occurred in two patients with suprarenal infection. Late deaths have occurred in three patients with one early graft infection (5%) resulting in the only one in-hospital death at 4 months. Sixteen patients remain alive at mean follow-up of 17.8 months (range, 4-47 months). There have been no late aortic or graft infections. During the same period, there were five unoperated patients, four of whom died of shock during hospitalization. Infected aortic aneurysm is common in Taiwan, and Salmonella species were the most common responsible microorganisms. With surgical intervention and prolonged intravenous antibiotics, in situ graft replacement provided a good outcome. The incidence of prosthetic graft infection was low, even in patients with infections due to Salmonella species and with in situ graft replacement.

Endovascular Repair of Recurrent Thoracoabdominal Aortic Aneurysm

To report the endovascular repair of a complicated, recurrent thoracoabdominal aortic aneurysm (TAAA) using stacked, customized stent-grafts. A 75-year-old man was evaluated for an enlarging 7-cm suprarenal abdominal aortic aneurysm. The patient had repair of a distal TAAA in the past, as well as multiple visceral revascularizations from the infrarenal aorta. A 3-segment aortic endograft with proximal and distal extensions was delivered with the aid of a prosthetic conduit from the right common iliac artery to the end of the right renal artery; spinal fluid drainage was performed to mitigate paraplegia. The stent-graft components were serially deployed from the level of the left common carotid artery and ended with the bare springs of the distal extension covering the renal arteries. The patient was discharged but returned within a month for drainage of a purulent retroperitoneal hematoma. He has since resumed his preoperative activities and remains well with documented exclusion of the aneurysm and satisfactory visceral and distal perfusion at 21 months. This case illustrates that aortic endografting can be a viable option for the treatment of recurrent thoracoabdominal aortic aneurysms.

Impact of endovascular repair on open aortic aneurysm surgical training

Purpose: The purpose of this study was to determine the impact of an endovascular stent-graft program on vascular training in open aortic aneurysm surgery. Methods: The institutional and vascular surgery fellow experience in aortic aneurysm repair during a 6-year period was reviewed. The 3-year period before introduction of endovascular repair was compared with the 3-year period after introduction of endovascular repair. All patients undergoing abdominal aortic aneurysm (AAA) or thoracoabdominal aortic aneurysm repairs were entered prospectively into a vascular registry and retrospectively analyzed to evaluate the changing patterns in aortic aneurysm treatment and surgical training. Results: Between July 1994 and June 2000, a total of 588 patients with AAA or thoracoabdominal aneurysms were treated at Stanford University Medical Center. There were 296 (50%) open infrarenal AAA repairs, 87 (15%) suprarenal AAA repairs, 47 (8%) thoracoabdominal aneurysm repairs, and 153 (26%) endovascular stent-grafts. The total number of aneurysms repaired per year by vascular fellows before the endovascular program was 71.3 ± 4.9 (range, 68-77) and increased to 124.7 ± 35.6 (range, 91-162) after introduction of endovascular repair (P <.05). This increase was primarily caused by the addition of endovascular stent-graft repairs by vascular fellows (51.0 ± 29.0/year [range, 23-81]). There was no change in the number of open infrarenal aortic aneurysm repairs per year, 53.0 ± 6.6 (range, 48-56) before endovascular repair versus 47.0 ± 1.7 (range, 46-49) after (P = not significant). There was a significant increase in the number of suprarenal AAA repairs per year by vascular fellows, 10.0 ± 1.0 (range, 9-11) before endovascular repair compared with 19.0 ± 6.5 (range, 13-26) after (P <.05). There was no change in the number of thoracoabdominal aneurysm repairs per year between the two groups, 8.0 ± 3.0 (range, 4-11) before endovascular repair compared with 7.6 ± 2.3 (range, 5-9) after. Conclusions: Introduction of an endovascular aneurysm stent-graft program significantly increased the total number of aneurysms treated. Although the number of open aneurysm repairs has remained the same, the complexity of the open aneurysm experience has increased significantly for vascular fellows in training. (J Vasc Surg 2001;34:885-91.)

The effect of acute normovolaemic haemodilution on blood transfusion requirements in abdominal aortic aneurysm repair.

to evaluate the impact of acute normovolaemic haemodilution (ANH) on the blood transfusion requirements in elective abdominal aortic aneurysm (AAA) repair in a single vascular unit. thirty-two patients underwent ANH during elective AAA repair between 1992 and 1997. The operation was performed by the same surgeon/anaesthetist team in 75% of cases. Their demographic details, type of aneurysm (infra-renal or supra-renal), preoperative blood cross match, use of intra-operative red cell salvage, blood loss, peri-operative bank blood requirements, pre-op and on-discharge haemoglobin levels and post-operative outcome were recorded. The results were compared to a group of 40 randomly selected patients (to represent the unit average) who underwent elective AAA repair by variable surgeon/anaesthetist teams without ANH in the same time period. there were more supra-renal AAA repairs in the ANH group (8/32) than in the non-ANH group (0/40, p<0.01). ANH patients required significantly less blood transfusion peri-operatively (median 2 units) than the non-ANH patients (median 3 units, p=0.02). There were no other significant differences between the variables measured. these results suggest that a dedicated team can achieve significant reductions in the use of heterologous blood transfusion compared to the vascular unit average experience by the effective use of ANH.

Congenital abdominal aortic aneurysm causing renovascular hypertension, cardiomyopathy, and death in a 19-day-old neonate

A full-term baby girl who was sent home day of life 2 was admitted to the hospital on day of life 7 for respiratory distress and poor feeding. The child was found to be hypertensive and in heart failure. Further workup led to the diagnosis of a suprarenal abdominal aortic aneurysm, but the infant had deteriorated clinically with heart failure, modest renal failure, renovascular hypertension, and no operative cure. The child died on day of life 20. Early diagnosis and prompt surgical resection are essential to managing this rare and lethal condition. J Pediatr Surg 36:1445-1449. Copyright © 2001 by W.B. Saunders Company.

Evolution of vascular fellowship training in the new era of endovascular techniques

Purpose: The endovascular technique has revolutionized the treatment of infrarenal abdominal aortic aneurysm (AAA). At our institution, we examined the impact of an endovascular program on the traditional operative training of the vascular fellows in the treatment of infrarenal AAA. Methods: We examined the records of our vascular fellows' experience from July 1995 to May 2000. We introduced the endovascular treatment for infrarenal AAA in 1995. Results: The fellows have performed increasing numbers of endovascular cases each year, with a predicted number of 124 cases for 1999-2000. However, despite an increase in the overall volume of patients with infrarenal AAA (102 cases in 1998-1999 and a predicted 160 cases in 1999-2000), the trainees will experience a reduction in the number of open AAAs from 61 cases in 1998-1999 to a predicted 36 cases in 1999-2000. However, the volume of open suprarenal AAA has also increased from eight cases in 1998 to 1999 to a predicted 24 cases in 1999-2000. With no significant change in the open aortoiliac occlusive cases from previous years, the current fellows will graduate with a similar volume of open aortic procedures as their predecessors. Conclusion: With the recent advances in endovascular technology, our traditional operative approach to the treatment of AAA disease may be lacking in the training of future vascular surgeons. At our institution, although fewer open infrarenal AAA cases were performed, the trainees have maintained the open aortic experience by performing an increased volume of suprarenal AAAs. We have to critically reevaluate and redefine what constitutes adequate vascular fellow experience in the surgical treatment of abdominal aortic aneurysms. (J Vasc Surg 2001;33:S106-10.)

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Tuberculous Aneurysm of the Abdominal Aorta: Endovascular Repair Using Stent Grafts in Two Cases

Tuberculous aneurysm of the aorta is exceedingly rare. To date, the standard therapy for mycotic aneurysm of the abdominal aorta has been surgery involving in-situ graft placement or extra-anatomic bypass surgery followed by effective anti-tuberculous medication. Only recently has the use of a stent graft in the treatment of tuberculous aortic aneurysm been described in the literature. We report two cases in which a tuberculous aneurysm of the abdominal aorta was successfully repaired using endovascular stent grafts. One case involved is a 42-year-old woman with a large suprarenal abdominal aortic aneurysm and a right psoas abscess, and the other, a 41-year-old man in whom an abdominal aortic aneurysm ruptured during surgical drainage of a psoas abscess.

Spinal cord ischemia after abdominal aortic operation: Is it preventable?

Purpose: Spinal cord ischemia after operation on the abdominal aorta is a rare event that is attributed to variations in the spinal cord blood supply. The purpose of this study was to evaluate the possible causes of this devastating event. Methods: A survey of patients among the members of the Southern Association for Vascular Surgery was performed, and 18 patients were identified with spinal cord ischemia manifested by paraplegia or paraparesis after abdominal aortic operation. Results: Preoperative computed tomographic, magnetic resonance, and aortographic results did not visualize the greater radicular artery (Adamkiewicz’s artery) in any patient. Eleven patients underwent resection of infrarenal abdominal aortic aneurysms (AAAs): seven of these patients had tube grafts, three had aortobifemoral grafts, and one had an aortobiiliac graft. Five other patients underwent placement of aortobifemoral grafts, and one patient underwent aortobiiliac graft placement for occlusive disease. One patient underwent suprarenal AAA resection with an interposition graft to a previous aortobiiliac graft. The mean operative time was 3 hours and 39 minutes (range, 2 hours and 45 minutes to 6 hours and 30 minutes), with a mean aortic cross-clamp time of 48 minutes (range, 24 to 97 minutes). Sixteen aortic cross-clamps were placed infrarenally and two suprarenally (one in a case of ruptured AAA, the other a suprarenal AAA). Seventeen proximal anastomoses were end to end. The average minimum systolic blood pressure during the aortic cross-clamping was 96 mm Hg (range, 80 to 130 mm Hg). All the patients had internal iliac artery flow preserved with either prograde perfusion (10 patients) or retrograde perfusion (eight patients), and one patient underwent unilateral internal iliac artery ligation because of aneurysmal disease. One aortobifemoral-graft limb necessitated thrombectomy, but no cases of massive peripheral embolization occurred. When paraplegia was suspected after operation (6 to 20 hours after surgery), five patients underwent lumbar drainage. No clinical improvement was noted. Conclusion: Interference with pelvic blood supply from prolonged aortic cross clamping, intraoperative hypotension, aortic embolization, and interruption of internal iliac artery circulation have all been suggested as possible causes of spinal cord ischemia. In this survey, none of these factors proved to be significant as the sole cause of spinal cord ischemia. In the performance of an aortic operation with an end-to-end proximal anastomosis in the presence of severe external or internal iliac artery disease, there may be an increased incidence of spinal cord ischemia despite appropriate surgical techniques to ensure internal iliac perfusion. Spinal cord ischemia after abdominal aortic operations appears to be a tragically unpredictable, random, and unpreventable event. (J Vasc Surg 1999;30:391-9.)

Renal failure after thoracoabdominal aortic surgery

Purpose: Renal failure remains a common and morbid complication after complex aortic surgery. This study was performed to identify perioperative factors that contribute to postoperative renal failure. Methods: The perioperative outcomes of 183 patients who underwent thoracoabdominal aortic surgery with supraceliac clamping were reviewed. During the interval from Jan. 1987 to Nov. 1996, thoracoabdominal aneurysm repair was performed in 154 patients (type I, 49 patients [27%]; type II, 21 patients [11.5%]; type III, 55 patients [30%]; type IV, 29 patients [16%]), suprarenal abdominal aortic aneurysm repair in 17 patients (9%), and visceral/renal revascularization procedures in 12 patients (6.5%). Intraoperative management included thoracoabdominal aortic exposure and clamp-and-sew technique with renal artery cold perfusion whenever the renal arteries were accessible (79% of cases). Results: Relevant clinical features included preoperative hypertension (85%), diabetes mellitus (8%), single functioning kidney (10%), recent intravenous contrast injection (34%), renal insufficiency (creatinine level greater than 1.5 mg/dl; 24%), and emergent operation (19%). Acute renal failure, defined as both a doubling of serum creatinine level and an absolute value greater than 3.0 mg/dl, occurred in 21 patients (11.5%), of whom five required hemodialysis (2.7%). Variables associated with this complication included a preoperative creatinine level greater than 1.5 mg/dl (p = 0.004) and a total cross-clamp time greater than 100 minutes (p = 0.035). The operative mortality risk (within 30 days; 8%) was significantly increased with renal failure (odds ratio, 9.2; 95% confidence interval, 2.6 to 33; p < 0.005). Conclusions: Renal failure, although uncommon in contemporary practice, greatly increases the risk of early death after thoracoabdominal aortic surgery. The overall incidence of renal failure and dialysis requirement in the present series compare favorably with those reported using other operative techniques, specifically partial left heart bypass and distal aortic perfusion. These data suggest that patients who have preoperative renal insufficiency are prone to postoperative renal failure. Furthermore, regional hypothermic perfusion and minimal clamp times are important elements in the prevention of renal failure after thoracoabdominal aortic surgery. (J Vasc Surg 1997;26:949-57.)

Preservation of renal function in juxtarenal and suprarenal abdominal aortic aneurysm repair

Deterioration in renal function is a common cause of morbidity in patients treated surgically for juxtarenal and suprarenal abdominal aortic aneurysms. We reviewed our experience over the last 8 years with 65 consecutive patients undergoing juxtarenal (n = 31) or suprarenal (n = 34) abdominal aortic aneurysm repair. The aneurysms were repaired with a transabdominal (n = 8), thoracoabdominal (n = 4), retroperitoneal (n = 22), or thoracoretroperitoneal (n = 31) approach. Proximal aortic clamps were placed at the suprarenal, supra-superior mesenteric artery, or supraceliac level. Renal hypothermia with cold heparinized saline solution renal artery perfusion was used to protect renal function in 38 patients with either preoperative renal insufficiency or with anticipated prolonged renal ischemia (> 30 minutes). Concomitant renal artery reconstruction was required in 30 patients. Significant operative morbidity developed in 23 (35.3%) patients. There was one (1.53%) perioperative death (0 to 90 days). Temporary dialysis was necessary in two patients. Preoperative renal insufficiency was a significant risk factor on multivariate analysis for a decline in renal function during the first postoperative week. However, serum creatinine concentration had returned to baseline or improved in all patients but two (3.1%) at the time of discharge. In spite of significantly longer renal ischemia, discharge creatinine levels were, on univariate analysis, statistically less than baseline creatinine levels in patients with suprarenal aneurysms, patients requiring renal reconstruction, and patients treated with renal hypothermia. The location of the proximal aortic clamp was not a factor in postoperative morbidity. There was no significant difference between juxtarenal and suprarenal aneurysms with respect to operating room time, transfusion requirements, days intubated, resumption of oral diet, or the length of hospitalization. Careful consideration of the route of exposure, location of the proximal aortic clamp, and the preservation of renal function with renal hypothermia and with the repair of significant renal artery lesions will result in minimal morbidity and mortality in patients requiring surgery for juxtarenal or suprarenal abdominal aortic aneurysms.