Can an accessory renal artery be safely covered during endovascular aortic aneurysm repair?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether coverage of an accessory renal artery (ARA) in patients undergoing endovascular aortic aneurysm repair (EVAR) is associated with increased risk of renal impairment. Altogether, 106 papers were located using the reported searches, of which 5 represented the best evidence to answer the question. The authors, journal, date and country of publication, study type, patient group studied, relevant outcomes parameters and results of these papers are tabulated. Our best evidence analysis included 116 patients who had one or more ARA excluded during EVAR. Segmental renal infarction occurred in varying numbers of patients (ranging from 0 to 84%). The authors consistently demonstrate that loss of renal mass is not associated with functional renal impairment, expressed by various outcome parameters such as serum creatinine, glomerular filtration rate (GFR), renal failure requiring dialysis and worsening hypertension. Comparisons of groups of patient with covered or preserved ARAs by one of the selected studies showed no difference in any of these renal outcome parameters, apart from a significantly higher renal infarct volume in the former group (P < 0.001). Subgroup analysis of patients with pre-existing renal dysfunction (GFR < 60 ml/h/m(2)) showed no difference in GFR change when comparing covered with uncovered ARA patient cohorts. No type II endoleak related to the covered ARA was reported in any of these studies. In conclusion, current evidence supports the safety of coverage of ARAs located in the proximal fixation zone to achieve seal in EVAR.