Sarac Timur P, Clair Daniel G, Hertzer Norman R, Greenberg Roy K, Krajewski Leonard P, O'Hara Patrick J, Ouriel Kenneth
Department of Vascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
J Vasc Surg. 2002 Dec;36(6):1104-11. doi: 10.1067/mva.2002.129638.
The increasing use of aortic endografts predictably will add to the complexity of open abdominal aortic aneurysm (AAA) repair and, therefore, the proportion of surgically treated infrarenal AAAs that are juxtarenal in location (JRA) will grow. This study reviews a single-center experience with JRAs.
Between June 1994 and December 2000, 138 patients underwent elective repair of a JRA, comprising 16.1% of 859 consecutive asymptomatic and intact symptomatic nonruptured infrarenal AAAs repaired over the same period. All patients with JRA needed proximal suprarenal clamping (SRC) or supravisceral (SVC) clamping. Patient demographics, selected risk factors, and operative details were recorded. Univariate analyses of selected risk factors for an adverse perioperative event were assessed, and multivariate analyses were performed with linear and logistic regression with backwards selection.
SRC was used in 95 patients (69%), and 43 patients (31%) underwent SVC. The mortality rate was 5.1% (7/138) for JRA repair, and 2.8% (20/720) for infrarenal AAA repair (P =.03). The mortality rate was significantly greater for those patients who received SVC compared with SRC (11.6% versus 2.1%; P =.02). Multivariate analysis identified SVC position as the only independent predictor of mortality (odds ratio [OR], 6.1; 95% CI, 1.1 to 32.9; P =.035). Transient renal insufficiency occurred in 39 patients (28.3%), but only eight patients (5.8%) needed dialysis. Patients who had SVC had a significantly greater rate of renal insufficiency than those who received SRC (41.9% versus 22.1%; P =.02). Multivariate analysis showed SVC position (OR, 3.3; 95% CI, 1.4 to 7.8; P =.008), diabetes (OR, 3.7; 95% CI, 1.1 to 12.9; P =.04), and preoperative renal insufficiency (OR, 5.8; 95% CI, 2.2 to 15.4; P <.001) were independent predictors of postoperative renal insufficiency. Renal ischemia during proximal clamping cannot alone explain renal complications because clamp time was shorter in patients with SVC (24.9 +/- 2.4 minutes versus 32.2 +/- 1.5 minutes; P =.009).
JRA repair can be accomplished with a low mortality rate, but a more proximal clamp position may adversely affect outcome in these patients. Postoperative renal insufficiency is related to diabetes, preoperative renal insufficiency, and SVC position. These results suggest SRC is safer than SVC for proximal aortic clamp control of JRAs. Although clamp level must be tailored to patient anatomy, outcome may be improved if the clamp level can be kept distal to the superior mesenteric artery origin.
主动脉腔内移植物使用的增加可预见地会增加开放性腹主动脉瘤（AAA）修复的复杂性，因此，手术治疗的肾下型AAA中位于肾旁位置（JRA）的比例将会增加。本研究回顾了单中心治疗JRA的经验。
1994年6月至2000年12月期间，138例患者接受了JRA择期修复手术，占同期连续859例无症状且症状未破裂的肾下型AAA择期修复手术患者的16.1%。所有JRA患者均需要近端肾上腺钳夹（SRC）或内脏上钳夹（SVC）。记录患者的人口统计学资料、选定的危险因素和手术细节。对选定的围手术期不良事件危险因素进行单因素分析，并采用向后选择的线性和逻辑回归进行多因素分析。
95例患者（69%）使用了SRC，43例患者（31%）接受了SVC。JRA修复的死亡率为5.1%（7/138），肾下型AAA修复的死亡率为2.8%（20/720）（P = 0.03）。接受SVC的患者死亡率显著高于接受SRC的患者（11.6%对2.1%；P = 0.02）。多因素分析确定SVC位置是死亡率的唯一独立预测因素（比值比[OR]，6.1；95%可信区间，1.1至32.9；P = 0.035）。39例患者（28.3%）发生短暂性肾功能不全，但仅8例患者（5.8%）需要透析。接受SVC的患者肾功能不全发生率显著高于接受SRC的患者（41.9%对22.1%；P = 0.02）。多因素分析显示SVC位置（OR，3.3；95%可信区间，1.4至7.8；P = 0.008）、糖尿病（OR，3.7；95%可信区间，1.1至12.9；P = 0.04）和术前肾功能不全（OR，5.8；95%可信区间，2.2至15.4；P < 0.001）是术后肾功能不全的独立预测因素。近端钳夹期间的肾缺血不能单独解释肾脏并发症，因为SVC患者的钳夹时间较短（24.�±2.4分钟对32.2±1.5分钟；P = 0.009）。
JRA修复可实现低死亡率，但更靠近近端的钳夹位置可能对这些患者的预后产生不利影响。术后肾功能不全与糖尿病、术前肾功能不全和SVC位置有关。这些结果表明，对于JRA的近端主动脉钳夹控制，SRC比SVC更安全。虽然钳夹水平必须根据患者解剖结构进行调整，但如果钳夹水平能保持在肠系膜上动脉起始部的远端，可能会改善预后。
