Results of supraceliac aortic clamping in the difficult elective resection of infrarenal abdominal aortic aneurysm

Abstract

We have used clamping of the aorta above the celiac axis (SC) in 30 of 431 elective resections of infrainguinal abdominal aortic aneurysms (AAA) during the past five years as an alternative to a difficult aortic cuff dissection. The results of SC clamping in these 30 patients are compared with the results of 379 routine aneurysm resections with infrarenal (IR) clamping and 22 additional aneurysm resections where the clamp was placed immediately above the renal arteries. These difficult cuff dissections occurred in 12 patients with inflammatory AAA, in 11 patients with juxtarenal AAA, and in seven patients with recurrent or noninfected false AAA of the proximal cuff. Patients with ruptured or suprarenal aneurysms and those undergoing combined operation for a visceral ischemic syndrome and an aneurysm were excluded from this study. Patients with SC clamping had similar operative mortality rates, comparable renal function, and frequency of cardiac events as patients with IR clamping. Blood loss was slightly higher in the SC group (p = 0.07) and serum aspartate amino transferase (AST) levels were three times higher than in the IR group; however, this was of no clinical significance. In contrast, those 22 patients whose aortas were clamped immediately above the renal arteries (AR) had higher perioperative mortality rates (2% IR, 3% SC vs 32% AR) and a higher incidence of kidney failure requiring dialysis (1% IR, 3% SC vs 23% AR). The mean values of serum creatinine and blood urea nitrogen were also significantly higher in the AR group when compared with both the IR and the SC groups (IR: 25 and 1.5 mg/dl, respectively; SC: 27 and 1.8 mg/dl; AR: 41 and 3.5 mg/dl). The single most important risk factor accounting for the differences between clamping above the celiac artery and clamping above the renal arteries was the presence of atherosclerotic debris in the nonaneurysmal, juxtarenal aortic segment. Clamping the aorta with juxtarenal atherosclerosis caused either atheroembolization to kidneys, legs, and intestine or injury to the aorta, renal arteries, or both; it was the cause of morbidity in all five cases of kidney failure requiring dialysis and accounted for all seven of the deaths in the AR group. SC clamping does not add risk to the patient undergoing resection of an infrarenal AAA and is the preferred method of achieving proximal control of the infrarenal aorta when a a hazardous cuff dissection is likely.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair

“…With regard to the risk of renal morbidity, we documented high rates of transient renal insufficiency of up to 70% for the JRA group in our series. This is much higher than that reported in other large studies (20-41%) in the past [4,6,8,9,13,14,16,17]. We trace this back to our stringent definition of renal failure, which starts at a creatinine level of 1.3 mg/dl [1] in contrast to other studies (>1.8 mg/dl).…”

“…A big issue with regard to the question of clamping location for JRA repair is also present in the literature. The study of Green et al [9] established that supravisceral clamping is safer than suprarenal clamping, due to the avoidance of embolization of atherosclerotic debris from the perirenal region. The San Francisco Group [13] and the Cleveland Clinic [17] already mentioned the methodological errors of Green's analysis on patients in whom complications developed due to failed infrarenal cross-clamping [9].…”

“…The study of Green et al [9] established that supravisceral clamping is safer than suprarenal clamping, due to the avoidance of embolization of atherosclerotic debris from the perirenal region. The San Francisco Group [13] and the Cleveland Clinic [17] already mentioned the methodological errors of Green's analysis on patients in whom complications developed due to failed infrarenal cross-clamping [9]. Data by Sarac [17] reported no significant difference in the mortality seen between suprarenally and infrarenally clamped aneurysms (2.1 vs 2.8%).…”

Postoperative Renal Function After an Abdominal Aortic Aneurysm Repair Requiring a Suprarenal Aortic Cross-Clamp

“…4 Furthermore, Green et al 5 identified atheroemboli to be another cause of postoperative renal insufficiency due to a suprarenal aortic cross-clamp.…”

Thrombosed abdominal aortic aneurysm associated with an extensively “shaggy” aorta repaired anatomically via a thoracoabdominal approach with supraceliac aortic clamping: Report of a case

“…[18][19][20] Nypaver et al 19 reported that aortic control immediately proximal to the renal arteries may prove problematic because of pararenal aortic atherosclerosis or proximity of the superior mesenteric artery to the renal arteries; they advocated supraceliac aortic cross-clamping as a safe and valuable technique for achieving proximal control in complex abdominal aortic repair. In their series, when the supraceliac aortic cross-clamping time was limited to less than 30 min, postoperative vital organ ischemic complications such as renal, hepatic, mesenteric, or spinal cord injury were rare.…”