Altered renal functions in patients with occlusion of an accessory renal artery after endovascular stenting of an infrarenal aneurysm

Clinical and Radiological Outcomes of Accessory Renal Artery Exclusion during Endovascular Repair of Abdominal Aortic Aneurysms

BACKGROUND

Accessory renal arteries (ARAs) frequently coexist with abdominal aortic aneurysms (AAA) and can influence treatment. This study aimed to retrospectively analyze the ARA's exclusion effect on patients undergoing standard endovascular aneurysm repair for AAA.

METHODS

The study focused on medium- and long-term outcomes, including type II endoleak, aneurysmal sac changes, mortality, reoperation rates, renal function, and infarction post-operatively.

RESULTS

76 patients treated with EVAR for AAA were included. One hundred and two ARAs were identified: 69 originated from the neck, 30 from the sac, and 3 from the iliac arteries. The ARA treatment was embolization in 15 patients and coverage in 72. Technical success was 100%. One-month post-operative computed tomography angiography (CTA) revealed that 76 ARAs (74.51%) were excluded. Thirty-day complications included renal deterioration in 7 patients (9.21%) and a blood pressure increase in 15 (19.73%). During follow-up, 16 patients (21.05%) died, with three aneurysm-related deaths (3.94%). ARA-related type II endoleak (T2EL) was significantly associated with the ARA's origin in the aneurysmatic sac. Despite reinterventions were not significantly linked to any factor, post-operative renal infarction was correlated with an ARA diameter greater than 3 mm and ARA embolization.

CONCLUSION

ARAs can influence EVAR outcomes, with anatomical and procedural factors associated with T2EL and renal infarction. Further studies are needed to optimize the management of ARAs during EVAR.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms

BACKGROUND

There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required.

METHODS

Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency.

RESULTS

Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality.

CONCLUSION

Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation.

Reconstruction of the accessory renal artery with autogenous vessels in aortic hybrid surgery: A case report

OBJECTIVE

Accessory renal artery (ARA) is a common variant of renal vessels. Currently, there are some controversies about reconstruction strategy and few cases reported in the literature. Individualized treatment should be carried out according to preoperative renal function evaluation and technical level.

METHODS

In this paper, a 50-year-old male patient was reported, who developed a dissecting aneurysm after thoracic endovascular aortic repair (TEVAR) and needed further intervention. Imaging showed that the left kidney was supplied by bilateral renal artery (false lumens), and there were left renal malperfusion complicated with abnormal renal function.

RESULTS

Autologous blood vessels were used to successfully reconstruct ARA with during hybrid surgery. Renal perfusion and renal function recovered rapidly after operation. There was no abnormality in renal indexes after 3 months follow-up.

CONCLUSION

It is beneficial and necessary to reconstruct ARA for patients with renal malperfusion or abnormal renal function before operation.

The preservation of accessory renal arteries should be considered the treatment of choice in complex endovascular aortic repair

OBJECTIVE

To evaluate renal function and renal parenchymal length changes secondary to the coverage or preservation of accessory renal arteries (ARA) in complex aortic repair.

METHODS

Single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f-b EVAR) who present ARA. Two groups were created, a preserved ARA group, with incorporation of the vessel as a dedicated fenestration or branch in the endograft plan, and a non-preserved ARA group, without incorporation of them. Early >30% decline of glomerular filtration rate (GFR), kidney infarcts and endoleaks (EL) were evaluated. Mid-term results with freedom from kidney shrinkage (defined as length decrease > 10%) at follow-up, freedom from GFR decrease >30% or need for postoperative dialysis at follow-up were also analyzed. Primary assisted patency of incorporated ARA was calculated.

RESULTS

From 2011-2020, 145 patients undergoing complex aortic repair presented with an ARA. After excluding ruptured aneurysms, 33 patients had the ARA preserved with their incorporation into the stentgraft (preserved ARA group), and 99 did not have preservation of them (not-preserved ARA group). There were no statistical differences in demographics or type of aneurysm. Patients in the ARA-preserved group had more ARA (median of 2 per patient vs 1 in the non-preserved ARA group, p 0,01) and bigger ARA (median 4 vs 3 mm in the non-preserved ARA group, p 0,001).Early postoperative worsening >30% of GFR (23 vs 6%, p 0,03) as well as postoperative renal infarction (57% vs 6%, p 0,001) and ARA-related EL (20 vs 0%, p 0,01) were statistically higher for the not-preserved ARA group.Mid-term kidney length showed significant shrinkage in the not-preserved ARA group compared to the ARA preserved group (9,7 vs 0%, p 0,001). Freedom from >30% GFR decline at 2 years was significantly higher for the preserved ARA group (83% vs 47%, p 0,01).Two-years primary assisted patency of incorporated ARA was 94%.

CONCLUSIONS

In complex aortic repair incorporation of ARA is feasible, with low complications and good primary assisted patency at 2 years. It leads to less postoperative early renal dysfunction as well as higher freedom for mid-term renal disfunction and kidney shrinkage.

Clinical effect of accessory renal artery coverage after endovascular repair of aneurysms in abdominal and thoracoabdominal aorta

BACKGROUND

The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms.

METHODS

An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality.

RESULTS

Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I² = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I² = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I² = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I² = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I² = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I² = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I² = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I² = 0%).

CONCLUSIONS

ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.

Impact of Accessory Renal Artery Coverage on Renal Function during Endovascular Aortic Aneurysm Repair

BACKGROUND

Long-term outcomes of accessory renal artery (ARA) coverage after endovascular aneurysm repair (EVAR) are unknown. We analyzed the impact of ARA coverage on renal function long-term.

METHODS

This retrospective, monocentric study included patients treated by EVAR between 2008 and 2016. Patients with at least one ARA covered with EVAR (ARA group) were compared with patients with no covered ARA (control group). Renal function was determined by estimating the glomerular filtration rate (eGFR) and graded according to chronic kidney disease (CKD) classification stages.

RESULTS

A total of 184 patients were included (ARA group, n = 25; control group, n = 159). Renal risk factors were similar in the 2 groups. Mean (±standard deviation) duration of follow-up was 41.6 ± 25.8 months. Preoperative eGFR (mL/min/1.73 m²) was 68.9 ± 17.8 in the ARA group and 72.5 ± 17.4 in the control group (P = 0.33), with a similar decline in the 2 groups during follow-up (-6.52 ± 11.6 ARA group vs. -6.43 ± 13.8 control group; P = 0.97). At the end of the study, 8 ARA patients and 56 controls had deteriorated by one CKD stage (32% vs. 35.2%, respectively; P = 0.75). Rate of renal infarction was significantly higher in the ARA group (96% vs. 1.9%; P < 0.0001). In multivariate analysis, suprarenal fixation was identified as a risk factor for a decline in renal function (odds ratio = 2.01 [95% confidence interval: 1.05-3.84]; P = 0.04).

CONCLUSIONS

ARA coverage after EVAR does not appear to affect renal function long-term. Suprarenal fixation led to a greater decline in renal function.

Smoking Associated T-Cell Imbalance in Patients With Chronic Pain

INTRODUCTION

Smoking is associated with several diseases and affects the immune system. Recently, published data demonstrate an involvement of T helper 17 cells (Th17) and regulatory T cells (Tregs) in the pathogenesis of chronic pain and pain intensity. The role of these T-cell subsets in smoking patients with chronic pain is nebulous so far. We therefore analyzed Th17 cells and Tregs in smokers and nonsmokers with chronic pain.

METHODS

Analyses of T-cell subsets, mRNA expression and T-cell related cytokine profiles were done in 44 patients with chronic pain. Twenty-two of these patients were smokers. Numbers of T-cell subsets were quantified by flow cytometry. mRNA expression of the Th17- (RAR-related orphan receptor gamma) and Treg (forkhead box protein P3)-specific transcription factors was determined by quantitative real-time PCR, and levels of cytokines were measured by Human Cytokine Multiplex Immunoassay.

RESULTS

Compared to nonsmokers, smokers showed significantly enhanced pain levels. On cellular basis, the number of pro-inflammatory Th17 cells (smokers: 2.2 ± 2.5% vs. nonsmokers: 0.5 ± 0.4%; p = .04) was increased, whereas the number of anti-inflammatory Tregs (smokers: 2.5 ± 0.9% vs. nonsmokers: 3.1 ± 1.1%; p = .02) was significantly decreased, resulting in an altered Th17/Treg ratio (Th17/Treg ratio: 0.9 ± 1.0 in smokers vs. 0.2 ± 0.1 in nonsmokers; p < .01). These findings were confirmed by quantitative real-time PCR. Analyses of cytokines revealed only marginal changes.

CONCLUSIONS

In patients with chronic pain, smoking is associated with enhanced pain levels together with an imbalance of the Th17/Treg ratio. The shift of the Th17/Treg ratio toward inflammation may explain in part the increased pain intensity in these patients.

IMPLICATIONS

Smoking is associated with increased pain levels and a pro-inflammatory Th17/Treg shift. The altered Th17/Treg ratio in smoking patients with chronic pain may partly explain their increased pain intensity.

GERMAN CLINICAL TRIAL REGISTER (DRKS)

Registration Trial DRKS00005954.

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair

OBJECTIVE

The objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms.

METHODS

We analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts.

RESULTS

There were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD.

CONCLUSIONS

Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.

Relationship between Accessory Renal Artery and Clinical Characteristics of Middle-Aged Patients with Primary Hypertension

Objectives

The association between accessory renal artery (ARA) and hypertension remains not fully understood. We observed the association between ARA and clinical characteristics among middle-aged patients with primary hypertension.

Methods

One hundred and sixty-two middle-aged (mean 39.82 ± 10.25 years, 58.0% male) patients with primary hypertension were enrolled, and patients underwent Computed Tomography Angiography (CTA) of renal arteries, ambulatory blood pressure monitor (ABPM), echocardiography, physical examination, and routine blood chemistry examinations. According to the CTA results, patients were divided into a non-ARA (n = 108) and ARA (n = 54) group. Direct renin concentration (DRC), plasma aldosterone concentration (PAC), ABPM, echocardiography, creatinine, and glomerular filtration rate were compared between the two groups.

Results

DRC (mU/L) (11.21 (5.34, 20.87) vs. 18.24 (10.32, 33.59), P=0.002) was significantly higher in the ARA group than in the non-ARA group. However, PAC (ng/dL) (98.30 (67.30, 134.00) vs. 116.50 (78.80, 137.25), P=0.103) was similar between these two groups. ABPM (mmHg) results showed that daytime (146.75 ± 17.04/95.86 ± 11.39 vs. 155.50 ± 14.76/100.48 ± 10.69, P < 0.05), night time (133.44 ± 17.50/85.28 ± 12.80 vs. 139.81 ± 14.64/89.83 ± 11.21, P < 0.05), and 24 h blood pressure (143.95 ± 15.99/93.90 ± 11.78 vs. 152.07 ± 13.85/98.11 ± 10.36, P < 0.05) were significantly higher in the ARA group than in the non-ARA group. Accordingly, echocardiographic-derived posterior left ventricular wall thickness value was higher in the ARA group than in the non-ARA group.

Conclusion

ARA is related to higher blood pressure and higher direct renin concentration in middle-aged patients with primary hypertension, and these patients deserve stricter blood pressure control. Our results provide important evidence for that ARA is a cause of hypertension and target organs damages.

Outcomes of Small Renal Artery Targets in Patients Treated by Fenestrated-Branched Endovascular Aortic Repair

OBJECTIVE

The aim was to evaluate renal related outcomes in patients who had incorporation of a small (<4.0 mm) renal artery (RA) during fenestrated-branched endovascular aortic repair (F-BEVAR).

METHODS

A total of 215 consecutive patients enrolled in a prospective F-BEVAR trial were reviewed. Computed tomography angiography centreline of flow reconstruction was used to measure mean RA diameter. Patients who had at least one <4.0 mm main or accessory RA incorporated by fenestration or directional branch (study group) were compared with patients who had incorporation of two ≥5.0 mm RAs (control group). Endpoints were technical success of RA incorporation, RA rupture and kidney loss, primary and secondary RA patency, RA branch instability and re-interventions, and renal function deterioration.

RESULTS

Twenty-four patients with 28 <4.0 mm RAs (16 accessory and 12 main RAs) were compared with 144 patients with 288 ≥5.0 mm incorporated RAs. Study group patients were significantly younger than controls (72 ± 8 vs. 75 ± 8 years, p = .04) and more often females (46% vs. 21%, p = .018); there were no differences in cardiovascular risk factors and aneurysm extent. Technical success was 92% for <4.0 mm and 99% for ≥5.0 mm RA incorporation (p = .05). Inadvertent RA rupture occurred in three patients in the study group (13%) and in one (1%) in the control group (p = .009) resulting in kidney loss in two study group patients (8%) and one (1%) control group patient (p = .05). At one year, primary patency was 79 ± 9% vs. 94 ± 1% (p < .001) and secondary patency was 84 ± 8% vs. 97 ± 1% (p < .001) for study vs. control group; freedom from branch instability was 79 ± 9% vs. 93 ± 2% (p = .005), respectively. There were no differences in re-intervention rates and renal function deterioration between the groups. The mean follow up time was 21 ± 14 months.

CONCLUSION

Incorporation of <4.0 mm RAs during F-BEVAR is associated with lower technical success, higher risk of arterial disruption and kidney loss, and lower patency rates at one year.

CT angiography with 15 mL contrast material injection on time-resolved imaging for endovascular abdominal aortic aneurysm repair

PURPOSE

To assess the utility of whole-aorta CT angiography (CTA) with 15 mL contrast material (CM) on time-resolved imaging for endovascular abdominal aortic repair (EVAR).

METHODS

Twenty-six patients with a high-risk of post-contrast acute kidney injury (PC-AKI) underwent CTA with 15 mL CM using temporal maximum intensity projection (tMIP-CTA) generated from time-resolved imaging. The aortoiliac CT values were measured. Two observers measured the arterial diameters in unenhanced CT and tMIP-CTA images, and image quality was evaluated on a 5-point scale. The presence of the accessory renal artery, inferior mesenteric artery (IMA) occlusion, and instructions for use (IFU) of EVAR were evaluated.

RESULTS

CT examinations were successfully performed, and no patients developed PC-AKI. The mean CT values of the whole aorta were 267.5 ± 51.4 HU, which gradually decreased according to the distal levels of the aorta. Bland-Altman analysis revealed excellent agreement for the external arterial diameter measurements between unenhanced CT and tMIP-CTA. Excellent interobserver agreement was achieved for the measurements of the external (ICCs, 0.910-0.992) and internal arterial diameters (ICCs, 0.895-0.993). Excellent or good overall image quality was achieved in 24 (92 %) patients. The presence of the accessory renal artery, IMA occlusion and the assessment of IFU were in 100 % agreement. Multivariate analysis revealed aortic volume as the most significant independent factor associated with strong aortic enhancement (p = 0.004).

CONCLUSIONS

Whole-aorta tMIP-CTA on time-resolved imaging is useful for maintaining contrast enhancement and image quality for EVAR planning, and can substantially reduce the amount of CM.

Anatomy and Physiology for the Abdominal Aortic Aneurysm Repair

In 2006, commercially produced endovascular aneurysm repair (EVAR) devices were approved by the Japanese Ministry of Health, Labour and Welfare, and their cost began to be covered by Japanese medical insurance. Meanwhile, the number of juxtarenal abdominal aortic aneurysms (AAA) to need the suprarenal clamp are increasing and the number of infra-renal AAAs are decreasing for open repair. In this era when EVAR has been growing rapidly for 11 years, it is a good opportunity to learn the surgical repair of AAA. I review the basic and advanced anatomy and physiology concepts which are needed for abdominal aortic repair, which are the proximal site (exposure of the proximal site, variation of renal arteries, variation of inferior vena cava and left renal vein, arcade of visceral branches of abdominal aorta, and coeliac plexus) and distal site (iliac artery, superior hypogastric plexus, ureter, inferior mesenteric artery, and lumbar arteries) separately. (This is a translation of Jpn J Vasc Surg 2019; 28: 173–177.)

Repair of abdominal aortic aneurysms: preoperative imaging and evaluation

Imaging is a critical component of the pre-procedure evaluation and planning of endovascular aneurysm repair (EVAR). Imaging is the mainstay for proper assessment of procedural candidacy, relevant vascular anatomy, device selection, and surgical approach. Computed tomography angiography (CTA) has long been considered the preferred modality for pre-operative imaging and evaluation prior to EVAR. Recently, advances in image quality and software technology have further enhanced the proceduralist's ability to plan and perform EVAR. In this review, we highlight the current state of the art to provide interventionalists a contemporary assessment of the available tools for pre-operative imaging and evaluation prior to EVAR.

Coverage of Accessory Renal Arteries During Endovascular Aortic Aneurysm Repair: What Are the Consequences and the Implications for Clinical Practice?

An accessory renal artery (ARA) represents an anatomic variation which can challenge endovascular aortic aneurysm repair (EVAR). The aim of this review was to summarize the current knowledge on postoperative outcomes following ARA coverage during EVAR. We performed a systematic literature review. The MEDLINE database was searched on September 2017, and 8 relevant studies were included. The frequency of ARA in patients undergoing EVAR varied between 9.5% and 16.2%, and the frequency of ARA coverage varied between 5.2% and 9.4%. Four reports did not observe any significant changes on postoperative renal function, whereas 1 study reported an early transient increase in creatinine after ARA coverage. The occurrence of renal infarct varied from 20% to 84%. Five studies did not observe endoleaks related to ARA coverage, whereas one reported the occurrence of type II endoleaks in 3 of 18 patients who had ARA coverage. No significant change in blood pressure, mortality, and mean length of hospital stay was observed. The ARA coverage can potentially have renal and vascular consequences, but none of them were critical. Further studies may be useful to identify preoperative criteria that may help to choose the most appropriate surgical approach before ARA coverage.