Pararenal and juxtarenal aortic aneurysms under the microscope in HTDI session at CX Aortic Vienna

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Left: Roberto Chiesa; Right: Andrea Kahlberg

State-of-the-art open and endovascular techniques for the treatment of pararenal and juxtarenal aortic aneurysms were put under the microscope of the specialist aortic team from San Raffaele Hospital (Milan, Italy), led by Roberto Chiesa, on day one at CX Aortic Vienna (24–26 October, Digital).

The Milan team reprised the popular How To Do It (HTDI) series that has featured at the previous two editions of the CX Aortic Vienna meeting. Utilising the new, interactive CX Aortic Vienna platform, enabled the Milan team to lead the discussion with vascular and cardiac surgery specialists from across the world.

Andrea Kahlberg (Milan, Italy) opened the session with a presentation looking at the state of the art of open and endovascular solutions for complex abdominal aortic aneurysms, including both juxtarenal and pararenal.

Open repair of complex abdominal aortic aneurysms (AAAs) in fit patients provides excellent outcomes in high-volume centres for both elective and urgent cases, Kahlberg summarised, after he had detailed standard definitions, current guidelines, and principles guiding patient selection and decision-making.

Furthermore, Kahlberg commented that endovascular repair by means of fenestrated endovascular aneurysm repair (FEVAR) with custom-made devices is the preferred choice in elective cases considered unfit or, after careful evaluation, in order to reduce perioperative mortality. Endovascular options other than custom-made FEVAR devices—including chimney grafts or in situ fenestrations—should be limited to exceptional or emergent situations, he added. When possible, centralisation to referral centres is mandatory, Kahlberg stated.

Following Kahlberg’s talk, two presentations highlighted tips and tricks for both open and endovascular treatment of juxtarenal and pararenal aortic aneurysms. Daniele Mascia (Milan, Italy) spoke on the open option, noting that the “most important adjunct” with this technique “remains surgical skills and technique”. The speaker underscored the importance of various technical aspects, including left renal vein management, aortic clamping, neck debridement, renal perfusion, and vessel management. Mascia concluded that open treatment of juxtarenal and pararenal aortic aneurysms is a “technically demanding surgery” and requires continuous improvement, even in the “total endovascular era”. He stressed the need for centralisation of aortic care, as well as for a specialised aortic team.

Luca Bertoglio (Milan, Italy) then outlined tips and tricks on the endovascular alternative, presenting the case report of an 80-year-old man with a 5.7cm juxtarenal aneurysm who was deemed unsuitable for open repair. He concluded that FEVAR is the “first choice” endovascular strategy for juxtarenal and pararenal aneurysms, adding that preloaded devices “ease the procedure.” However, he noted that off-the-shelf and quick delivery devices are needed to treat all-comer patients in the elective setting.


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