Open Repair with Suprarenal Clamp Placement is ... - VascularWeb
Open Repair with Suprarenal Clamp Placement is ... - VascularWeb
Open Repair with Suprarenal Clamp Placement is ... - VascularWeb
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<strong>Open</strong> <strong>Repair</strong> <strong>with</strong> <strong>Suprarenal</strong> <strong>Clamp</strong><strong>Placement</strong> <strong>is</strong> the Best WayMark F. Conrad, MD, MMScDiv<strong>is</strong>ion of Vascular and Endovascular Surgery,Massachusetts General Hospital,Ass<strong>is</strong>tant Professor of Surgery, Harvard Medical School
D<strong>is</strong>closuresNone
Outline• MGH Experience• Review of Literature• Snorkel/ Chimney• Fenestrated Grafts
Methods227 patients treated at MGH from 2001 – 2007<strong>Open</strong> JAAA Resectiondefined by need for a suprarenal clampExcluded type IV Thoracoabdominal aneurysms
True Juxtarenal/PararenalAneurysmsInfrarenal neck ≤ 1cm clamp placement needsto be suprarenal/supraceliac
<strong>Suprarenal</strong> AneurysmsOne or both renals originate from AAA separate reconstruction
Demographic and Clinical FactorsVariable %Male 71%Mean Age 75 (51-95)HTN 88%Renal Insufficiency (Cr>1.5) 21%COPD 18%Cardiac 38%Diabetes 10%Smoking 76%Steroids 4.4%
Anatomic/Treatment FeaturesOperative approach %Left flank 92%Dacron 96%Tube 83%Proximal <strong>Clamp</strong><strong>Suprarenal</strong>SupramesentericSupraceliac71%13%16%
Renal ReconstructionRenal reconstructionNTotal patients 57 (25%)Aortorenal bypass 45Renal artery stent (intra-op) 11Renal orifice endarterectomy 6Renal artery re-implantation 2
30 Day OutcomesComplicationElectiveDeath 6 (2.9%)Renal insufficiency 19 (9.5%)Dialys<strong>is</strong> 4 (2%)
Freedom from all cause Mortality120100Non-rupturedRuptured% Survival806074%402028% p
Pre-operative predictors of mortalityIn non-ruptured patients:RR CI p valueCreatinine 1.73 1.10-2.58 0.02Steroids 2.20 1.39-3.23
Surveillance Imaging75% of survivors (112 of 149 patients)mean 40 monthsRenal artery patencyLong term anatomic follow-up
Surveillance Imaging – Renal arteryPatency160 Renal arteries imaged <strong>with</strong> contrastPatentThrombosedNative 140 (98.5%) 2 (1.5%)Bypass 10 (77%) 3 (23%)Stents 5 (100%) 0
Surveillance Imaging – Anatomicfollow-upNo anastomotic pseudoaneurysms2 patients (1.8%) <strong>with</strong> contiguous aneurysmaldegeneration30 patients (27%) were diagnosed <strong>with</strong> remoteaneurysms on follow-up imaging12 (30%) iliac aneurysms14 descending thoracic aortic aneurysms4 TEVAR1 open repair
Long term Renal functionFollow-up Creatinine in 118 patientsAverage 44.7 months (range 2-105)17% followed >5yrsAdditional 3% of patients developed CRI (totalof 12%)2 patients <strong>with</strong> peri-operative renal insufficiencyprogressed to dialys<strong>is</strong>
<strong>Open</strong> JAA <strong>Repair</strong> - Mayo126 Consecutive patients (6yrs)15 renal artery procedures (10 end)30 day mortality .8%Renal Insufficiency 18% (5 HD)
Aortorenal Bypass60 pts renovasc reconstruction w/ AAA46 graft, 17 Carrel patch30 day mortality 1.7%Renal Insufficiency 33% (No perm HD)
Systemic ReviewMeta analys<strong>is</strong> of 21studies<strong>Open</strong> JAAA repair30 day mortality 2.9%New onset Dialys<strong>is</strong> 3.3%
Chimney StentsMidterm results show 72 Patients safety and feasibility<strong>with</strong> excellent Procedure patency Related and Mortality a low incidence 0% ofendoleaks 12 month follow-up
Comparative Data21 Chimney vs. 21 <strong>Open</strong>It appears 30-day to have mortality similar equal mortality 4.8% to openrepair but long-term AKI 29% durability vs. 5% open remains to bedetermined 12mo patency 84%
Fenestrated Stent GraftsInitial U.S. multicenter data 1French Multicenter Experience 2High technical successPeri-operative mortality 2%4% peri-operative dialys<strong>is</strong>4 (3%) renal artery occlusionsLimited to 2 year follow-up1. Greenberg RK et al. J Vasc Surg 2009; 50: 730.2. Amiot S et al. Eur J Endovasc Surg 2010; 39: 537.
Off the Shelf Fenestrated Stent GraftsCurrently in US multicenter trialPre-loaded sheaths for renalselectionMesenteric ScallopFabric redundancy adjusts forvariation in renal anatomyBasic configuration will treat 80%of JAA aneurysms
Long-term Results100 patients over 8 yearsFenestrated Cook Zenith30-day mortality 1%25% of patients had deterioration of renal fxn5 yr survival 59%
SummaryOutcome <strong>Open</strong> Chimney Fenestration30-day Mortality 3% 0-5% 1%5-year Survival 75% NA 59%Renal Insufficiency 12-30% 33% 25%Dialys<strong>is</strong> 3% NA NA
Conclusion<strong>Open</strong> JAAA repair remains the gold standard <strong>with</strong> anelective peri-operative mortality of 2.9%, renalinsufficiency of 12%, and excellent long-termdurability.Fenestrated grafts will increase endovascular optionsfor JAAA but progressive loss of renal functionremains a problem.Alternative therapies such as chimney grafts andhome-made fenestrations have had early successbut little <strong>is</strong> known regarding their durability.
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