Risk factors and early outcomes of acute renal injury after thoracic aortic endograft repair for type B aortic dissection

Abstract

BackgroundThoracic endovascular aortic repair (TEVAR) has become an emerging treatment modality for acute type B aortic dissection (TBAD) patients in recent years. The risk factors and impacts of acute kidney injury (AKI) after percutaneous TEVAR, however, have not been widely established.MethodsWe retrospectively studied the clinical records of 305 consecutive patients who admitted to our institution and had TEVAR for TBAD between December 2009 and June 2013. The patients were routinely monitored for their renal functions preoperatively until 7 days after TEVAR. The Kidney Disease Improving Global Guidelines (KDIGO) criteria were used for AKI.ResultsOf the total 305 consecutive patients, 84 (27.5%) developed AKI after TEVAR, comprising 66 (21.6%) patients in KDIGO stage 1, 6 (2.0%) patients in stage 2 and 12 (3.9%) patients in stage 3. From the logistic regression analysis, systolic blood pressure (SBP) on admission >140 mmHg (odds ratio [OR], 2.288; 95% CI, 1.319–3.969) and supra-aortic branches graft bypass hybrid surgery (OR, 3.228; 95% CI, 1.526–6.831) were independent risk factors for AKI after TEVAR. Local anesthesia tended to be a protective factor (OR, 0.563; 95% CI, 0.316–1.001). The preoperative renal function, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or statin administration, volume of contrast agent, range of TBAD and false lumen involving renal artery were not associated with post-operation AKI. The in-hospital mortality and major adverse events were markedly increased with the occurrence of AKI (7.1% vs 0.9%, P=0.006; 14.3% vs 3.2%, P<0.001, respectively).ConclusionsTEVAR for TBAD has a high incidence of AKI, which is associated with worse in-hospital outcomes. SBP on admission and supra-aortic branches graft bypass hybrid surgery were the most significant risk factors. Renopreventive measures should be considered in high-risk patients.

Perioperative Renal Pharmacological Protection During Cardiovascular Surgery

“…In thoracic endovascular aortic repair (TEVAR), modern case series using RIFLE criteria to define AKI reported incidences of 14-22%, with RRT required in 0.6-7% of patients [27][28][29]. A similar incidence was found in TEVAR for type B aortic dissection [30] Incidence of RIFLE-, AKIN-, KDIGO-or ARISe-defined AKI after EVAR is similar, with a 5-19% reported incidence, with most of studies reporting a 0% rate of dialysis [31].…”

Outcomes and risk management in type B aortic dissection patients with acute kidney injury: a concise review

“…Gorla et al [40] indicated that the use of nephrotoxic contrast media has been associated with renal injury following TEVAR, with the mean contrast medium dose of 356 ± 197 mL. However, the report of Luo et al did not confirm these results [11], with the mean contrast medium dose of 168.2 ± 46.2 mL, which may explain the discrepancy.…”

“…Higher SBP on admission may be associated with renal artery involvement, which activates the renin-angiotensin-aldosterone system and induces a dramatic increase in BP [19]. Additionally, higher SBP acts directly as a parietal stressor and indirectly as a pro-inflammatory trigger, mainly by inducing macrophage recruitment and activation, which causes generalized ischemia of the kidney and the accidence of AKI [11,42]. A report by Luo et al [11] showed that the cutoff value for SBP on admission >140 mmHg was the most relevant predictive factor of AKI after TEVAR (OR, 2.288; 95% CI, 1.319 À 3.969; p ¼ .003).…”

“…Additionally, higher SBP acts directly as a parietal stressor and indirectly as a pro-inflammatory trigger, mainly by inducing macrophage recruitment and activation, which causes generalized ischemia of the kidney and the accidence of AKI [11,42]. A report by Luo et al [11] showed that the cutoff value for SBP on admission >140 mmHg was the most relevant predictive factor of AKI after TEVAR (OR, 2.288; 95% CI, 1.319 À 3.969; p ¼ .003). SBP should be carefully monitored in particular, with the aim of lowering the systolic blood pressure to <120 mmHg using intravenous b-blockers (such as labetalol or esmolol) and vasodilators [4].…”

“…Additionally, the occurrence of AKI increased the 10-year mortality of type B aortic dissection patients regardless of other risk factors, even in patients with recovered renal function on hospital discharge [9]. However, the incidence, characteristics, and risk factors of AKI in type B aortic dissection patients treated medically or surgically are not adequately described [9][10][11]. Most researches have concentrated mainly on the types of conditions requiring TEVAR, such as transections to penetrating ulcers and aneurysms, dissections [12,13].…”