Renal Function after Fenestrated or Branched Endovascular Aortic Repair: The Early Impairment Predictive Factors

Post-Operative and Mid-Term Renal Function Impairment Following Elective Fenestrated Endovascular Aortic Repair for Complex Aortic Aneurysms: Incidence and Risk Factors Analysis

Background. The aim of this study was to assess the incidence of two post-operative acute kidney injury (AKI) stages according to the Risk, Injury, Failure, Loss of function, End-stage (RIFLE) criteria in patients undergoing fenestrated endovascular aortic repair (FEVAR) for complex aortic aneurysms. Furthermore, we analyzed predictors of post-operative AKI and mid-term renal function deterioration and mortality. Methods. We included all patients who underwent elective FEVAR for abdominal and thoracoabdominal aortic aneurysms between January 2014 and September 2021, independently from their preoperative renal function. We registered cases of post-operative acute kidney injury (AKI) both at risk (R-AKI) and injury stage (I-AKI) according to the RIFLE criteria. Estimated glomerular filtration rate (eGFR) was noted preoperatively, at the 48th post-operative hour, at the maximum post-operative peak, at discharge, and then during follow-up approximately every six months. Predictors of AKI were analyzed with univariate and multivariate logistic regression models. Predictors of mid-term chronic kidney disease (CKD) (stage ≥ 3) onset and mortality were analyzed using univariate and multivariate Cox proportional hazard models. Results. Forty-five patients were included in the present study. Mean age was 73.9 ± 6.1 years and 91% of patients were males. Thirteen patients (29%) presented with a preoperative CKD (stage ≥ 3). Post-operative I-AKI was detected in five patients (11.1%). The aneurysm diameter, thoracoabdominal aneurysms and chronic obstructive pulmonary disease were identified as predictors of AKI in univariate analysis (OR 1.05, 95% CI [1.005-1.20], p = 0.030; OR 6.25, 95% CI [1.03-43.97], p = 0.046; OR 7.43, 95% CI [1.20-53.36], p = 0.031; respectively), yet none of these factors were significative on multivariate analysis. Predictors of CKD onset (stage ≥3) during follow-up on multivariate analysis were age (HR 1.16, 95% CI [1.02-1.34], p = 0.023), post-operative I-AKI (HR 26.82, 95% CI [4.18-218.10], p < 0.001) and renal artery occlusion (HR 29.87, 95% CI [2.33-309.05], p = 0.013), while aortic-related reinterventions where not significantly associated with this outcome in univariate analysis (HR 0.66, 95% CI [0.07-2.77], p = 0.615). Mortality was influenced by preoperative CKD (stage ≥3) (HR 5.68, 95% CI [1.63-21.80], p = 0.006) and post-operative AKI (HR 11.60, 95% CI [1.70-97.51], p = 0.012). R-AKI did not represent a risk factor for CKD (stage ≥ 3) onset (HR 1.35, 95% CI [0.45-3.84], p = 0.569) or for mortality (HR 1.60, 95% CI [0.59-4.19], p = 0.339) during follow-up. Conclusions. In-hospital post-operative I-AKI represented the main major adverse event in our cohort, influencing CKD (≥ stage 3) onset and mortality during follow-up, which were not influenced by post-operative R-AKI and aortic-related reinterventions.

Effect of renal function on patient survival after endovascular thoracoabdominal and pararenal aortic aneurysm repair

BACKGROUND

Renal dysfunction can be a prohibitive risk for open repair of complex thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs). However, the effect of renal dysfunction from fenestrated and branched endovascular aneurysm repair (FB-EVAR) on outcomes is poorly defined. Our objective was to review the association of renal function on patient survival after FB-EVAR.

METHODS

The present study reviewed the clinical data of consecutive patients enrolled in a prospective nonrandomized study to investigate FB-EVAR for PRAAs and TAAAs at a single institution with 1 year of follow-up (2013-2017). The patients were categorized by preoperative chronic kidney disease (CKD) classification, and the early- and long-term mortality was assessed.

RESULTS

During the study period, 231 patients had undergone FB-EVAR for 80 PRAAs, 89 type I-III TAAAs, and 62 type IV TAAAs. The mean age was 74.6 ± 6.7 years, and 71% were men. Of the 231 patients, 126 had had CKD stage 1-2, 96 CKD stage 3, and 9 CKD stage 4-5 (all with baseline creatinine >2.0 mg/dL). Patients with CKD stage 4-5 had demographic data similar to those with normal renal function but had had slightly larger aneurysms (6.5 vs 7 cm; P = .15). The 30-day mortality was 0.5% (n = 1) for those with CKD 1-3 vs 0% for those with CKD 4-5 (P = .73). The 1- and 3-year survival analysis showed no major hazards (95% vs 88% and 84% vs 75%, respectively; log-rank P = .98) between the CKD 1-3 and CKD 4-5 groups. The median follow-up period was 2.6 years (interquartile range, 1.5-3.7 years). Two patients with CKD 4-5 had died during the follow-up period.

CONCLUSIONS

Although a small sample size for evaluation, selected patients with CKD 4-5 might have similar short- and long-term mortality compared with those with normal to moderate renal dysfunction after FB-EVAR. Although a major contraindication for open repair, renal dysfunction might not be as prohibitive for endovascular repair in well-selected patients.