[Open repair for pararenal abdominal aortic aneurysm: the strategy and pitfalls for safe surgery]

Pararenal abdominal aortic aneurysm (PRAAA) includes two types of AAA : juxtarenal (JRAAA) and suprarenal (SRAAA). JRAAA is defined as aneurysms that extend up to but do not involve the renal arteries, necessitating suprarenal aortic clamping for repair. SRAAA is defined as aneurysms that extend up to the superior mesenteric artery, involving one or both renal arteries to be repaired. The surgical repair of PRAAAs requires more extensive aortic exposure and may result in ischemic injury to kidneys and visceral organs with higher morbidity and mortality compared with infrarenal AAAs. The four approaches to PRAAA repair are: 1) midline abdominal incision, transperitoneal, left renal vein divided or mobilized; 2) midline abdominal incision, transperitoneal, left medial visceral rotation technique 3) left flank incision, retroperitoneal; and 4) thoracoabdominal incision, thoracoretroperitoneal approach. The four positions of proximal clamping are: 1) suprarenal; 2) interrenal; 3) supramesenteric; and 4) supraceliac aorta. The surgical strategy should be determined based on computed tomography and magnetic resonance angiography imaging, and severe atherosclerotic or calcified aorta should never be clamped to prevent lethal embolic complications. Although developing fenestrated endovascular technology can be used in some cases of PRAAA repair, open surgery with thorough preoperative assessment and careful utilization of techniques to prevent visceral and renal ischemic injury is safe, effective, and durable and remains the gold standard for repair.