Marrocco-Trischitta Massimiliano M, Melissano Germano, Kahlberg Andrea, Vezzoli Giuseppe, Calori Giliola, Chiesa Roberto
Department of Vascular Surgery, San Raffaele Scientific Institute, Università Vita-Salute, San Raffaele, Milan, Italy.
Ann Vasc Surg. 2009 Nov-Dec;23(6):770-7. doi: 10.1016/j.avsg.2009.04.002. Epub 2009 Jul 19.
Open repair of juxtarenal abdominal aortic aneurysms (JAAAs), which necessitates clamping above one (interrenal clamping, interRC) or both renal arteries (suprarenal clamping, supraRC), is associated with an increased risk of perioperative renal derangements. We reviewed our experience to investigate the impact of aortic clamping site during JAAA repair on peri- and postoperative glomerular filtration rate (GFR).
Between January 2001 and March 2006, 32 patients (28 male, four female; mean age 70.5+/-5.6 years) were submitted to elective open repair of JAAA. SupraRC was required in 12 patients and performed with cold renal perfusion (CRP) in five cases; interRC was required in 20 and performed with CRP in eight. GFRs were estimated through postoperative day 4 using the Cockcroft-Gault equation and compared to those of concurrent controls undergoing infrarenal AAA repair, matched 1:1 by gender, age, aneurysm size, preoperative GFR, and left renal vein management. GFR values were also evaluated and compared between groups at a mean follow-up of 29.0+/-23.7 months. Renal dysfunction was defined as a decrease of GFR >or=20%. Statistics were determined as appropriate for the variables of interest.
No perioperative mortality was recorded and no differences in major complication rates were observed between groups (p=0.16). Operative time was longer in JAAA patients (154+/-47 vs. 132+/-41 min, p=0.019). Mean renal ischemia time was 16.7+/-7.7 min. Postoperatively, GFR values up to day 4 were significantly worse in JAAA patients compared to controls (p=0.0007), with a fourfold risk of renal dysfunction at postoperative day 4 (34% vs. 9%, odds ratio [OR]=4.44, 95% confidence interval [CI] 1.1-18.1; p=0.029). At univariate analysis, supraRC was found to be the only factor associated with perioperative renal dysfunction (OR=11.3, 95% CI 2.0-63.1; p=0.003). At follow-up, two patients with supraRC died and another two required dialysis permanently. When compared to those with interRC or infrarenal clamping, patients with supraRC showed a persistent renal dysfunction at follow-up (p=0.005).
Elective JAAA repair with renal ischemia time <or=30 min is safe, but supraRC entails a significant perioperative and mid-term GFR reduction. In contrast, interRC provides results similar to those obtained after infrarenal AAA repair, allowing postoperative recovery of renal function to preoperative values.
肾旁腹主动脉瘤（JAAA）的开放修复术需要在一侧肾动脉上方（肾间阻断，interRC）或双侧肾动脉上方（肾上腺上阻断，supraRC）进行阻断，这与围手术期肾功能紊乱风险增加相关。我们回顾了我们的经验，以研究JAAA修复术中主动脉阻断部位对围手术期和术后肾小球滤过率（GFR）的影响。
2001年1月至2006年3月期间，32例患者（28例男性，4例女性；平均年龄70.5±5.6岁）接受了JAAA择期开放修复术。12例患者需要supraRC，其中5例采用冷肾灌注（CRP）；20例患者需要interRC，其中8例采用CRP。使用Cockcroft-Gault方程评估术后第4天的GFR，并与同期接受肾下腹主动脉瘤修复术的对照组进行比较，对照组按性别、年龄、动脉瘤大小、术前GFR和左肾静脉处理情况1:1匹配。在平均随访29.0±23.7个月时，也对两组的GFR值进行了评估和比较。肾功能不全定义为GFR下降≥20%。根据感兴趣的变量适当确定统计方法。
未记录围手术期死亡病例，两组间主要并发症发生率无差异（p=0.16）。JAAA患者的手术时间更长（154±47 vs. 132±41分钟，p=0.019）。平均肾缺血时间为16.7±7.7分钟。术后，JAAA患者术后第4天的GFR值明显低于对照组（p=0.0007），术后第4天肾功能不全的风险增加四倍（34% vs. 9%，优势比[OR]=4.44，95%置信区间[CI] 1.1-18.1；p=0.029）。单因素分析发现，supraRC是围手术期肾功能不全的唯一相关因素（OR=11.3，95% CI 2.0-63.1；p=0.003）。随访时，2例接受supraRC的患者死亡，另外2例需要永久透析。与接受interRC或肾下阻断的患者相比，接受supraRC的患者在随访时表现出持续性肾功能不全（p=0.005）。
肾缺血时间≤30分钟的JAAA择期修复术是安全的，但supraRC会导致围手术期和中期GFR显著降低。相比之下，interRC的结果与肾下腹主动脉瘤修复术后相似，可使术后肾功能恢复到术前水平。
