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

Abstract

Purpose

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.

Materials and Methods

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.

Results

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.

Conclusion

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.

INTRODUCTION

Juxtarenal aortoiliac occlusive disease (AIOD) remains challenging for endovascular treatment because renal ostial compromise and embolization may occur during recanalization and proximal stent deployment. Clinically silent renal infarction can be overlooked unless dedicated imaging is performed, and standardized strategies for renal risk mitigation in juxtarenal AIOD have not been well established [1].

To address these risks while preserving the minimally invasive advantages of endovascular therapy, adjunctive techniques such as temporary renal ostial balloon protection and chimney covered stent reconstruction have been used selectively. However, the real-world frequency of renal protection or reconstruction and the spectrum of renal embolic events (REEs) associated with these workflows have not been completely reported.

Therefore, we report a single-center case series of juxtarenal AIOD treated with kissing-covered stents using a balloon-assisted, selectively applied renal protection approach. This study aimed to quantify REEs, including clinically silent renal infarction detected on postoperative computed tomography angiography (CTA), assess the frequency of renal chimney reconstruction, and present a preoperative CTA-based morphological framework to facilitate procedural planning and standardized reporting.

MATERIALS AND METHODS

1) Patient selection

This single-center retrospective observational study included consecutive patients treated between September 2017 and December 2022. The study was approved by the Institutional Ethics Committee of Fuwai Hospital (No. 2022–977), and written informed consent was obtained from each patient. Patients were eligible if they had: (1) AIOD with Trans-Atlantic Inter-Society Consensus (TASC) II type D juxtarenal involvement on preoperative CTA; and (2) undergone endovascular aortoiliac reconstruction at our institution. Patients without bifurcation involvement and those who underwent hybrid procedures were excluded (Fig. 1). Baseline demographics, comorbidities, symptoms, ankle-brachial index (ABI), and renal function, including serum creatinine (SCr) and estimated glomerular filtration rate (eGFR), were retrieved from electronic medical records.

Fig. 1.

Workflow summary of the CTA-based planning framework, applied renal protection strategy, and key renal and aortoiliac outcomes in patients with juxtarenal aortoiliac occlusive disease. AIOD, aortoiliac occlusive disease; CTA, computed tomography angiography; KDIGO, Kidney Disease: Improving Global Outcomes; AKI, acute kidney injury.

2) Preoperative CTA assessment and morphology classification

Preoperative CTA defined the cranial extent of occlusion relative to the renal ostia and assessed renal artery origin symmetry, lesion-to-ostium relationship, ostial atherosclerotic disease, juxtarenal thrombus burden, and expected proximal landing zone (Fig. 2). These findings indicated the need for thrombolysis, balloon protection, and/or chimney reconstruction. A simplified CTA morphology classification was applied (Fig. 3): Subtype I, symmetric renal origins with lesion reaching both ostia; Subtype IIa, asymmetric renal origins with lesion reaching only the lower ostium; Subtype IIb, wedge-shaped lesion involving both ostia; and Subtype III, lesion above both ostia. This classification was intended as a pragmatic planning checklist rather than a deterministic algorithm; the final strategy could be modified according to intraprocedural findings or thrombolysis-related lesion changes.

Fig. 2.

Representative aortic imaging of juxtarenal aortoiliac occlusive disease. (A) Preoperative computed tomography angiography of the abdominal aorta, and (B) abdominal aortic angiogram.

Fig. 3.

Simplified CTA-based morphological classification of juxtarenal aortoiliac occlusion according to its relationship to the renal artery ostia. CTA, computed tomography angiography.

3) Endovascular procedure: general technique

The procedures were performed under moderate sedation and local anesthesia via left brachial and bilateral common femoral artery access. Antegrade intraluminal crossing was attempted first; when unsuccessful, bidirectional techniques (Subintimal Arterial Flossing with Antegrade-Retrograde Intervention [SAFARI], rendezvous) were used [2]. True-lumen position was confirmed by contrast injection before reconstruction. Definitive aortoiliac reconstruction was performed using kissing covered self-expanding stents across the bifurcation [3,4]. Completion angiography was performed to assess flow restoration, residual stenosis, and renal perfusion (Fig. 4).

Fig. 4.

Representative endovascular procedure. (A) Alignment of the guidewire and catheter, (B) bilateral renal balloon protection, and (C) implantation of kissing covered self-expanding stents.

4) Balloon-assisted selective renal protection

Balloon protection was applied selectively based on the CTA subtype: bilateral protection for Subtype I, unilateral protection of the lower renal artery for Subtypes IIa and IIb, and bilateral protection with bailout readiness for Subtype III. The target renal artery was catheterized via brachial access, and the balloon diameter was selected at 90%-100% of the CTA-measured reference diameter to achieve ostial shielding without overdilation. For bilateral protection, one renal artery was accessed via the brachial artery and the contralateral artery via femoral access using a rapid-exchange balloon. Balloons were inflated immediately before kissing predilation, proximal stent deployment, and post-deployment dilation, and were deflated promptly after each step. Completion angiography was used to confirm patency, and bailout reconstruction was performed if embolization or flow-limiting compromise was identified.

5) Selective renal reconstruction

Renal reconstruction was performed for: (1) planned proximal kissing stent extension above the renal ostium; (2) significant pre-existing renal ostial disease requiring concomitant treatment; or (3) bailout for intraoperative embolization or flow-limiting ostial compromise. Chimney reconstruction was strictly reserved for cases in which the proximal stent edge extended above the renal ostium, whereas standard renal artery techniques were used when the edge was flush with or below the ostium. Self-expanding covered stents (VIABAHN^®, W. L. Gore & Associates) were used for chimney reconstruction via brachial access. Repeat aortography after the juxtarenal steps confirmed renal patency.

6) Adjunct catheter-directed thrombolysis (CDT)

CDT was considered only when all the following were present: recent symptomatic deterioration within 3 months, low-attenuation juxtarenal thrombus on CTA, markedly elevated D-dimer/fibrin degradation products (FDPs), and soft, compressible lesions during wire traversal. The primary goal was to reduce the juxtarenal thrombus burden and lower the proximal disease level, potentially obviating the need for renal ostial intervention. A multi–side-hole infusion catheter (5-Fr; Uni-Fuse, AngioDynamics) was positioned across the thrombotic segment, and the working length (10-50 cm) was selected based on the extent of the lesion. Urokinase was infused at 20,000 IU/h with heparin titrated to an activated partial thromboplastin time of 60-80 seconds, and the systolic blood pressure was targeted at ~130 mmHg. CDT was discontinued upon: (1) adequate angiographic thrombus reduction at planned reassessment (48-72 hours); (2) major bleeding; or (3) clinical deterioration. The full protocol details have been previously published elsewhere [5].

7) Postprocedural management and follow-up

Postprocedural antithrombotic therapy was individualized, with low-dose rivaroxaban used for thrombotic lesions and dual antiplatelet therapy used for non-thrombotic lesions. Predischarge CTA was performed routinely in all patients, typically on postoperative days 3-5, to confirm technical success, assess patency, and detect silent renal infarctions. SCr and eGFR were recorded preoperatively, on postoperative day 1, and at discharge. Patients with chronic kidney disease (CKD) or procedure-related renal impairment were referred to the nephrology department for serial eGFR monitoring, nephrotoxin avoidance, blood pressure optimization, and duplex renal surveillance. The length of the hospital stay was also recorded. Clinical and imaging follow-up was conducted at 3, 6, and 12 months and annually thereafter.

8) Definitions and outcome measures

The primary outcomes were acute kidney injury (AKI), assessed at the patient level, and REEs, assessed at the renal artery level. AKI was defined and staged according to the Kidney Disease: Improving Global Outcomes (KDIGO) creatinine criteria (SCr increase ≥26.5 μmol/L within 48 hours or ≥1.5 times baseline within 7 days) [6]; urine-output criteria were not applied due to incomplete documentation. REEs were defined as either intraoperative angiographic embolization requiring intervention or silent renal infarction detected on postoperative CTA. Renal infarction on CTA was defined as a new, well-demarcated, wedge-shaped area of parenchymal hypoenhancement or non-enhancement that was not present preoperatively and interpreted in conjunction with renal artery patency and angiographic findings. Complications and reinterventions were categorized as early (during hospitalization or within 30 days) or late (after 30 days). To explore contributors to AKI, contrast exposure was categorized as ≤100 mL vs. >100 mL per procedure (hospital pharmacy records), and balloon inflation count was estimated as three inflations per protected renal artery (kissing predilation, proximal deployment, and post-deployment dilation) plus one additional inflation per stented renal artery (postdilation).

9) Statistical analysis

The analyses were primarily descriptive in nature. Continuous variables are reported as mean±standard deviation (SD) or median (interquartile range [IQR]), and categorical variables are reported as n (%). ABI changes were analyzed using the Wilcoxon signed-rank test. For exploratory AKI comparisons, Fisher’s exact test was used for categorical variables and the Mann–Whitney U-test for continuous variables; no correction for multiple comparisons was applied, given the hypothesis-generating intent. Statistical analyses were performed using SPSS ver. 25.0 (IBM Co.).

RESULTS

1) Baseline characteristics

Eleven patients with juxtarenal AIOD were included; one preoperatively occluded renal artery reduced the renal artery–level denominator to 21. The baseline characteristics of the patients are summarized in Table 1, and 1 patient had CKD at baseline. Mean hospital stay was 13.2±3.9 days (median [IQR], 12 [11-17] days; range, 6-19 days).

Table 1.

Baseline characteristics of the study cohort

Variable	Value
Patients (n)	11
Age (y)	62.5±11.6
Male sex	10 (90.9)
Hypertension	7 (63.6)
Diabetes mellitus	3 (27.3)
Hyperlipidemia	6 (54.5)
Coronary heart disease	3 (27.3)
Prior cerebral infarction	2 (18.2)
Smoking history	10 (90.9)
Current smoker	5 (45.5)
Rutherford category
II	1 (9.1)
III	9 (81.8)
IV	1 (9.1)
Preoperative ABI	0.45 (0.00-0.54)
Baseline SCr, μmol/L	79.00 (65.85-88.53)
Baseline eGFR, mL/min/1.73 m2	95.33 (79.43-107.59)
CKD at baseline	1 (9.1)
Renal artery disease on CTA
Severe stenosis	1 (4.5)
Preexisting occlusion	1 (4.5)

Values are presented as number only, number (%), median (interquartile range), or mean±standard deviation.

ABI, ankle-brachial index; SCr, serum creatinine; eGFR, estimated glomerular filtration rate; CKD, chronic kidney disease; CTA, computed tomography angiography.

CKD defined as eGFR <60 mL/min/1.73 m² at baseline. Patient-level variables are reported for each patient (n=11). ABI was reported per limb (n=22) and renal artery disease on CTA per renal artery (n=22); percentages for both used 22 as the denominator.

2) CTA morphology classification and procedural planning

The lesions were classified as Subtypes I (n=3), IIa (n=3), IIb (n=5), or III (n=0). Bilateral balloon protection was planned for all Subtype I cases, and unilateral protection of the lower renal artery was planned for all Subtypes IIa and IIb cases. Planned renal ostial interventions included lower renal artery chimney reconstruction in Subtype IIb cases and standard stenting for preexisting ostial stenosis in 1 Subtype IIa case. Details are summarized in Table 2. Four patients (Cases 5, 6, 10, and 11) underwent preoperative CDT. In 2 cases, thrombus reduction modified the planned strategy: Case 6 (Subtype I) was converted to infrarenal AIOD, requiring no renal intervention, and Case 10 was downgraded from Subtype IIb to Subtype IIa, thereby obviating chimney reconstruction.

Table 2.

Renal-artery level strategies and outcomes (21 renal arteries)

Case	CTA subtype	Preproceduralthrombolysis	Renal artery side	Balloon protection	Renal stenting	Indication for stenting	Renal embolic event	Event type
1	IIa	No	L	4×40	-	-	No	-
			R	-	-	-	Yes	Silent partial infarction on postop CTA
2	I	No	L	5×40	-	-	No	-
			R	4×30 (RX)	-	-	No	-
3	I	No	L	5×20	-	-	No	-
			R	4×20 (RX)	-	-	No	-
4	IIb	No	L	5×40	VBH; 6×50	Wedged lesion & renal stenosis	No	-
			R (occluded)	-	-	-	-	-
5	IIb	Yes	L	-	-	-	No	-
			R	5×40	VBH; 5×25	Wedged lesion	No	-
6	I	Yes	L	-	-	-	No	-
			R	-	-	-	No	-
7	IIb	No	L	5×20	VBH; 5×50	Wedged lesion	No	-
			R	-	-	-	No	-
8	IIa	No	L	5×20	VBH; 5×25	Bailout for renal embolization	Yes	Symptomatic embolization requiring stenting
			R	5×20	VBH; 5×25	Renal stenosis	No	-
9	IIb	No	L	5×20	VBH; 5×25	Wedged lesion	Yes	Silent partial infarction on postop CTA
			R	-	-	-	No	-
10	IIb	Yes	L	4×40	-	-	No	-
			R	-	-	-	No	-
11	IIa	Yes	L	-	-	-	No	-
			R	5×40	-	-	No	-

CTA, computed tomography angiography; L, left; R, right; RX, rapid exchange; VBH, Viabahn^® (W. L. Gore & Associates). Balloon sizes are presented as diameter×length (mm). A dash indicates not applicable or not performed.

3) Procedural details and applied renal-protection strategy

All procedures were performed via left brachial and bilateral femoral access, and 2 patients underwent concomitant left subclavian stenting. Among the 22 treated limbs, unidirectional crossing was successful in 11 limbs (antegrade brachial, n=4; retrograde femoral, n=7), and SAFARI was required in the remaining 11 limbs. All aortoiliac stents were deployed in a kissing configuration (Table 3).

Table 3.

Aortoiliac stent details

Case	Kissing VBH/mm		Kissing level	Extended stents/mm
	Left	Right		Left	To	Right	To
1	7×150	7×150	Infrarenal	BMS 6×150	EIA	VBH 6×100	EIA
2	7×150	7×150	Infrarenal	VBH 7×100	EIA	BMS 7×120	EIA
3	8×100	8×100	Infrarenal	VBH 7×100	CIA	VBH 7×150, BMS 7×60	EIA
4	7×150	7×150	Inter-renal	VBH 6×100, BMS 7×40	EIA	BMS 7×60	EIA
5	8×150	8×150	Inter-renal	-	CIA	-	CIA
6	8×150	8×150	Infrarenal	BMS 7×80	EIA	-	CIA
7	8×150	8×150	Inter-renal	VBH 7×100	EIA	VBH 8×100	EIA
8	8×150	8×100	Inter-renal	VBH 7×100, BMS 7×60	EIA	VBH 7×150, BMS 7×40	EIA
9	8×150	8×100	Inter-renal	VBH 7×100	EIA	VBH 7×50	CIA
10	8×150	8×150	Infrarenal	VBH 7×150	EIA	VBH 7×150	EIA
11	9×150	8×100	Infrarenal	VBH 7×50, BMS 7×60	EIA	VBH 7×150, BMS 7×40	EIA

VBH, Viabahn^® (W. L. Gore & Associates); BMS, bare metal stent; EIA, external iliac artery; CIA, common iliac artery.

Renal balloon protection was applied in 12 of 21 renal arteries. Among the Subtype I cases, Case 6 required no protection after CDT, whereas the remaining 2 cases underwent bilateral protection (4 renal arteries). All 3 Subtype IIa cases and 5 Subtype IIb cases underwent unilateral protection of lower renal artery. Bilateral protection used combined brachial and femoral access, whereas unilateral protection used brachial access alone.

Renal stenting was performed in 6 of 21 renal arteries in 5 patients. Four chimney stents were placed in the lower renal artery in 4 Subtype IIb cases per plan. In 1 Subtype IIa (Case 8), bilateral renal stenting resulted from sequential intraoperative findings. Post-kissing dilation aortography revealed a floating thrombus at the ostium of the lower (right) renal artery with preexisting stenosis, despite balloon protection. To mitigate embolic risk, the proximal kissing construct was extended above the ostium, necessitating chimney reconstruction. Completion aortography then revealed symptomatic embolization of the higher (left) renal artery, which had not been protected because of its superior location. Bailout stenting was performed using a self-expanding covered stent (VIABAHN^®) via the standard renal ostial technique because no balloon-expandable covered stent was available. All 6 renal stents placed in this series were VIABAHN^® self-expanding covered stents.

4) Primary outcomes: AKI and REEs

AKI occurred in 2 of 11 patients (18.2%), both with KDIGO stage 1; no patient required renal replacement therapy. In exploratory comparisons, AKI occurred exclusively in CDT-treated patients (2/4 vs. 0/7; P=0.109), and CDT patients underwent 2 procedural stages, each involving contrast administration. AKI also occurred exclusively in patients treated with >100 mL of iodixanol during definitive reconstruction (2/5 vs. 0/6; P=0.182). The estimated balloon inflation count did not differ (median 3.5 vs. 4.0; P=0.63). These analyses are hypothesis-generating only.

REEs occurred in 3 of 21 renal arteries (14.3%): 1 symptomatic intraoperative embolization (Case 8, unprotected left renal artery) and 2 silent renal infarctions detected on predischarge CTA (Case 1, unprotected right renal artery; Case 9, balloon-protected and stented lower left renal artery). No embolic event caused deterioration of renal function beyond that observed in the AKI cases described above.

5) Early complications and early reinterventions

Early stent thrombosis occurred in 2 patients. One patient developed acute renal chimney thrombosis on postoperative day 1 (flank pain), and was treated with CDT and additional stent placement. The second patient developed acute iliac thrombosis on postoperative day 2 (limb cooling), and was treated with CDT and external iliac covered stent placement. One femoral access-site pseudoaneurysm (1.36×0.98 cm) was found on predischarge CTA, which was managed conservatively and resolved spontaneously on follow-up imaging.

6) Follow-up outcomes

During a mean follow-up of 24.4±18.1 months, aortoiliac primary patency was 95.5% (21/22 limbs), and secondary patency was 100%. The primary patency rate of renal chimney stents was 83.3% (5/6 stents). The single primary patency loss was the acute in-hospital chimney thrombosis described above, which was successfully recanalized by CDT during the index hospitalization; however, the same stent was occluded permanently at the 2-year follow-up, with progressive ipsilateral renal atrophy and absent parenchymal perfusion on subsequent imaging. No further reintervention was performed, and secondary patency was therefore also 83.3%.

Regarding renal function, the patient with baseline CKD remained stable throughout follow-up. Neither of the 2 patients with procedure-related AKI returned to their preoperative SCr baseline; both remained in CKD stage IIIa at follow-up without requiring renal replacement therapy.

At the latest available imaging follow-up, all aortoiliac stents and the remaining renal chimney stents were widely patent. No late reinterventions were performed; the permanently occluded renal chimney stent identified at the 2-year follow-up was managed conservatively, given the absence of symptoms and the development of ipsilateral renal atrophy. Two patients died of nonvascular causes during the follow-up (gastric cancer recurrence and acute leukemia, respectively).

DISCUSSION

Endovascular treatment of juxtarenal AIOD carries renal risks that extend beyond changes in SCr alone. REEs occurred in 3 of 21 (14.3%) renal arteries in our series, including silent infarction detectable only on postoperative CTA, and both patients with procedure-related AKI had incomplete renal recovery, remaining in CKD stage IIIa at follow-up. Although aortoiliac patency outcomes in this study (primary, 95.5%; secondary, 100%) were consistent with prior kissing covered stent series for complex AIOD [7,8], renal outcomes received less systematic attention in these reports and warrant inclusion as endpoints alongside traditional limb perfusion metrics.

The CTA-based morphology framework translates juxtarenal risk into a reproducible planning language that helps operators anticipate protection requirements, chimney readiness, and possible CDT. In the present study, it functioned as a planning tool rather than a fixed algorithm, because the final strategy was occasionally modified according to thrombus reduction or intraoperative findings. Similar anatomy-based planning frameworks have been described previously [9,10]. However, although the framework guided selective unilateral protection in many cases, REEs were not confined to the arteries considered at planned risk. Selective or unilateral protection should therefore not lead to complacency; completion aortography should include careful assessment of both renal ostia, including unprotected arteries, to detect flow abnormalities requiring bailout intervention.

Chimney reconstruction was reserved for cases in which the proximal stent edge extended above the renal ostium; otherwise, standard renal artery techniques were used. All renal stents in our series, including those for preexisting ostial stenosis, were ultimately deployed in a chimney configuration because the juxtarenal reconstruction geometry required them to traverse the ostium and run proximally in parallel with the kissing aortoiliac construct. This L-shaped configuration requires resistance to kinking that balloon-expandable stents cannot reliably provide, which is the primary rationale for using self-expanding covered stents in our series, a device-selection consideration similar to that described in the chimney endovascular aneurysm repair and fenestrated repair literature [11-13]. The trade-off is a lower radial force, which may have contributed to the acute in-hospital chimney thrombosis and underscores the importance of antithrombotic management and surveillance after chimney reconstruction. In selected cases, meticulous post-dilation or adjunctive intraluminal scaffolding (‘stent-in-stent’) may help improve radial support, though intraluminal scaffolding carries increased metal burden and a theoretical restenosis risk that must be weighed against the benefit.

CDT lowered the proximal disease level and avoided planned renal ostial intervention in 2 of the 4 treated cases, which is consistent with previous reports [5]. It is most likely to benefit lesions with an acute-on-chronic thrombotic component, such as recent deterioration, CTA-visible thrombus, elevated D-dimer or FDP levels, and soft lesion consistency during wire traversal. However, chronic fibrocalcific occlusions are unlikely to respond, and evidence specific to juxtarenal AIOD remains limited [14,15]. In addition, thrombus mobilization during lysis carries a theoretically relevant risk of renal embolization, and a 2-stage strategy increases cumulative contrast exposure, which may have contributed to AKI in our cohort.

This study has several limitations. The retrospective, single-center design and small sample size precluded identification of independent predictors of AKI or embolic risk. Contrast volume and balloon inflation time were not prospectively recorded, and surrogate measures were used for exploratory analyses. The 2-stage CDT strategy further complicated estimation of total contrast exposure. In addition, the absence of a comparator group limits conclusions regarding the relative renal safety across strategies. Despite routine postoperative CTA, the long-term renal stent durability and functional outcomes require larger prospective studies. Notwithstanding these limitations, this study provides a practical approach to juxtarenal AIOD endovascular treatment by combining CTA-based risk stratification, selective balloon protection, selective rather than routine chimney reconstruction, and judicious CDT in thrombotic lesions, and may help inform future comparative research.

CONCLUSION

Balloon-assisted selective renal protection is feasible during endovascular treatment of juxtarenal AIOD. However, REEs, including clinically silent renal infarctions detectable only on postoperative CTA, may still occur, and selective renal ostial intervention remains necessary in a subset of patients. A CTA-based morphological framework may facilitate preprocedural planning and more standardized reporting of renal outcomes alongside conventional aortoiliac endpoints. In carefully selected thrombotic cases, adjunctive CDT may help reduce the proximal treatment level. Further studies are required to better define renal risk predictors and to optimize protection and reconstruction strategies.

Funding Statement

FUNDING None.