WHAT THIS PAPER ADDS This multicentre study suggests that in fit patients, open juxtarenal abdominal aneurysm repair can be performed with acceptable operative risk and with durable results in terms of both graft integrity and preservation of renal function. Predictors of acute kidney injury (AKI) were pre-existing chronic kidney disease, diabetes, hypertension, and age. The level and duration of renal artery clamping (24 AE 7 min, range 10e55 min) were not associated with an increased risk of AKI in this group of fit patients. Objectives: With a focus on renal function, the goal of this multicentre study was to assess peri-operative complications and late mortality of open surgical repair (OSR) of juxtarenal abdominal aortic aneurysms (JRAAA). Methods: From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a JRAAA in five French academic centres were evaluated retrospectively. The definition of JRAAA was an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck <10 mm. End points included postoperative death; acute kidney injury (AKI) defined by the RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease) criteria; and long term follow-up with freedom from chronic renal decline (CRD) and any graft related complications. Factors predictive of renal insufficiency were determined by multivariable analysis. Results: Of 315 patients, 292 (92.6%) were men (mean age 68 AE 8 years), and 73 (23.2%) had baseline chronic kidney disease (CKD) with an estimated glomerular filtration rate of <60 mL/min/1.73 m 2. The level of aortic clamping was supracoeliac (n ¼ 11), suprarenal (n ¼ 235), or inter-renal above one renal artery (n ¼ 69).The mean duration of renal artery clamping was 24 AE 7 min (range 10e55 min). Eleven patients (3.5%) presented with a renal artery stenosis that was treated conservatively. Perfusion of the renal arteries with a chilled Ringer's solution was used selectively in seven patients (2.2%). The overall 30 day mortality was 0.9% (three patients). AKI occurred in 53 patients (16.8%). Nine patients (2.9%) required temporary dialysis and one patient required chronic dialysis. Predictors of AKI were preexisting CKD (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.13e4.48; p ¼ .021], diabetes (OR 3.15, 95% CI 1.48e6.71; p ¼ .003), hypertension (OR 3.38, 95% CI 1.33e8.57; p ¼ .01), and age (OR 1.05, 95% CI 1.01e1.10; p ¼ .014). The level of aortic clamping and duration of renal artery clamping were not associated with an increased risk of AKI. The KaplaneMeier survival estimate was 71% AE 5% at five years. Predictors of CRD during follow up were AKI (hazard ratio [HR] 15.81, 95% CI 5.26e47.54; p ¼ .001), diabetes (HR 4.56, 95% CI 1.57e13.17; p ¼ .005), and pre-existing CKD (HR 2.93, 95% CI 1.19e7.20; p ¼ .019), with freedom from CRD of 89% AE 3% at five years. Surveillance imaging was obtained by computed tomography angiography in 290 patients (92.6%) at a mean follow up of 4.3 AE 2.4 years. Renal artery occlusion occurre...
Postoperative follow-up was carried out at one month, six months, one year, then annually by angio-CT. Results: 21 patients were treated during the study period with a mean age of 74.2 ± 8.4 years. The average follow-up was 55.2 ± 24.8 months. Four patients were symptomatic. Embolization was carried out with coils in 19 patients, or with amplatzer. The technical success of the preserving strategy was 95.2%. One patient could not have a complete embolization of the sac for technical reason (stability). This patient presented a rupture at 34 months requiring surgical conversion in emergency. No pelvic or colic ischemia occurred. In the remaining 20 patients, three endoleaks were detected (15%) requiring endovascular reintervention with an extension. Seventeen patients presented a regression of the sac (80.9%), three a stability (14.2%) and one a growth (4.7%). Among the 21 preserving procedures, two cases of buttock claudication were observed at one month. Only one persisted in the long term in a patient presenting a contralateral occlusion. Four unrelated deaths occurred during the follow-up. Conclusion: A strategy preserving the efferent vessels in the endovascular treatment of the IHA appears an effective in terms of aneurysmal exclusion, and well tolerated with a low risk of claudication in this series. These results must be confirmed in a larger number of patients.
Objectives: With a focus on renal function, the goal of this multicentre study was to assess peri-operative complications and late mortality of open surgical repair (OSR) of juxtarenal abdominal aortic aneurysms (JRAAA). Methods: From February 2005 to December 2015, 315 consecutive patients undergoing elective OSR of a JRAAA in five French academic centres were evaluated retrospectively. The definition of JRAAA was an aortic aneurysm extending up to but not involving the renal arteries, i.e., a short neck <10 mm. End points included post-operative death; acute kidney injury (AKI) defined by the RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease) criteria; and long term follow-up with freedom from chronic renal decline (CRD) and any graft related complications. Factors predictive of renal insufficiency were determined by multivariable analysis. Results: Of 315 patients, 292 (92.6%) were men (mean age 68 6 8 years), and 73 (23.2%) had baseline chronic kidney disease (CKD) with an estimated glomerular filtration rate of <60 mL/min/1.73 m 2. The level of aortic clamping was supracoeliac (n = 11), suprarenal (n = 235), or inter-renal above one renal artery (n = 69). The mean duration of renal artery clamping was 24 6 7 min (range 10e55 min). Eleven patients (3.5%) presented with a renal artery stenosis that was treated conservatively. Perfusion of the renal arteries with a chilled Ringer's solution was used selectively in seven patients (2.2%). The overall 30 day mortality was 0.9% (three patients). AKI occurred in 53 patients (16.8%). Nine patients (2.9%) required temporary dialysis and one patient required chronic dialysis. Predictors of AKI were pre-existing CKD (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.13e4.48; p = .021], diabetes (OR 3.15, 95% CI 1.48e6.71; p = .003), hypertension (OR 3.38, 95% CI 1.33e8.57; p = .01), and age (OR 1.05, 95% CI 1.01e1.10; p = .014). The level of aortic clamping and duration of renal artery clamping were not associated with an increased risk of AKI. The KaplaneMeier survival estimate was 71% 6 5% at five years. Predictors of CRD during follow up were AKI (hazard ratio [HR] 15.81, 95% CI 5.26e47.54; p = .001), diabetes (HR 4.56, 95% CI 1.57e13.17; p = .005), and pre-existing CKD (HR 2.93, 95% CI 1.19e7.20; p = .019), with freedom from CRD of 89% 6 3% at five years. Surveillance imaging was obtained by computed tomography angiography in 290 patients (92.6%) at a mean follow up of 4.3 6 2.4 years. Renal artery occlusion occurred in two patients (0.7% of imaged renal arteries). One patient (1.9%) had an aneurysm of the visceral aorta and eight patients had a descending thoracic aneurysm. Conclusions: This multicentre study suggests that in fit patients, open JRAAA repair can be performed with acceptable operative risk with durable results in terms of both graft integrity and preservation of renal function.
Highlights Acute aortic abdominal dissection is a rare complication of retroperitoneal laparoscopic paraaortic lymph node dissection. Aortic dissection may be part of differential diagnoses in patients with groin and abdominal pain after paraaortic staging. Uncomplicated type B aortic abdominal dissection should be managed during the subacute phase. Early contrast-enhanced computed tomography should be performed in case of abdominal pain after paraaortic lymphadenectomy. Retroperitoneal laparoscopic paraaortic lymph node dissection should be performed at referral cancer centers.
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