Impact of Chronic Kidney Disease on Outcomes After Abdominal Aortic Aneurysm Repair

Abstract

Introduction and objectives:Ultrasound-guided access allows for direct visualization of the access artery during percutaneous endovascular aneurysm repair (EVAR). We hypothesize that the use of ultrasound guidance allowed us to safely increase the use of percutaneous EVAR and to benefit from its lower rates of wound complications.Methods: A retrospective record review was performed of all elective EVAR from 2005 to 2010 at an academic tertiary care center. Patients were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes and stratified by percutaneous vs femoral cutdown access. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (Ն16F) or small (Ͻ16F). Outcomes were wound complications (infections or clinically significant hematomas), operative time, length of stay, and discharge disposition. Predictors of percutaneous failure and femoral cutdown access were determined.Results: Percutaneous access was used in 141 patients (281 arteries) and femoral cutdown in 104 patients (208 arteries). Ultrasound-guided access was introduced in 2006. Percutaneous access increased from 0% in 2005 to 92.9% of elective EVAR in 2010. The remaining 7% had planned cutdown for concomitant femoral-femoral bypass. The success rate with percutaneous access was 95.1%. Failures included hemorrhage in eight and occlusion of the artery in five. Percutaneous access had fewer wound complications (0% vs 7.6%, P Յ .01) and shorter operative time (157.6 vs 207.5 minutes, P Յ .001). Length of stay (3.2 vs 4.1 days, P ϭ .09) and discharge home (91.5% vs 84.3%, P ϭ .08) had trends towards significance. No difference was seen in body mass index (26.6 vs 26.8 kg/m 2 , P ϭ .73). There were no predictors of femoral cutdown access. Only peripheral arterial disease predicted percutaneous failure (odds ratio, 4.59; 95% confidence interval, 1.27-15.57; P ϭ .025).Conclusions: Ultrasound guidance has prompted the increased use of percutaneous EVAR in nearly all elective EVAR cases. Percutaneous access has fewer wound complications and shorter operative time and can be performed safely with a high success rate.

Contrast Free Duplex-Assisted EVAR in Patients with Chronic Renal Insufficiency

“…1) This particular group is at risk for developing contrastinduced nephropathy (CIN). The incidence of CIN rises with 5-8% annualy.…”

Post-Stress Perfusion Abnormalities Detected on Myocardial Perfusion Single-Photon Emission Computed Tomography Predict Long-Term Mortality After Elective Abdominal Aortic Aneurysm Repair

“…25,26 A reasonably high number of patients undergoing elective AAA repair, however, suffer from CKD. 17 Approximately half of the present patients had concomitant moderate to severe CKD. Therefore, it might be better to avoid use of contrast medium to prevent contrastinduced nephropathy.…”

Renal function 5 years after open and endovascular aortic aneurysm repair from a randomized trial

“…A subset of patients remain at risk of deteriorating renal function after AAA repair, especially those with more advanced pre‐existing renal impairment. These patients are more likely to have higher morbidity and mortality rates than those with relatively normal renal function. Long‐term survival after elective aneurysm repair has improved over time despite a change in case mix towards older patients with more co‐morbidity.…”

“…Renal dysfunction, defined as a decline in estimated glomerular filtration rate (eGFR), is a strong predictor of impaired survival, especially after vascular surgery. During EVAR, renal dysfunction is of specific concern owing to the administration of nephrotoxic contrast agents and instrumentation in the juxtarenal aorta.…”

“…During follow‐up, however, EVAR has higher reintervention rates than OR and, together with the use of contrast‐enhanced computed tomography (CT) follow‐up, the presumed initial advantages of EVAR for kidney function may be negated or even outweighed. Preoperative kidney function should not drive the decision between OR and EVAR, yet there is evidence that chronic renal impairment is a good predictor of both worse short‐ and long‐term outcomes after abdominal aortic aneurysm (AAA) surgery. The aim of this study was to compare renal function 5 years after OR and EVAR for AAA.…”