title: Repair of pararenal abdominal aortic aneurysms. An analysis of operative management.
abstract: OBJECTIVE
  To analyze different operative approaches for repair of pararenal abdominal aortic aneurysm, to define factors associated with perioperative morbidity, particularly renal insufficiency, and to compare the results of pararenal abdominal aortic aneurysm repair with standard infrarenal repair.
  
  
  METHODS
  Case series review of all patients undergoing repair of nonruptured pararenal abdominal aortic aneurysms over 7 consecutive years at a tertiary care teaching hospital.
  
  
  METHODS
  Fifty-three consecutive patients with nonruptured atherosclerotic pararenal abdominal aortic aneurysms undergoing operative repair. A comparison group of 65 patients randomly selected from a pool of 384 patients undergoing concurrent infrarenal abdominal aortic aneurysm repair.
  
  
  METHODS
  Operative morbidity and mortality, postoperative renal insufficiency, estimated blood loss, perioperative blood and fluid requirements, and length of hospital stay.
  
  
  RESULTS
  Postoperative renal insufficiency was more likely when concomitant renal revascularization was performed (P = .007) or when any major intraoperative complication occurred (P = .008). Retroperitoneal abdominal aortic aneurysm repair was associated with lower estimated blood loss (P = .05) and less fluid requirement within the first 24 hours following operation than transperitoneal repair (P = .03). No differences in outcome measures were identified with regard to site of proximal aortic clamping (supraceliac vs suprarenal). Pararenal abdominal aortic aneurysms were larger and their repair was associated with greater estimated blood loss (P = .007), intraoperative blood replacement (P < .001), and a longer hospital stay (P = .02) than infrarenal abdominal aortic aneurysms.
  
  
  CONCLUSIONS
  Pararenal abdominal aortic aneurysm repair is a technically challenging operation associated with significant morbidity. A retroperitoneal approach facilitates repair. The site of proximal aortic cross-clamping should be dictated by technical factors and not by any perceived outcome advantages.
authors.affiliation: Division of Vascular Surgery, Henry Ford Hospital, Detroit, Mich.
authors.forename: T J
authors.initials: TJ
authors.lastname: Nypaver
authors.forename: A D
authors.initials: AD
authors.lastname: Shepard
authors.forename: D J
authors.initials: DJ
authors.lastname: Reddy
authors.forename: J P
authors.initials: JP
authors.lastname: Elliott
authors.forename: R F
authors.initials: RF
authors.lastname: Smith
authors.forename: C B
authors.initials: CB
authors.lastname: Ernst
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D011446:Prospective Studies; D012077:Renal Artery / Q000601:surgery; D012086:Reoperation; D015996:Survival Rate; D016896:Treatment Outcome