Objectives: Widespread application of infrarenal endovascular aneurysm repair (EVAR) has resulted in a proportionate increase in open juxtarenal aortic aneurysm (JAA) repairs. Fenestrated endograft technology for JAA is developing rapidly, but only limited outcomes are known. The aim of this study was to review our open JAA experience in an era of fenestrated endograft technology, identify factors associated with increased surgical risk, determine early and midterm outcome, and provide a basis for comparison for future endovascular procedures.
Methods: Data from 126 consecutive patients who underwent elective JAA repair requiring suprarenal aortic clamping from 2001 to 2006 were analyzed retrospectively. Electronic medical chart reviews were used to record 30-day complication rates. Multivariate analyses were performed to identify risk factors associated with surgical morbidity. Mail-out questionnaires and telephone surveys were conducted to determine long-term follow-up.
Results: Ninety-eight males and 28 females (median age 74 years; range 55 to 93) were included in the study. Preoperative risk factors included: coronary artery disease (CAD) 58%, pulmonary disease 41%, renal insufficiency (serum creatinine [Cr] > 1.5mg/dL) 17%, and diabetes 9%. Fifteen patients underwent concomitant renal artery revascularization. Mean operative time was 319 minutes (range 91 to 648). Thirty-day mortality was 1/126 (0.8%). Median hospital length of stay was 7 days (range 3 to 85); median intensive care unit length of stay was 2 days (1 to 64). Complications included renal insufficiency (Cr increase > 0.5 mg/dL) in 22 (18%), cardiac in 17 (13%), and pulmonary in 14 (11%). Five patients required temporary hemodialysis; only one after hospital dismissal. Mean follow-up was 48 months (range 9-80). On multivariate analysis, age > or = 78 years (P = .001), male gender (P = .04), hypertension (P =.01), previous myocardial infarction (P = .047), and diabetes (P =.009) were predictive of cardiac complications. Renal artery revascularization (P = .01) and prior MI (P = .04) were multivariate predictors of pulmonary complications. Both prolonged operative (> or =351 minutes, P = .02) and renal ischemia (> or =23 minutes, P =.004) times predicted postoperative renal insufficiency. One, 3, and 5-year cumulative survival rates were 93.9%, 78.3%, and 63.8%, respectively and were not significantly different than an age- and gender-matched sample of the US population (P = .16). Mortality was not predicted by any specific risk factors.
Conclusions: Open surgical repair of JAA is associated with low mortality and remains the gold standard. Although 18% had renal complications, only one patient had permanent renal failure. Patients with a combination of physiologic and anatomic risk factors identified on multivariate analysis may benefit from fenestrated endograft repair.