Renal Artery Occlusion After Standard Endovascular Aneurysm Repair: Incidence, Mechanisms, and Individualized Management

Background/Objectives: Direct renal artery compromise after standard endovascular aneurysm repair (EVAR) is rare and may result from mechanical ostial coverage or atheroembolism. We estimated its incidence and described mechanism-specific management and renal outcomes. Methods: We retrospectively reviewed all consecutive elective standard infrarenal EVAR procedures performed at a single center from March 2016 to June 2025, excluding repairs requiring planned renal incorporation. The primary event was complete renal artery occlusion or severe compromise requiring revascularization. We assessed mechanism, timing, management, renal function, dialysis, target-vessel patency, and survival. Results: Among 973 EVAR procedures, three patients developed renal artery compromise (0.31%; exact 95% confidence interval, 0.06–0.90%): inadvertent right ostial coverage, right atherothrombotic occlusion from a thrombus-bearing proximal aorta, and left occlusion with severe right compromise after proximal cuff deployment. Endovascular salvage succeeded in both attempted cases; the unilateral embolic occlusion was managed conservatively. All patients developed acute kidney injury, but none required dialysis. Median follow-up was 67.6 months. Conclusions: Recognized renal artery compromise after standard EVAR was uncommon in this cohort. These three cases illustrate a mechanism-informed approach to individualized assessment but cannot establish the superiority of any management strategy.