Abstract:With the accelerating aging of the population, the coexistence of abdominal aortic aneurysm (AAA) and chronic renal insufficiency (CRI) has become increasingly common, posing substantial challenges to perioperative management and adversely affecting patient outcomes. Although endovascular aortic repair (EVAR) is the standard minimally invasive treatment for AAA, the routine use of contrast-enhanced computed tomography and intraoperative angiography carries a significant risk of nephrotoxicity in CRI patients, potentially leading to contrast-induced nephropathy and acute kidney injury, and consequently increasing the risks of heart failure and mortality. To address these challenges, we propose the "ACIER" renal protection strategy, a structured perioperative management framework encompassing five key components: assessment of renal function, control of renal high-risk factors, enhancement of renal reserve, intraoperative reduction of renal injury, and early postoperative renal salvage. This strategy integrates refined risk stratification, contrast-sparing techniques, alternative imaging modalities, and dynamic postoperative renal monitoring, aiming to minimize contrast-related renal injury and improve outcomes in high-risk patients undergoing EVAR. The ACIER strategy provides a practical and individualized approach for the safe application of EVAR in patients with AAA complicated by CRI.