title: Preservation of Clinically Relevant Accessory Renal Arteries in Infrarenal AAA Patients With Adequate Proximal Landing Zones Undergoing EVAR.
abstract: OBJECTIVE
  To report techniques to preserve the flow to relevant accessory renal arteries (ARA) in patients undergoing infrarenal endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) with adequate landing zones.
  
  
  METHODS
  ARAs that originate inferior to the lowest ipsilateral main renal artery, supply one-third of the renal parenchyma, and having a diameter >4 mm have significant clinical importance. Between May 2012 and January 2015, among 389 high-risk patients with infrarenal AAAs who underwent standard EVAR, 9 (2.3%) patients each presented with a coexistent clinically relevant ARA. Their perfusion was secured by placing covered stents in the target ARA, parallel and outside of the main abdominal, as chimney grafts. Evaluation of acute and chronic renal decline was based on the consensus definition of RIFLE criteria (risk, injury, failure, loss, and end-stage) and chronic kidney disease (CKD) staging system, respectively.
  
  
  RESULTS
  The procedure was completed successfully in all cases. In the immediate postoperative period, no acute kidney injury was observed based on the RIFLE criteria. Eight of the 9 covered stents remained patent during a mean follow-up of 13.8 ± 6.2 months. A single covered stent occlusion was observed 30 days postoperatively with infarction of the caudal pole of the kidney. This patient developed renal function impairment based on the CKD staging system 12 months after the initial procedure. For the remaining 8 patients, improvement of one CKD stage (n=1) or no change (n=7) in the CKD stage was observed.
  
  
  CONCLUSIONS
  In AAA patients unfit for surgical revascularization, EVAR is associated with a significant decline in renal function. For this reason, preservation of relevant coexistent ARAs using the chimney technique should be considered as an option.
authors.affiliation: Department of Vascular Surgery, St Franziskus Hospital Münster, Germany.
authors.forename: Nizar
authors.initials: N
authors.lastname: Abu Bakr
authors.affiliation: Department of Vascular Surgery, St Franziskus Hospital Münster, Germany Clinic for Vascular and Endovascular Surgery, University of Münster, Germany.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Torsello
authors.affiliation: Department of Vascular Surgery, St Franziskus Hospital Münster, Germany Division of Vascular Surgery, University of Thessaloniki, Greece.
authors.forename: Georgios A
authors.initials: GA
authors.lastname: Pitoulias
authors.affiliation: Department of Vascular Surgery, St Franziskus Hospital Münster, Germany.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Stavroulakis
authors.affiliation: Department of Vascular Surgery, St Franziskus Hospital Münster, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Austermann
authors.affiliation: Department of Vascular Surgery, St Franziskus Hospital Münster, Germany konstantinos.donas@gmail.com.
authors.forename: Konstantinos P
authors.initials: KP
authors.lastname: Donas
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation / Q000379:methods*; D000072226:Computed Tomography Angiography; D057510:Endovascular Procedures / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D011474:Prosthesis Design; D012039:Regional Blood Flow; D012077:Renal Artery / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D012079:Renal Circulation; D051436:Renal Insufficiency, Chronic / Q000175:diagnosis / Q000503:physiopathology*; D012307:Risk Factors; D015607:Stents; D016896:Treatment Outcome
keywords: abdominal aortic aneurysm; accessory renal artery; chimney technique; covered stent; endovascular aneurysm repair; renal impairment; stent-graft