title: Incidence of renal infarctions after endovascular AAA repair: relationship to infrarenal versus suprarenal fixation.
abstract: OBJECTIVE
  To analyze the incidence and etiology of renal infarctions following endovascular abdominal aortic aneurysm (AAA) repair detected on computed tomography (CT) and determine any association with infrarenal versus suprarenal fixation.
  
  
  METHODS
  Between August 1994 and October 2001, 663 patients (604 men; mean age 68.5 years, range 40-98) underwent endovascular AAA repair with predominately bifurcated (505, 77%) stent-grafts. About a third (202, 30%) of the devices were deployed in a suprarenal position. Contrast-enhanced CT scans were performed on days 10, 90, and 365 after operation and then annually. Two radiologists blinded to procedural details compared the preoperative and postoperative scans to identify renal infarctions from inadvertent renal artery occlusion by the endograft. Only patients with inadvertent infarctions were analyzed relative to endograft fixation position and stent-graft type.
  
  
  RESULTS
  Mean follow-up was 37 months (range 0.1-75). Overall renal infarction rate was 11.9% (n=79); 23 (3.4%) patients suffered from limited, segmental infarction due to intentional covering of preoperatively diagnosed accessory renal arteries. Unintentional renal ischemia was identified in 56 (8.5%) patients. In this subgroup, 39 (19%) were observed in the 202 patients with suprarenal fixation versus 17 (3.7%) in the 461 stent-grafts positioned infrarenally (RR 3.35, 95% CI 2.20 to 5.04, p<0.00001). There was a significant correlation between the incidence of infarction and the device type (14.3% for modular grafts versus 5.6% for unibody designs, p=0.0002). Seventeen (2.6%) patients suffered from unilateral kidney loss, with dialysis required in 2 cases. Creatinine and urea showed no significant postoperative elevation in the overall patient population, but both levels were significantly (p<0.02) elevated in patients with complete unilateral renal infarcts.
  
  
  CONCLUSIONS
  Transrenal fixation of aortic endografts had a 3-fold higher risk for renal infarction in this large patient population. There is no significant difference for specific endografts, but modular designs were associated with a higher rate of renal infarction. The need to occlude preoperatively diagnosed accessory renal arteries with an endograft should be considered a contraindication for current available devices.
authors.affiliation: Department of Vascular Surgery, University of Heidelberg, Germany. dittmar_boeckler@med.uni-heidelberg.de
authors.forename: Dittmar
authors.initials: D
authors.lastname: Böckler
authors.forename: Martin
authors.initials: M
authors.lastname: Krauss
authors.forename: Ulrich
authors.initials: U
authors.lastname: Mansmann
authors.forename: Mustafa
authors.initials: M
authors.lastname: Halawa
authors.forename: Ralph
authors.initials: R
authors.lastname: Lange
authors.forename: Thomas
authors.initials: T
authors.lastname: Probst
authors.forename: Dieter
authors.initials: D
authors.lastname: Raithel
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D021721:Balloon Occlusion / Q000009:adverse effects* / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D006801:Humans; D015994:Incidence; D007238:Infarction / Q000453:epidemiology* / Q000209:etiology; D007668:Kidney / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011336:Probability; D011379:Prognosis; D011446:Prospective Studies; D012077:Renal Artery; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution; D016019:Survival Analysis