Suprarenal Aortic Aneurysm Repair Research Articles

Cerebral embolization during endovascular infrarenal, juxtarenal, and suprarenal aortic aneurysm repair, high-risk maneuvers, and associated neurologic outcomes

BackgroundRisk factors for postoperative cognitive decline after noncardiac surgery are multifactorial and poorly understood. Evidence suggests that perioperative microembolic damage to the brain on movement of wires and catheters during endovascular aortic procedures may play an important role. Endovascular aortic aneurysm repair requires invasive manipulation of wires and cannulas within the aorta, but research into cerebral emboli during aortic aneurysm repair and cognitive or neurologic injury is scarce and limited to thoracic aneurysms. This study prospectively studied embolic phenomena detected in the middle cerebral artery during infrarenal, juxtarenal, and thoracic endovascular aortic repair (TEVAR) and investigated links to delirium, stroke, and postoperative cognitive decline. MethodsThere were 60 patients who received continuous left-sided perioperative transcranial Doppler monitoring during endovascular aortic aneurysm repair (bifurcated graft for infrarenal aneurysm, n = 18; endovascular aneurysm sealing graft, n = 16; endovascular aneurysm sealing and renal “chimney” stent, n = 17; and thoracic aneurysm, n = 3). The procedure was time stamped for events such as stiff wire insertion and graft deployment. A battery of cognitive tests designed to test several cognitive domains were performed preoperatively and at 90 days postoperatively. ResultsTEVAR and chimney grafts demonstrated significantly greater numbers of total procedural emboli compared with standard bifurcated grafts (mean emboli, 36.2 and 13.39, respectively; bifurcated graft, 5.81; P < .05). The highest risk maneuvers were guidewire and pigtail catheter insertion. This was the case for all procedures including infrarenal aneurysm repair. A higher perioperative embolic load was associated with medium-term cognitive decline in list recall but not with incidence of delirium or stroke. Risk of cognitive decline did not relate to procedure type. Antiplatelet use failed to demonstrate a protective effect. ConclusionsPatients are at risk of cerebral emboli during several types of endovascular aortic surgery, although TEVAR remains the highest risk procedure. As yet, there are no validated protective measures available to prevent cerebral emboli and their associated risks of clinical and subclinical neurologic injury.

Sonographic Changes in Optic Nerve Sheath Diameter Associated with Supra- versus Infrarenal Aortic Aneurysm Repair.

Quantification of changes in optic nerve sheath diameter (ONSD) using ocular sonography (OS) constitutes an elegant technique for estimating intracranial and intraspinal pressure. Aortic aneurysm repair (AAR) is associated with a reasonable risk of increased spinal fluid pressure, which is largely dependent on the extent of aneurysm repair (supra- vs. infrarenal). The aim of this study was to compare ONSD measurements in patients with suprarenal AAR (sAAR) or infrarenal AAR (iAAR). Thirty patients who underwent elective endovascular repair of infrarenal aortic aneurysms (Group iAAR) were included in the study; the characteristics in these cases were prospectively analyzed and compared with those in a previously investigated group of 28 patients treated for suprarenal aortic aneurysms (Group sAAR). Six measurements of ONSDs were performed in each patient at five consecutive time points. Statistical analysis was performed using the Wilcoxon test. A P value < .05 was considered statistically significant. A highly significant difference between pre- and postinterventional values could be detected in both patient groups (P < .01). In Group sAAR, there was a mean .3-mm increase of the ONSD, whereas in Group iAAR, a mean .2-mm decrease could be detected. Both groups roughly reached baseline values by the end of their inpatient stay. ONSD changes seem to be a reliable marker to estimate spinal perfusion. Since OS provides a suitable bedside tool for rapid reevaluation, it may guide physicians in the identification and treatment of patients at high risk for spinal cord ischemia.

Remote Ischemic Preconditioning May Attenuate Renal Ischemia-Reperfusion Injury in a Porcine Model of Supraceliac Aortic Cross-Clamping

Aim: The effect of remote ischemic preconditioning (RIPC) in decreasing renal ischemia-reperfusion injury (IRI) during a suprarenal aortic cross-clamping was examined in a swine model. Materials and Methods: Four groups of pigs were examined: (a) ischemia-reperfusion (IR) group, renal IRI produced by 30 min of supraceliac aortic cross-clamping; (b) RIPC I group, the same renal IRI following RIPC by brief occlusion of the infrarenal aorta (15 min ischemia and 15 min reperfusion); (c) RIPC II group, the same renal IRI following RIPC by brief occlusion of the infrarenal aorta (3 cycles of 5 min ischemia and 5 min reperfusion); (d) sham group. Renal function was assessed before and after IRI by examining creatinine, neutrophil gelatinase-associated lipocalin (NGAL), TNF-α, malondialdehyde (MDA), cystatin C and C-reactive protein (CRP) from renal vein blood samples at specific time intervals. Results: Both RIPC groups presented significantly less impaired results compared to the IR group when considering MDA, cystatin C, CRP and creatinine. Between the two RIPC groups, RIPC II presented a better response with regard to CRP, NGAL, TNF-α, MDA and cystatin C. Conclusions: Remote IR protocols and mainly repetitive short periods of cycles of IR ameliorate the biochemical kidney effects of IRI in a model of suprarenal aortic aneurysm repair.

PS34 Comparison of Renal Perfusion Solutions During Suprarenal Aortic Aneurysm Repair

PS34 Comparison of Renal Perfusion Solutions During Suprarenal Aortic Aneurysm Repair

Intraoperative Factors Affecting Renal Outcome After Open Repair of Suprarenal Aortic Aneurysms

The open repair of suprarenal aortic aneurysm requires supraceliac aortic cross-clamping and separate renal artery reconstruction. The aim of this study was to determine the intraoperative factors responsible for postoperative renal dysfunction. Between January 1, 2000 and May 31, 2010, 54 suprarenal aortic aneurysms were repaired at our center (mean age of the patients, 66 ± 8 years). All cases were operated through a left retroperitoneal approach without left renal vein division. Acute kidney injury was defined as a 50% increase of serum creatinine level from the preoperative baseline concentration. Perioperative variables were tested to be correlated with renal dysfunction (Spearman rank). The ischemic time was 28 ± 8 minutes for the mesentery and the right kidney and 63 ± 16 minutes for the left kidney. The total aortic clamping time was 115 ± 27 minutes. The volume of autologous transfusion was 957 ± 479 mL, allogeneic transfusion was 936 ± 473 mL, and colloids and crystalloids was 7,194 ± 2,201 mL. Two patients died. Acute kidney injury occurred in 15 patients, with complete recovery at discharge. The autologous blood transfusion volume (P = 0.009, r = 0.36) and the total aortic clamping time (P = 0.04, r = 0.30) were correlated with renal dysfunction. Postoperative renal dysfunction based on the variation in creatinine serum level was transient and requires further investigation using sensitive biomarkers for tubular ischemia.

Percutaneous Stenting of an Iatrogenic Superior Mesenteric Artery Dissection Complicating Suprarenal Aortic Aneurysm Repair

Percutaneous Stenting of an Iatrogenic Superior Mesenteric Artery Dissection Complicating Suprarenal Aortic Aneurysm Repair