Balloon-Assisted Selective Renal Artery Protection in the Endovascular Management of Juxtarenal Aortoiliac Occlusion

This study aimed to evaluate the feasibility and safety of balloon-assisted selective renal protection during endovascular treatment of juxtarenal aortoiliac occlusive disease (AIOD) and to present a preoperative computed tomography angiography (CTA)-based morphological framework for procedural planning and standardized reporting.

This single-center retrospective study, conducted between 2017 and 2022, included patients with juxtarenal AIOD treated with kissing covered self-expanding stents. Renal protection balloons were applied selectively based on preoperative CTA findings and the anticipated proximal stent extension. Renal reconstruction was performed selectively for planned proximal stent extension above the renal ostium, significant ostial disease, or bailout in cases of embolization or flow limitation. The primary outcomes were acute kidney injury (AKI; Kidney Disease: Improving Global Outcomes creatinine criteria, patient level) and renal embolic events (REEs, renal artery level), defined as angiographic embolization requiring intervention or clinically silent renal infarction on postoperative CTA. Patency and follow-up estimated glomerular filtration rates were also assessed.

Eleven patients (21 renal arteries, excluding 1 preexisting renal artery occlusion) were treated with 100% technical success. AKI occurred in 2/11 patients (18.2%), both stage 1. REEs occurred in 3/21 renal arteries: one symptomatic embolization required stenting, and two showed clinically silent partial renal infarction on postoperative CTA. Six renal stents were implanted, with a primary patency rate of 83.3% (5/6). One patient developed acute in-hospital thrombosis requiring thrombolysis, and the same stent became permanently occluded at the 2-year follow-up and was managed conservatively. Aortoiliac primary patency was 95.5% (21/22 limbs), and secondary patency was 100%. No late reinterventions were observed during a mean follow-up of 24.4 months.

Balloon-assisted selective renal protection is feasible in juxtarenal AIOD. However, REEs, including clinically silent infarctions, may still occur, and selective renal reconstruction remains necessary in a subset of patients. The CTA-based morphological framework may facilitate preprocedural planning and standardized reporting of renal outcomes alongside traditional aortoiliac endpoints.