Left Subclavian Artery Coverage Association With Neurologic Events in Trauma Patients Undergoing Thoracic Endovascular Repair

Abstract

Objective: For the open treatment of juxtarenal aortic aneurysms (JRAAs), some argue for the removal of all proximal aneurysmal aorta to prevent future degeneration, whereas others deem it unnecessary. This study sought to compare perioperative and long-term outcomes of two different approaches to JRAA.Methods: Patients 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 and decline in renal function. Univariate and Kaplan-Meier analyses were performed.Results: There were 199 patients identified: 56% PLI (n ¼ 112) and 44% LRB (n ¼ 87). The majority were male (68%), white (89%), and smokers (58%). Mean age was 71.5 6 8.5 years. LRB was more likely to have chronic kidney disease (28% vs 13%; P ¼. 007) and larger preoperative proximal neck diameters (29 vs 25 mm; P < .001). LRB had longer postoperative length of stay (10.8 vs 8.3 days; P ¼ .022), longer operative times (5.4 vs 3.9 hours; P < .001), and higher operative blood loss (1.9 vs 1.6 L; P ¼ .04). Overall 30-day mortality was 2% (n ¼ 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 (29% vs 14%; P ¼ .012). During 3-year follow-up, there was no difference in anastomotic aneurysmal degeneration or sac growth. In the long term, LRB was more likely to develop an occluded left renal artery (20% vs 0%; P ¼ .004) and right renal artery stenosis (29% vs 3%; P ¼ .002). However, neither group was more likely to have a decline in renal function (PLI, 23%; LRB, 25%; P ¼ .84). There was no difference in 5-year mortality (P ¼ .721). Conclusions:The technique of removing all proximal aneurysmal aorta with a beveled anastomosis and left renal artery bypass was not protective against aneurysmal growth, nor was a difference seen in renal function decline or mortality. Furthermore, LRB led to longer length of stay and operative times with increased risk of 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 JRAA.