Management of pararenal aneurysms of the abdominal aorta.

The operative treatment of 77 patients with atherosclerotic aneurysms of the pararenal aorta (54 juxtarenal and 23 suprarenal) is analyzed. Repair of these complex lesions is formidable because of difficult exposure, renal ischemia and myocardial strain as a result of proximal aortic occlusion, and associated renal atherosclerosis with secondary renal functional impairment. Nineteen (25%) patients were normotensive with normal renal function. Sixteen patients (21%) had hypertension alone and 42 (54%) were hypertensive with abnormal renal function. There were multiple renal arteries in 22% of patients. Aortic reconstruction involved infrarenal graft in 27 patients (35%), infrarenal graft plus pararenal aortic endarterectomy (TEA) in 26 (34%), and infra- and pararenal aortic graft in 24 (31%). Twenty-two patients (30%) had normal renal arteries and therefore no renal reconstruction. Of the 55 patients who required combined aortic and renal artery repair, 24 required renal artery repair because of involvement of the renal arteries by the aneurysm and 31 because of atherosclerotic renal artery disease. TEA was the most common technique of renal artery repair (54 of 93 arteries, 58%), followed by reimplantation (18 arteries) and prosthetic graft (13). The perioperative mortality rate was 1.3%. The perioperative morbidity rate was 28% and consisted principally of renal insufficiency (23%). This was usually transient (44%) and (89%) mild. Renal morbidity was adversely affected by renal ischemia status, severity of renal artery disease and extent of renal revascularization. Following reconstruction, hypertension was cured or improved in 77% of patients and abnormal renal function was cured or improved in 46% and stabilized in an additional 39% of patients. These results show that combined aortic aneurysm repair and renal artery reconstruction can be performed with minimal mortality and an acceptable morbidity. Aggressive intraoperative monitoring is necessary to minimize myocardial complications. Careful attention must be paid to the technical details of the reconstruction, especially in minimizing renal ischemia, to reduce the subsequent incidence of renal function deterioration.