Early Renal Function Alterations in Renal Branches vs. Renal Fenestrations – A Dynamic Scintigraphy Based Prospective Study

Abstract

This single centre prospective study involved 67 patients treated by fenestrated and branched endovascular aneurysm repair (F/BEVAR) technology, who were divided into two groups depending on the renal bridging configurations (fenestration vs. branch). The renal outcomes were studies with standard laboratory parameters (serum creatinine levels and estimated glomerular filtration rate calculation with the Chronic Kidney Disease Epidemiology Collaboration equation) and with 99m Tc dynamic renal scintigraphy to determine whether the configurations have different effects on the renal function. It was found that branches were associated with a more significant decrease in the glomerular filtration rate already evident on three month renal scintigraphy and stable at one year.Objective: The objective of this prospective single centre study was to assess whether branches and fenestrations have different outcomes on renal function in the early phase. Methods: From March 2018 to June 2019, 67 patients who underwent elective fenestrated and branched endovascular aneurysm repair (F/BEVAR) procedures were enrolled in this study. The patients were divided into two groups according to the renal bridging component configuration (fenestration vs. branch). All of them underwent dynamic renal scintigraphy with 99m Tc diethylenetriaminepentaacetic acid (DTPA), two weeks pre-operatively, and three months and one year post-operatively. The primary end points were periprocedural technical success, 30 day major adverse events, differences in glomerular filtration rate (GFR) between the branch and fenestration configurations, and variations between the pre-operative and the postoperative dynamic renal scintigraphy. Results: Overall, 135 kidneys were analysed: 63 in the 32 patients treated with fenestrations, and 72 in the 35 patients treated with branches; the mean GFR on baseline scintigraphy was 58.4 AE 30.9 mL/min in the fenestration group, and 65.1 AE 29.2 mL/min in the branch group. Only kidneys associated with a patent fenestration/branch were included in the split GFR final analysis. The mean total GFR at three month scintigraphy decreased by 6.0 AE 2.9 mL/min in the fenestration group and by 23.4 AE 6.4 mL/min in the branch group. The split GFR decreased by 3.5 AE 0.6 mL/min in the fenestration group, and by 15.4 AE 5.4 mL/ min in the branch group. The GFR decrease remained stable at one year. Conclusion:In this study, the use of branches for renal arteries during F/BEVAR resulted in a greater decrease in the GFR than in those patients who were treated with fenestrations alone. The scintigraphic alterations were evident at an early phase.

Fenestrations, Branches, and the Kidney

“…This is important given that SCr will only deviate outside normal value(s) only once at least half of the functioning renal mass has been affected. In their study, Orrico et al 1 reported that the mean total GFR at the three month scintigraphy decreased by 6.0 AE 2.9 mL/min in the fenestration group and by 23.4 AE 6.4 mL/min in the branch group. However, at one year, the decrease in GFR remained stable.…”

“…We read with great interest the study by Orrico et al in the present issue. 1 Renal dysfunction after aortic intervention is a common and important complication. 2,3 Early literature used mostly inconsistent or inappropriate reporting criteria, such as absolute deviation in serum creatinine (SCr) levels, which made data interpretation difficult.…”

“…4,5 Given that FEVAR and BEVAR are fairly recent technological advances, their exact impact on renal function has not been investigated to a great extent, especially regarding the underlying pathophysiological mechanisms. 1 It would be naïve to think that contrast related injury is the only mechanism involved in renal injury in this context. The potential mechanisms include a plethora of mechanistic pathways: pre-existing chronic kidney disease, pre-existing poor cardiovascular reserve, occult cardiovascular/renal disease, renal micro-emboli, dehydration or pre-renal injury, and ischaemiae reperfusion injury.…”

“…Within this context, the study by Orrico et al 1 aimed to assess whether fenestrations and or branches as part of a F/BEVAR have different outcomes on renal function in the early term (i.e., peri-operatively and within a year). The study recruited 67 patients who underwent an elective FEVAR or BEVAR.…”

Editor's Choice – Pre-Operative Moderate to Severe Chronic Kidney Disease is Associated with Worse Short-Term and Mid-Term Outcomes in Patients Undergoing Fenestrated-Branched Endovascular Aortic Repair

“…Recently, Orrico et al showed that use of branches was associated with a greater decrease in the eGFR than use of fenestrations, which was already evident on three month renal scintigraphy and stable at one year, but the evolution and clinical significance of these data still need to be documented. 31 Therefore, although use of fenestrations over branches might be warranted for incorporation of renal arteries based on these preliminary data, it should always be borne in mind that selection of stent graft design is often mandated by the need to accommodate the aortic anatomy at the level of target vessel origin. In fact, durability of both fenestrations and branches after complex EVAR procedures remains a debated issue, 32 even after the introduction of newer generation bridging stent grafts 33e35 and refined assessment of their geometrical configuration, 36e38 and future research should focus on risk prediction models for loss of RA patency that could better inform how to structure adequate follow up protocols.…”