Outcomes of accessory renal artery occlusion during endovascular aneurysm repair.

OBJECTIVE: Accessory renal arteries are frequently encountered when patients are evaluated for endovascular abdominal aortic aneurysm repair (EVAR). Some have considered their presence a contraindication to EVAR in fear of endoleak and the end result of renal function. We sought to determine whether the coverage of accessory renal arteries during EVAR was associated with any adverse sequelae.
METHODS: Retrospective review of the medical records and computed tomographic scans of all patients undergoing EVAR (1998 to 2003) was performed. Note was made of the presence or absence of accessory renal arteries, hypertension, and renal function. Preoperative computed tomographic images were compared with postoperative images to determine the presence of renal infarction. A control group of 26 consecutive patients without accessory renal arteries was used for comparison of the results of EVAR.
RESULTS: EVAR was performed in 550 patients over the study interval. The mean follow-up was 16 months (range, 1-48 months). The average age was 74 years (range, 57-90 years). Thirty-five patients (6.6%; 32 male and 3 female) were documented to have accessory renal arteries; the average number of accessory arteries was 2 (range, 1-4). Bilateral accessory arteries were present in 13 patients: all but 1 patient (n = 34) had a left-sided accessory renal artery, and 23 had a right-sided accessory renal artery. EVAR was performed with a variety of endografts: AneuRx (n = 10), Talent (n = 7), PowerLink (n = 7), Zenith (n = 5), LifePath (n = 4), and Ancure (n = 2). There were no mortalities. Twelve endoleaks were documented: three type I, eight type II, and one type III. The accessory renal arteries were not implicated in any of the endoleaks, and none of these accessory vessels was embolized before or after EVAR. Seven patients (20%) had renal infarcts associated with EVAR that were noted on follow-up computed tomographic scans. The mean follow-up for patients with segmental infarction was 23 months (range, 8-48 months). Hypertensive status did not change in any patient in whom an accessory renal artery had been covered. The average serum creatinine was 1.08 mg/dL (range, 0.6-1.8 mg/dL) before EVAR in patients with accessory renal arteries covered by an endovascular graft and did not change significantly in response to EVAR. Serum creatinine increased almost twofold in two patients but spontaneously resolved in follow-up. The average preoperative creatinine clearance was 79 mL/min (range, 35-166 mL/min) in patients without an accessory renal artery and was 80 mL/min (range, 35-167 mL/min) after EVAR. The average preoperative creatinine clearance was 67 mL/min (range, 31-137 mL/min) in patients with an accessory renal artery and 68 mL/min (range, 45-83 mL/min) in patients with renal infarcts. None of the patients required temporary or permanent dialysis. There was no difference between control patients and patients with covered accessory renal arteries with respect to hypertensive status, presence of renal infarcts, serum creatinine, or creatinine clearance after EVAR.
CONCLUSIONS: Occlusion of accessory renal arteries is not associated with clinically significant signs or symptoms, even in patients with mild or moderate renal insufficiency. Sacrifice of accessory renal arteries most commonly does not lead to detectable renal infarction, either clinically or radiographically. When segmental infarction of the kidney does result, it seems to be well tolerated in this group of patients. Accessory renal arteries were not found to contribute to endoleaks and should not be prophylactically embolized.