Results of Open Surgical Repair of Chronic Juxtarenal Aortic Occlusion

Abstract

Purpose: The aim of study was to review the results of open surgical repair (OSR) of chronic juxtarenal aortic occlusion (JRAO).

Materials and methods: We retrospectively reviewed the results of OSR performed in 47 patients (male, 92%; mean age, 59.9±9.3 years [range, 44-79]) with chronic JRAO during the past 21 years. In order to reduce intraoperative renal ischemic time (RIT), we excised a portion of the occluded segment of the infrarenal aorta without proximal aortic clamping. We then performed suprarenal aortic clamping with both renal arteries clamped, removed the proximal aortic thrombus cap, confirmed both renal artery orifices, and moved the suprarenal aortic clamp to the infrarenal aorta to allow renal perfusion and standard aortoiliac reconstruction. We investigated early (<30 days) postoperative surgical morbidity (particularly renal function), operative mortality, and longterm patient survival. We conducted risk factor analysis for postoperative renal insufficiency.

Results: The mean intraoperative RIT was 10.7±5.5 minutes (range, 3-25), including 6 patients who underwent concomitant pararenal aortic thromboendarterectomy. Postoperatively, five (11%) patients had transient renal insufficiency, one had pneumonia, and one patient had an acute myocardial infarction. However, there was no operative mortality or newly developed dialysis-dependent renal failure. Postoperative follow up was available in 36 (77%) patients for a mean period of 6.3 years (range, 1 month-17 years). Kaplan Meier calculations of patient survival at 5 and 10 years after surgery were 91.2% and 83.6%, respectively.

Conclusion: We have experienced short RIT, acceptable early postoperative results and long-term survival after OSR of chronic JRAO.

Keywords: Juxtarenal aortic occlusion; Renal complication; Renal ischemic time; Surgical results.

Fig. 1.

Surgical photograms showing surgical procedures for a patient with juxtarenal aortic occlusion. (A) Resection of a segment of occluded infrarenal aorta without suprarenal aortic clamping. (B) Removal of thrombotic cap under the suprarenal aortic clamp, with both renal arteries controlled. (C) Transfer suprarenal aortic clamping to the infrarenal aorta allowing renal perfusion. (D) Standard aorto-femoral bypass under the infrarenal aortic clamping.

Fig. 2.

Schematic drawing of the surgical reconstruction of the juxtarenal aortic occlusion to minimize renal ischemic time. (A) Segmental excision of the occluded infrarenal aortic segment (3 cm in length) without supra-renal aortic clamping. (B) Vertical aortotomy under the supra-renal aortic cross clamping and bilateral renal artery control (left renal vein division may be required during this procedure). (C) Pararenal aortic thromboendarterectomyor renal ostialendarterectomy (if required) through the vertical aortotomy. (D) Proximal aortic anastomosis after vertical aortotomy closure after moving the aortic clamp to the infrarenal aorta.

Fig. 3.

Cumulative survival of patients after open surgical repair of juxtarenal aortic occlusion.