Renal function changes after snorkel/chimney repair of juxtarenal aneurysms

Introduction As endovascular techniques (EVAR) continue to advance, eligibility of patients with anatomically complex abdominal aortic aneurysms (AAA) for EVAR is increasing. However, it remains largely unclear whether complex EVAR is associated with favorable outcome over conventional open repair and how outcomes compare to infrarenal EVAR. The purpose of this study was to examine perioperative outcomes of patients undergoing complex EVAR, focusing on differences with complex open repair and standard infrarenal EVAR. Methods We identified all patients undergoing non-ruptured complex EVAR, complex open repair, and infrarenal EVAR in the Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program. Aneurysms were considered complex if the proximal extent was juxta- or suprarenal, and/or when the Cook Zenith Fenestrated endograft was used. Independent risks were established using multivariable logistic regression analysis. Results A total of 4584 patients were included, with 411 (9.0%) undergoing complex EVAR, 395 (8.6%) complex open repair, and 3778 (82.4%) infrarenal EVAR. Perioperative mortality following complex EVAR was 3.4% vs. 6.6% after open repair (P=.038), and 1.5% after infrarenal EVAR (P=.005). Postoperative acute kidney injuries occurred in 2.3% of complex EVAR patients vs. 9.5% of those undergoing complex open repair (P<.001), and 0.9% of infrarenal EVAR patients (P=.007). Compared to complex EVAR, complex open repair was an independent predictor of 30-day mortality (OR: 2.2, 95% CI:1.1–4.4), renal function deterioration (4.8, 2.2–10.5), and any complication (3.7, 2.5–5.5). When comparing complex to infrarenal EVAR, infrarenal EVAR was associated with favorable 30-day mortality (0.5, 0.2–0.9), and renal outcome (0.4, 0.2–0.9). Conclusions In this study assessing the perioperative outcomes of patients undergoing repair for anatomically complex AAAs, complex EVAR had fewer complications compared to complex open repair, but –in turn– did carry a higher risk of adverse outcomes than infrarenal EVAR. Further research is warranted to determine whether the benefits of EVAR compared to open repair for complex AAA treatment are maintained during long-term follow-up.

Section: Discussionmentioning

confidence: 71%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Perioperative outcome of endovascular repair for complex abdominal aortic aneurysms

Ultee

Zettervall

Soden

et al. 2017

“…Importantly, the frequency of AKI demonstrated by this and other work is 9 to 10 times greater than the 2.9% we report in elective EVAR. 28,29 The extrapolated mortality implications are ominous and must be managed to afford patients full benefit from minimally invasive aortic repair technology.…”

Section: Discussionmentioning

confidence: 99%

Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair

Zarkowsky

Hicks

Bostock

et al. 2016

Objective The reported frequency of renal dysfunction after elective endovascular aneurysm repair (EVAR) varies widely in current surgical literature. Published research establishes pre-existing end-stage renal disease as a poor prognostic indicator. We intend to quantify the mortality effect associated with renal morbidity developed postoperatively and to identify modifiable risk factors. Methods All elective EVAR patients with preoperative and postoperative renal function data captured by the Vascular Quality Initiative between January 2003 and December 2014 were examined. The primary study end point was long-term mortality. Preoperative, intraoperative, and postoperative parameters were analyzed to estimate mortality stratified by renal outcome and to describe independent risk factors associated with post-EVAR renal dysfunction. Results This study included 14,475 elective EVAR patients, of whom 96.8% developed no post-EVAR renal dysfunction, 2.9% developed acute kidney injury, and 0.4% developed a new hemodialysis requirement. Estimated 5-year survival was significantly different between groups, 77.5% vs 53.5%, respectively, for the no dysfunction and acute kidney injury groups, whereas the new hemodialysis group demonstrated 22.8% 3-year estimated survival (P < .05). New-onset postoperative congestive heart failure (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.18-10.38), return to the operating room (OR, 3.26; 95% CI, 1.49-7.13), and postoperative vasopressor requirement (OR, 2.68; 95% CI, 1.40-5.12) predicted post-EVAR renal dysfunction, whereas a preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 was protective (OR, 0.33; 95% CI, 0.21-0.53). Volume of contrast material administered during elective EVAR varies 10-fold among surgeons in the Vascular Quality Initiative database, but the average volume administered to patients is statistically similar, regardless of preoperative eGFR. Multivariable logistic regression demonstrated nonsignificant correlation between contrast material volume and postoperative renal dysfunction. Conclusions Any renal dysfunction developing after elective EVAR is associated with decreased estimated long-term survival. Protecting renal function with a rational dosing metric for contrast material linked to preoperative eGFR may better guide treatment.

“…31 Several reports have shown that although chEVAR might overcome the anatomic risk, it is associated with higher perioperative renal dysfunction. 32–34 The chEVAR is primarily used in patients with juxtarenal or higher AAAs or when the neck of an infrarenal aneurysm is considered hostile. Thus, to make a fair comparison, we sought to examine only infrarenal AAAs in an attempt to make the anatomic risks as homogeneous as possible.…”

Section: Discussionmentioning

confidence: 99%

Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure

Nejim

Arhuidese

Rizwan

et al. 2017

Objective Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome. Methods Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients’ demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease. Results Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m2 (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001). Conclusions Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients’ risk factors that might contribute to postoperative ARF.