Endovascular repair of proximal para-anastomotic aneurysms after previous open abdominal aortic aneurysm reconstruction.

OBJECTIVE: To evaluate the safety, efficacy and durability of endovascular repair for proximal para-anastomotic aneurysms after previous open abdominal aortic aneurysms prosthetic reconstruction and share our experience. METHODS: We retrospectively reviewed the data of all patients with previous open abdominal aortic aneurysms prosthetic reconstruction who underwent endovascular repair for proximal para-anastomotic aneurysms between May 2003 and January 2013 in our center (Nuremberg South Hospital). Key clinical outcomes included technical success rate, peri-operative morbidity and mortality, mid-term complications, reinterventions and open conversion rates. RESULTS: Totally, 24 patients of proximal para-anastomotic aneurysm were treated by endovascular repair. Successful deployments of stent graft were achieved in all patients (100%). Median hospital stay was 6.7 days. One patient had minor type Ia endoleak and one patient developed wound infection. There were no early open conversions and deaths. During a median follow-up of 43 months (range, 7-67 months), computed tomography angiography revealed type Ia endoleaks in four patients (16.7%). The overall reintervention and open conversion rates during follow-up were 16.7% (4/24) and 4.2% (1/24), respectively. Estimates of freedom from reintervention were 91.7% at 1 year, 87.1% at 3 years and 80.9% at 5 years. There was significant difference in freedom from reintervention between proximal para-anastomotic aneurysms patients treated with tube and unibody bifurcated stent grafts (p = 0.034). The cumulative mortality rate was 12.5% (3/24), actuarial analysis for all patients estimated survival rates of 95.8% at 1 year and 87.3% at 5 years. CONCLUSIONS: Proximal para-anastomotic aneurysms are severe complications after abdominal aortic aneurysm open reconstruction. Closer follow-up and prompt treatment are necessary. Endovascular treatment for proximal para-anastomotic aneurysms is effective, safe and durable. Unibody bifurcated stent graft proved to be suitable for most proximal para-anastomotic aneurysms with various anatomical features.

Preliminary embolization of the hypogastric artery to expand the applicability of endovascular aneurysm repair.

PURPOSE: To evaluate the efficacy and safety of preliminary hypogastric artery (HA) embolization prior to endovascular aneurysm repair (EVAR). METHODS: A retrospective review was conducted of all 101 consecutive patients (91 men; mean age 73.4 ± 8.7 years) who underwent preliminary embolization of 133 HAs ∼4 to 6 weeks prior to EVAR from January 2005 to August 2009. Fourteen patients with 19 HAs were treated using coils, while 87 patients were treated with Amplatzer Vascular Plugs (AVP) in 114 HAs. All the patients were evaluated before discharge; at 1, 3, and 6 months; and annually thereafter to evaluate the clinical symptoms, potential endoleaks, and the aneurysm size. RESULTS: In the coil group, complete occlusion was achieved in 16 (84.2%) of 19 procedures. There were no acute pelvic ischemic symptoms after HA embolization or EVAR. Five (35.7%) patients had buttock claudication and 2 (16.7%) of 12 men experienced new erectile dysfunction after embolization. At a mean 42.2-month follow-up (range 14-58), 3 (21.4%) patients had a type II leak via retrograde flow in the HA without aneurysm growth and were under observation. In the AVP group, all 114 HAs in 87 patients were successfully occluded; there was no device dislodgment or acute pelvic or limb ischemia observed. Buttock claudication and new sexual dysfunction developed in 12 (13.8%) patients and 4 (5.1%) of 79 men after the procedure, respectively. During a mean 26.4-month follow-up (range 4-54), 2 (2.3%) patients developed distal type I endoleaks after EVAR, but angiography confirmed that neither of the endoleaks was related to the vessel embolized with the AVP. Comparing the outcomes of the treatment groups, the AVP was placed with fewer intraoperative complications (p = 0.013) and more complete occlusion (p = 0.01) than coil embolization. The rate of buttock claudication was lower in the AVP group (p = 0.042). CONCLUSION: Hypogastric artery embolization prior to EVAR is safe and effective. In our experience, the AVP affords easier and more precise placement and provides more complete occlusion, with fewer intraoperative and postoperative ischemic complications than coil embolization.

Endovascular treatment of abdominal aortic aneurysms: indications and results.

Endovascular aneurysm repair (EVAR) is an attractive alternative to open surgical approach in treating abdominal aortic aneurysms (AAA). In Nuerenberg in our 14-year experience of 1502 cases (ending December 2007) we used 13 different endografts. The median follow-up was 41 months (1.0-98) and the AAA had a mean diameter of 52.4 mm. Five-hundred and nineteen cases were done using Powerlink grafts. The 30 day mortality was 1.7%. The total reintervention rate was 5.3%, while no distal migration, conversion or post EVAR rupture occurred. At the Army's Center for Cardiovascular Diseases, Bucharest, between July 2008 and December 2009, 15 patients underwent EVAR for AAA. We used the following types of endografts: one Anaconda, three Medtronic Talent, seven Endologix Powerlink and four EVITA Jotec. The mean hospitalization time was three days. Follow-up was done by CT-scan at one, three, six, and 12 months. No endoleaks or infection were seen in the short and medium term follow-up. EVAR is an appropriate treatment for selected patients, especially those at high risk for open surgical repair. The future of EVAR as the potential gold standard for aortic aneurysm therapy rests upon the vision and creativity of both surgeons and technology innovators to realize the potential of endovascular interventions.

Collected world and single center experience with endovascular treatment of ruptured abdominal aortic aneurysms.

BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed.

Techniques for precise thoracic endograft placement.

Precise endograft placement in the thoracic aorta is challenging due to the special local anatomy and unique hemodynamic blood flow. We are employing many techniques together to launch the endograft precisely to the target location: various debranching techniques to extend the proximal landing zone, magnified imaging with full exposition of the supra-arch branches and the proximal landing area to achieve a clear and accurate view, screen markers of the landing target for guidance of deployment, 1-2 cm proximally to the cranial landing marker before launching in case of any displacement, steady deployment of the endograft in hypotensive status or within the temporary heart asystole period induced by intravenous adenosine administration. If a balloon angioplasty or a proximal cuff is inevitable, the abovementioned techniques should be repeated. Our single center results have proved the combined techniques for precise thoracic endograft placement reliable, effective, simple and practical.

Two-year single-center experience with thoracic endovascular aortic repair using the EndoFit thoracic stent-graft.

PURPOSE: To analyze our single-center experience of thoracic endovascular aortic aneurysm repair (TEVAR) using the EndoFit Thoracic Aortic Endograft. METHODS: A retrospective review was conducted of 87 consecutive patients (64 men; median age 67.8+/-8.7 years, range 24-88) undergoing TEVAR using the EndoFit thoracic stent-graft from December 2005 to December 2007. Slightly more than half (n = 46) of the patients had thoracic aortic aneurysm, while 41 had thoracic aortic dissection. Seventeen cases were performed emergently. All patients had imaging follow-up before discharge; at 1, 3, and 6 months; and annually thereafter. RESULTS: The technical success rate was 100%. Fifty-five (63.2%) patients had different debranching procedures to extend the proximal or distal landing zone. The in-hospital and 30-day mortality rate was 9.2% (8/87). Neurological complications occurred in 8 (9.3%) patients, including 5 strokes (2 fatal) and 3 cases of paraplegia. One intraoperative massive bleeding from an ascending aortic debranching anastomosis was rescued with the aid of a pump. Five patients had immediate proximal type I endoleak; 3 were remedied with a proximal cuff, 1 was rescued with tri-lobe balloon, and 1 was left untreated. One type II endoleak remains under observation. The average follow-up was 15.2 months (range 5-29), during which 10 (11.5%) patients died of causes unrelated to the aneurysm or stent-graft. All the extra-anatomical bypasses and stent-grafts were patent; no stent-graft kinking, collapse, or dislocation was detected. Two post-TEVAR proximal endoleaks were remedied with a proximal cuff after debranching. There was no post-TEVAR rupture or conversion to open surgery. CONCLUSION: Our 2-year single-center experience using the EndoFit system for TEVAR showed a high technical success rate and a low incidence of device- or aneurysm-related complications. The flexible, hydrophilic introducer was easy to insert and track through the vasculature. The debranching techniques to extend the landing zones not only broaden the applicability of TEVAR but also reduce post-TEVAR complications.

Experience with the Endologix Powerlink endograft in endovascular repair of abdominal aortic aneurysms with short and angulated necks.

Endovascular aortic aneurysm repair (EVAR) for anatomically suitable abdominal aortic aneurysms (AAAs) has gained wide acceptance in the past decade, and EVAR for anatomically challenging or unsuitable AAAs such as short and angulated neck AAAs has become a hotly debated subject. The objective of this study is to summarize the unique experience of EVAR for short / angulated neck AAAs with Powerlink unibody bifurcated stent-graft. Data were retrospectively analyzed from 519 patients in our single unit from February 1999 to December 2007 who underwent EVAR using the Powerlink endograft, and had short or angulated necks. Short neck was defined as < or = 15 mm for the infrarenal neck length, and it was divided into 2 groups: Group A (short neck), 54 cases with the length 11 to 15 mm; and Group B (very short neck), 26 cases with the length < or = 10 mm. Angulated neck of 37 cases which was defined as > or = 60 degrees angulation between the longitudinal axis of infrarenal aorta and the aneurysm. The unique strategy of treating short / angulated neck AAAs is to build up the endoluminal exclusion system from the native aortic bifurcation to the renal artery level with suprarenal fixation. The Powerlink unibody bifurcated stent graft was implanted anatomically fixed on the aortic bifurcation and a long suprarenal cuff was built up to the renal arteries. A Palmaz stent can be used for proximal fixation and sealing enhancement in the most challenging necks. The follow-up imaging was performed at 1 month, 6 months, and yearly thereafter. The technical success rate was 97.4% (114/117). Intraoperative complications included 3 conversions due to delivery access problems, 6 proximal type I endoleaks, and 5 type II endoleaks. The 30-day mortality was 1.7% (2/117). The 2.6-year follow-up showed 4 (3.4%) proximal type I endoleaks, which were revised with proximal cuff and/or Palmaz stent. Limb occlusion occurred in 2 cases, and the total re-intervention rate was 5.3%. Three (2.6%) type II endoleaks were left in observation. There were 3 (2.6%) partial renal infarctions, no stent-graft distal migration, and no post-EVAR ruptures. Our experience demonstrates that building up the endoluminal exclusion system from the abdominal aortic bifurcation to the renal artery level using the Powerlink fully supported unibody bifurcated stent-graft with a long suprarenal cuff, and a Palmaz stent when needed, proved safe and effective in treating AAAs with short and angulated necks.

Connective tissue growth factor is overexpressed in complicated atherosclerotic plaques and induces mononuclear cell chemotaxis in vitro.

OBJECTIVE: Atherosclerotic blood vessels overexpress connective tissue growth factor (CTGF) mRNA, but the role of CTGF in atherosclerosis remains controversial. To assess the hypothesis that CTGF is involved in atherosclerotic plaque progression, we investigated CTGF protein expression and distribution in the different types of plaque morphology. METHODS AND RESULTS: Serial cross-sections of 45 human carotid plaques were immunohistochemically analyzed for the presence of CTGF protein, neovascularization (von Willebrand factor), macrophages (CD68), and T cells (CD3). The lesions were categorized according to American Heart Association (AHA) classification as fibrous (type IV and V) or complicated plaques (type VI). The levels of CTGF were significantly higher in complicated compared with fibrous plaques (P=0.002). CTGF accumulated particularly in the rupture-prone plaque shoulder and in the areas of neovascularization or infiltration with inflammatory cells. Macrophage-like cells stained positive for CTGF protein in plaques. Subsequent in vitro studies showed that although monocyte-derived macrophages do not produce CTGF on stimulation with transforming growth factor-beta, lipopolysaccharide, or thrombin, they take it up from culture medium. Furthermore, CTGF induces mononuclear cell chemotaxis in a dose-dependent manner. CONCLUSIONS: CTGF protein is significantly increased in complicated compared with fibrous plaques and may enhance monocyte migration into atherosclerotic lesions, thus contributing to atherogenesis.

TAArget versus EndoFit thoracic stent-grafts in thoracic endovascular aortic repair: a retrospective comparison of early and mid-term results in a single center.

BACKGROUND: Aim of the study was to compare our early and mid-term results using EndoFit and TAArget thoracic stent-grafts in thoracic endovascular aortic repair (TEVAR). METHODS: We retrospectively reviewed 169 consecutive TEVAR cases (69.1±8.9 years) performed using the EndoFit or TAArget thoracic stent-grafts from December 2005 to January 2011 in our single center. Debranching procedures were needed in 111 (65.7%) cases before TEVAR. 87 (51.5%) patients who received EndoFit stent-graft between December 2005 and December 2007 were entered into Group A while the other 82 (48.5%) patients treated from January 2008 to January 2011 using TAArget stent-graft into Group B. RESULTS: The technical success rate was 100% in both groups. 111 (65.7%) cases had 6 different debranching procedures prior to TEVAR to extend the proximal or distal landing zone. In group A, 5 cases had intraoperative proximal type I endoleak, while no occurrence in group B. The overall 30-day mortality rate was 5.3% (9/169), with statistical difference (Group A: 9.2%, 8/87 versus Group B: 1.2%, 1/82; P=0.049). Neurological complications occurred in 8 (4.7%) patients, all of the cases were in group A (8/87). There were 10 (6.3%) deaths recorded during the average of 29.0 months (range 15-42) follow-up period, all of the patients were in group A (Group A: 12.7%, 10/79 versus Group B: 0%, 0/81; P=0.003), no death was related to the aneurysm or the stent-graft. In Group A, 2 cases had post-TEVAR proximal type I endoleak. CONCLUSION: Better clinical outcomes are highly dependent on accumulated learning curve and improved newer-generation devices and delivery systems. The second generation device TAArget's new featuring uniform external fixation and TTTM Tortuous tracker delivery system allow better external fixation and precise deployment.

Carotid plaque echolucency increases the risk of stroke in carotid stenting: the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) study.

BACKGROUND: Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy. Cerebral embolization is the most devastating complication of CAS, and the echogenicity of carotid plaque has been indicated as one of the risk factors involved. This is the first study to analyze the role of a computer-assisted highly reproducible index of echogenicity, namely the gray-scale median (GSM), on the risk of stroke during CAS. METHODS AND RESULTS: The Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) registry included 418 cases of CAS collected from 11 international centers. An echographic evaluation of carotid plaque with GSM measurement was made preprocedurally. The onset of neurological deficits during the procedure and the postprocedural period was recorded. The overall rate of neurological complications was 3.6%: minor strokes, 2.2%, and major stroke, 1.4%. There were 11 of 155 strokes (7.1%) in patients with GSM < or =25 and 4 of 263 (1.5%) in patients with GSM >25 (P=0.005). Patients with severe stenosis (> or =85%) had a higher rate of stroke (P=0.03). The effectiveness of brain protection devices was confirmed in those with GSM >25 (P=0.01) but not in those with GSM < or =25. Multivariate analysis revealed that GSM (OR, 7.11; P=0.002) and rate of stenosis (OR, 5.76; P=0.010) are independent predictors of stroke. CONCLUSIONS: Carotid plaque echolucency, as measured by GSM < or =25, increases the risk of stroke in CAS. The inclusion of echolucency measured as GSM in the planning of any endovascular procedure of carotid lesions allows stratification of patients at different risks of complications in CAS.

Seventeen years' experience of late open surgical conversion after failed endovascular abdominal aortic aneurysm repair with 13 variant devices.

PURPOSE: To investigate the causes and results of late open surgical conversion (LOSC) after failed abdominal aortic aneurysm repair (EVAR) and to summarize our 17 years' experience with 13 various endografts. METHODS: Retrospective data from August 1994 to January 2011 were analyzed at our center. The various devices' implant time, the types of devices, the rates and causes of LOSC, and the procedures and results of LOSC were analyzed and evaluated. RESULTS: A total of 1729 endovascular aneurysm repairs were performed in our single center (Nuremberg South Hospital) with 13 various devices within 17 years. The median follow-up period was 51 months (range 9-119 months). Among them, 77 patients with infrarenal abdominal aortic aneurysms received LOSC. The LOSC rate was 4.5 % (77 of 1729). The LOSC rates were significantly different before and after January 2002 (p < 0.001). The reasons of LOSC were mainly large type I endoleaks (n = 51) that were hard to repair by endovascular techniques. For the LOSC procedure, 71 cases were elective and 6 were emergent. The perioperative mortality was 5.2 % (4 of 77): 1 was elective (due to septic shock) and 3 were urgent (due to hemorrhagic shock). CONCLUSION: Large type I endoleaks were the main reasons for LOSC. The improvement of devices and operators' experience may decrease the LOSC rate. Urgent LOSC resulted in a high mortality rate, while selective LOSC was relatively safe with significantly lower mortality rate. Early intervention, full preparation, and timely LOSC are important for patients who require LOSC.

Accumulation of immune cells and high expression of chemokines/chemokine receptors in the upstream shoulder of atherosclerotic carotid plaques.

The presence of immune cells is important for plaque destabilization. Disturbed flow conditions were shown to enhance the recruitment of circulating immune cells. Thus, we analyzed in 54 atherosclerotic carotid plaques the frequency of different immune cells, HLA-DR, chemokines, and chemokine receptors, comparing the upstream with the downstream plaque shoulder. The presence of neovascularization and intraplaque hemorrhages was investigated by CD34 immunostaining and Mallory's iron stain. Immunohistochemical analyses were performed to detect smooth muscle cells (SMC: actin), macrophages (CD68), T cells (CD3), dendritic cells (DC: fascin), mature DC (CD83), and the expression of HLA-DR, chemokine receptors (CCR-2, CCR-6), and chemokines (MCP-1, MIP-3alpha). Significantly more SMC were detected downstream than upstream (p<0.001). In contrast, significantly more macrophages (p=0.01), DC (p=0.03), mature DC (p=0.007), and a higher expression of HLA-DR (p=0.004), CCR-2 (p=0.002), CCR-6 (p<0.001), MCP-1 (p=0.04), and MIP-3alpha (p=NS) were observed upstream than downstream. Immune cells were strongly associated with neovascularization. The abundance of SMC downstream provides an explanation for distal plaque growth. Enhanced recruitment of immune cells through neovessels into the upstream shoulder might be contributing to plaque destabilization.

Aortocaval fistula after stent-graft repair.

PURPOSE: To report an aortocaval fistula after stent-graft repair and the feasibility of interventional treatment. CASE REPORT: A 78-year-old man with a 61-mm infrarenal aortic aneurysm (AA) was treated successfully with a Zenith bifurcated stent-graft. Three years later, the patient presented with deteriorating renal function and acute bronchial obstruction. Computed tomography showed an aortic diameter increased to 90 mm, dilatation of the inferior vena cava, and a distal type I endoleak. The patient's condition quickly deteriorated, and emergent imaging found a fistula with brisk flow between the aneurysm sac and the left iliac vein within a distal type I endoleak. During emergency endovascular repair, iliac extensions were implanted in the right common iliac artery and left external iliac artery. The left hypogastric artery was coil embolized to exclude flow into the aneurysm sac. After positioning the extensions, cardiac function improved, and the fistula was no longer palpable. The cardiac indices and renal function normalized, and he was discharged 20 days after admission. CONCLUSION: Aortocaval fistulas are a rare complication of AA stent-graft repair and may be successfully treated by interventional means.

Decrease in circulating myeloid dendritic cell precursors in coronary artery disease.

OBJECTIVES: We analyzed the frequency of myeloid dendritic cell (mDC) and plasmacytoid dendritic cell (pDC) precursors in blood of patients with coronary artery disease (CAD) and in atherosclerotic carotid plaques of patients with cerebrovascular disease (CVD). BACKGROUND: Circulating DC precursors are reduced in several autoimmune diseases. Atherosclerosis has features of an autoimmune disease, such as the presence of autoantibodies or autoreactive T cells. Tissue-resident DCs were previously described in atheromata, and it is assumed that they are important for the activation of T cells against autoantigens there. METHODS: Circulating mDC and pDC precursors were flow cytometrically detected in healthy controls (n = 19), CAD patients with stable (n = 20) and unstable angina pectoris (n = 19), and acute myocardial infarction (n = 17). In human carotid plaques (n = 65), mDC and pDC precursors were identified immunohistochemically. RESULTS: Circulating mDC precursors were significantly reduced in patients with stable angina pectoris (0.19%, p = 0.04), unstable angina pectoris (0.16%, p = 0.004), and acute myocardial infarction (0.08%, p < 0.001) compared with control patients (0.22% of peripheral blood mononuclear cells). In contrast, pDC numbers were not significantly altered. Circulating mDC precursors inversely correlated with high-sensitivity C-reactive protein (r = -0.38, p = 0.001) or interleukin-6 (r = -0.42, p < 0.001). In contrast to pDC, significantly more mDC precursors were observed in vulnerable carotid plaques (24, 0.25 mm2; n = 31; p = 0.003) than in stable ones (6.4, 0.25 mm2; n = 34). CONCLUSIONS: Similar to autoimmune diseases, circulating mDC precursors were significantly reduced in patients with CAD. The emergence of mDC precursors in vulnerable plaques suggests their recruitment into atheromata as a possible reason for their decrease in blood. In contrast, no significant association of circulating pDC precursors with atherosclerosis was observed.

Surgical conversion after endovascular grafting for abdominal aortic aneurysms.

PURPOSE: To analyze the indications, results, and technical problems associated with conversion after endoluminal repair of abdominal aortic aneurysms (AAA) based on a 6-year experience in endovascular grafting. METHODS: From August 1994 to May 2000, 520 patients with AAA were deemed candidates for endovascular therapy based on data from contrast-enhanced computed tomography and aortography. Any conversions were performed using an open operation modified according to the indication for conversion, elapsed time from the endoluminal repair, and type of endograft (tube, bifurcated, infra-/suprarenal fixation). RESULTS: Conversion to open repair was required in 37 (7.1%) cases: 23 tube grafts and 14 bifurcated devices. Seventeen (3.2%) conversions occurred at the original operation and 20 (3.8%) were performed secondarily. Indications for primary conversion were mainly device defects (n = 5) or access problems (n = 5), while secondary conversion was primarily owing to type I endoleak (n = 16). The conversion rate was significantly higher in modular devices (5.9%) than unibody designs (1.4%) (p = 0.003). The rate of primary conversions diminished from 10.9% in 1994-1995 to 2.4% between 1996 and 2000, as did the overall mortality rate, from 8.3% in the first time period to 0% in the second for elective conversions, but emergency operations had 40% mortality. CONCLUSIONS: Most AAAs require bifurcated devices for complete exclusion, and older model modular grafts have higher conversion rates. Primary conversion decreases as more experience in endoluminal grafting is acquired. Emergency open repair results in a high mortality rate.

Incidence of renal infarctions after endovascular AAA repair: relationship to infrarenal versus suprarenal fixation.

PURPOSE: 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.