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TYPE OF RESEARCH Retrospective NSQIP database review KEY FINDINGS:: Comparison of FEVAR vs OSR for juxtarenal abdominal aortic aneurysms in patients with renal disease showed similar 30-day mortality. However, FEVAR was associated with fewer renal and pulmonary complications compared to OSR. TAKE HOME MESSAGE FEVAR is better for patients with chronic renal insufficiency due to decreased renal and pulmonary complications. Table of Contents Summary This retrospective NSQIP review evaluated 30-day outcomes between fenestrated endovascular aneurysm repair vs open surgical repair of juxta-renal aortic aneurysms (JAAA) in patients with chronic renal insufficiency. There was no significant difference in 30-day mortality, but FEVAR was associated with fewer renal and pulmonary complications. The authors prefer FEVAR over OSR for JAAA in patients with renal disease. ABSTRACT   OBJECTIVE: : Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. METHODS All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. RESULTS There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, p=0.001) and less likely to be smokers (25.8% vs 42.1%; p = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups. Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; p=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; p=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; p<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; p=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, p<0.0001; hospital stay: 3 days vs 8 days, p<0.0001). CONCLUSION For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.