Glomerular filtration rate is a predictor of mortality after endovascular abdominal aortic aneurysm repair

Outcomes of Thoracic and Complex Endovascular Aortic Repair in Patients with Renal Insufficiency

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (cEVAR) are effective and minimally invasive treatment options for preventing rupture and decreasing mortality of aortic aneurysms. Patients with renal insufficiency are prone to worse postoperative cardiovascular morbidity and mortality due to the atherosclerosis burden as well as increased levels of angiotensin II. Nonetheless, knowledge about the outcomes of aortic stent graft therapy in patients with chronic kidney disease (CKD) or dialysis is scarce. This study aimed to examine outcomes after TEVAR and cEVAR in patients on CKD and dialysis.

METHODS

Utilizing data from the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network database, we retrospectively evaluated patients who underwent TEVAR or cEVRA from 2010 to 2018. Patients were divided into patients with no CKD or dialysis, CKD patients, and dialysis patients. Outcomes were in-hospital stroke, myocardial infarction (MI), spinal cord ischemia (SCI), 30-day mortality, 1-year mortality, aneurysmal rupture, and reintervention. In-hospital outcomes were assessed using multivariable logistic regression analysis and 1-year outcomes were evaluated using Kaplan-Meier Survival and Cox regression analyses.

RESULTS

A total of 4,867 patients were included in the study, 2,694 had no CKD or dialysis, 2,047 had CKD, and 126 were on dialysis. Dialysis patients were significantly younger, and more likely to be non-White and of Hispanic/Latino origin. They were also more likely to have medical comorbidities. CKD patients had higher odds of in-hospital MI (odds ratio [OR]: 2.02, 95% confidence interval [CI] (1.43-2.86), P < 0.001) and 30-day mortality (OR: 1.56, 95% CI (1.18-2.07), P < 0.001) compared to patients with no CKD or dialysis. Dialysis patients had higher odds of 30-day mortality (OR: 3.31, 95% CI (1.73-6.35), P < 0.001). At 1 year, dialysis was associated with a higher risk of mortality (hazard ratio [HR]: 3.48, 95% CI (2.39-5.07), P < 0.001) and reintervention (HR: 1.72, 95% CI (1.001-2.94), P < 0.049). CKD was associated with a higher risk of mortality (HR: 1.45, 95% CI (1.21-1.75), P < 0.001) compared to patients with no CKD or dialysis.

CONCLUSIONS

Among patients undergoing TEVAR or cEVAR, there was no significant difference in the risk of in-hospital stroke, SCI, and 1-year aneurysmal rupture among dialysis and CKD patients compared to patients with no CKD or dialysis. However, CKD patients had twice the risk of in-hospital MI. Dialysis patients had a higher risk of 1-year reintervention. Both dialysis and CKD patients had a higher risk of 30-day and 1-year mortality.

Learning curve of transfemoral carotid artery stenting in the Vascular Quality Initiative registry

OBJECTIVE

With the recent expansion of the Centers for Medicare and Medicaid Services coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. Because approximately 30% of perioperative strokes/deaths post-CAS occur after discharge, appropriate thresholds for in-hospital event rates have been suggested to be <4% for symptomatic and <2% for asymptomatic patients. This study evaluates the tfCAS learning curve using Vascular Quality Initiative (VQI) data.

METHODS

We identified VQI patients who underwent tfCAS between 2005 and 2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. The primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/myocardial infarction (MI), 30-day mortality, in-hospital stroke/transient ischemic attack (stroke/TIA), and access site complications. The relationship between outcomes and procedure counts was analyzed using the Cochran-Armitage test and a generalized linear model with restricted cubic splines. Our results were then validated using a generalized estimating equations model to account for the variability between physicians.

RESULTS

We analyzed 43,147 procedures by 2476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2%-1.7%), in-hospital stroke/death/MI (5.8%-1.7%), 30-day mortality (4.6%-2.8%), in-hospital stroke/TIA (5.0%-1.1%), and access site complications (4.1%-1.1%) as physician experience increased (all P values < .05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1%-1.6%), in-hospital stroke/death/MI (2.6%-1.6%), 30-day mortality (1.7%-0.4%), and in-hospital stroke/TIA (2.8%-1.6%) with increasing physician experience (all P values <.05). The in-hospital stroke/death rate remained above 2% until 13 procedures.

CONCLUSIONS

In-hospital stroke/death and 30-day mortality rates after tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. Nevertheless, a substantially high rate of in-hospital stroke/death was found in physicians' first 25 procedures. With the recent Centers for Medicare and Medicaid Services coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased postoperative complications.

Impact of Physician Experience on Stroke or Death Rates in Transfemoral Carotid Artery Stenting: Insights from the Vascular Quality Initiative

Objective

With the recent expansion of the Centers for Medicare and Medicaid Services (CMS) coverage, transfemoral carotid artery stenting (tfCAS) is expected to play a larger role in the management of carotid disease. Existing research on the tfCAS learning curve, primarily conducted over a decade ago, may not adequately describe the current effect of physician experience on outcomes. This study evaluates the tfCAS learning curve using VQI data.

Methods

We analyzed tfCAS patient data from 2005-2023. Each physician's procedures were chronologically grouped into 12 categories, from procedure counts 1-25 to 351+. Primary outcome was in-hospital stroke/death rate; secondary outcomes were in-hospital stroke/death/MI, 30-day mortality, and in-hospital stroke/TIA. The relationship between outcomes and procedure counts was analyzed using Cochran Armitage test and a generalized linear model with restricted cubic splines, validated using generalized estimating equations.

Results

We analyzed 43,147 procedures by 2,476 physicians. In symptomatic patients, there was a decrease in rates of in-hospital stroke/death (procedure counts 1-25 to 351+: 5.2% to 1.7%), in-hospital stroke/death/MI (5.8% to 1.7%), 30-day mortality (4.6% to 2.8%), in-hospital stroke/TIA (5.0% to 1.1%) (all p-values<0.05). The in-hospital stroke/death rate remained above 4% until 235 procedures. Similarly, in asymptomatic patients, there was a decrease in rates of in-hospital stroke/death (2.1% to 1.6%), in-hospital stroke/death/MI (2.6% to 1.6%), 30-day mortality (1.7% to 0.4%), and in-hospital stroke/TIA (2.8% to 1.6%) with increasing physician experience (all p-values<0.05). The in-hospital stroke/death rate remained above 2% until 13 procedures.

Conclusions

In-hospital stroke/death and 30-day mortality rates post-tfCAS decreased with increasing physician experience, showing a lengthy learning curve consistent with previous reports. Given that physicians' early cases may not be included in the VQI, the learning curve was likely underestimated. With the recent CMS coverage expansion for tfCAS, a significant number of physicians would enter the early stage of the learning curve, potentially leading to increased post-operative complications.

Chronic kidney disease impacts outcomes after abdominal aortic aneurysm repair

OBJECTIVE

Chronic kidney disease (CKD) and end-stage renal disease are traditionally associated with worse outcomes after endovascular and open repair of abdominal aortic aneurysm (AAA). This study stratifies outcomes of AAA repair by approach, CKD severity, and dialysis dependence.

METHODS

All patients undergoing elective infrarenal open aneurysm repair (OAR) and endovascular aortic repair (EVAR) with preoperative renal function data captured by the Vascular Quality Initiative between January 2003 and September 2020 were analyzed. Patients were stratified by CKD class as follows: CKD stages 1 and 2, CKD stage 3a, CKD stage 3b, CKD stages 4 and 5, and dialysis. Primary outcomes were perioperative and 1-year mortality. Predictors of survival were identified by Cox multivariate regression models.

RESULTS

In total, 53,867 elective AAA repairs were identified: 5396 (10%) OARs and 48,471 (90%) EVARs. Most patients were White (90%) and male (81%), with a mean age of 73 ± 9 years. Patients who underwent EVAR were older and had more comorbidities. The use of elective EVAR for AAA increased from 52% in 2003 to 91% in 2020 (P < .001). The OAR cohort had more perioperative complications and short-term mortality. The CKD 1 and 2 group had the highest 1-year survival compared with the other groups after both OAR and EVAR. On Cox regression analysis, after EVAR, compared with CKD 1 and 2, worsening CKD stage (CKD 3a: hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.93-1.68; P = .13; CKD 3b: HR, 1.74; 95% CI, 1.23-2.45; P < .050; CKD 4-5: HR, 3.23; 95% CI, 2.13-4.88; P < .001), and dialysis (HR, 4.48; 95% CI, 1.90-10.6; P < .001) were independently associated with worse 1-year survival rates. After OAR, compared with CKD 1 and 2, worsening CKD stage (CKD 3a: HR, 1.08; 95% CI, 0.96-1.20; P = .20; CKD 3b: HR, 1.60; 95% CI, 1.41-1.81; P < .001; CKD 4-5: HR, 2.85; 95% CI, 2.39-3.41; P < .001), and dialysis (HR, 3.79; 95% CI, 3.01-4.76; P < .001) were independently associated with worse 1-year survival rates.

CONCLUSIONS

Regardless of the treatment approach, CKD severity is an important predictor of perioperative and 1-year mortality rates after infrarenal AAA repair and may reflect the natural history of CKD. Open repair is associated with high perioperative mortality risk in patients with CKD stages 4 and 5, as well as end-stage renal disease. Individualization of patient decision-making is especially important in patients with a glomerular filtration rate of less than 45 and perhaps consideration should be given to raising the threshold for elective AAA repair in these patients. Further studies focusing on appropriate size threshold for repair in these patients may be warranted.

Selection criterion for endovascular aortic repair in those with chronic kidney disease

OBJECTIVE

Endovascular aortic repair (EVAR) is the preferred method of repair for abdominal aortic aneurysms (AAAs). However, patients with advanced chronic kidney disease (CKD) are a high-risk group, and it is unknown which patients with CKD benefit from EVAR vs continued surveillance. The purpose of this study was to identify which patients with advanced CKD may benefit from EVAR.

METHODS

The Vascular Quality Initiative Database was utilized to identify elective EVARs for AAAs. Patients were excluded if they underwent urgent or emergent repairs. CKD stages were categorized based on preoperative estimated glomular filtration rate (eGFR) and dialysis status. Predicted 1-year mortality of untreated AAAs was calculated by modifying a validated comorbidity score that predicts 1-year mortality (Gagne Index) without repair. The primary outcome was actual 1-year mortality, which was compared with the predicted 1-year mortality without repair.

RESULTS

A total of 34,926 patient met study criteria. There were differences in Gagne Indices among the varying classes of CKD. Patients with CKD 4 and CKD 5 had the highest 1-year mortality rates, followed by CKD 3b, which was significantly higher than those with CKD 1 and CKD 2. Patients with CKD 4 had no differences between actual 1-year mortality with EVAR and predicted 1-year survival without EVAR across all AAA sizes. Those with CKD 5 had worse actual 1-year survival with EVAR than predicted 1-year survival without EVAR for AAAs <5.5 cm. Patients with CKD 5 only experienced an actual mortality benefit with EVAR compared with predicted 1-year mortality without EVAR for AAAs ≥7.0 cm.

CONCLUSION

The current data suggest that patients with CKD 3b, 4, and 5 represent a high-risk group who may not benefit from elective EVAR utilizing traditional size criteria. Patients with CKD 4 and 5 with AAAs <5.5 cm do not benefit from elective EVAR. In patients with CKD 5, elective EVAR may need to be reserved for AAAs ≥7.0 cm unless there are other concerning anatomic characteristics.

The impact of postoperative blood glucose levels on complications and prognosis after esophagectomy in patients with esophageal cancer

PURPOSE

This study aimed to characterize postoperative blood glucose fluctuation in patients who underwent esophagectomy for esophageal cancer, and to define its impact on complications and prognosis.

METHODS

The subjects of this retrospective study were 284 patients who underwent esophagectomy at Osaka University Hospital between 2015 and 2017. Data analyzed included clinicopathological background, the immediate postoperative blood glucose level (IPBG), postoperative blood glucose variability (PBGV), insulin dosage, postoperative complications, and prognosis.

RESULTS

The median IPBG and PBGV were 170 (64-260) mg/dl and 64.5 (11-217) mg/dl, respectively. Postoperative pneumonia was more common in patients with PBGV > 100 mg/dl (P = 0.015). Patients with IPBG < 170 mg/dl had significantly worse 5-year overall survival (OS) and 5-year recurrence-free survival (RFS) than those with IPBG > 170 mg/dl (54.5% vs. 80.4%, respectively, [P < 0.001] and 44.3% vs. 69.3%, respectively, [P = 0.001]). The 5-year OS rates were 43.5%, 68.3%, 80.6%, and 79.0% for patients with IPBG < 154, 154-170, 170-190, and ≥ 190 mg/dl, respectively. The corresponding 5-year RFS rates were 38.1%, 52.4%, 77.0%, and 61.3%, respectively. Multivariate analysis revealed that IPBG < 154 mg/dl and pathological stage were independent poor prognostic factors for OS.

CONCLUSION

PBGV was associated with postoperative pneumonia, and low IPBG was an independent poor prognostic factor for patients with esophageal cancer.

Effectiveness of a new cardiac risk scoring model reclassified by QRS fragmentation as a predictor of postoperative cardiac event in patients with severe renal dysfunction

Background

It is difficult to evaluate the risk of patients with severe renal dysfunction before surgery due to various limitations despite high postoperative cardiac events. This study aimed to investigate the value of a newly reclassified Revised Cardiac Risk Index (RCRI) that incorporates QRS fragmentation (fQRS) as a predictor of postoperative cardiac events in patients with severe renal dysfunction.

Methods

Among the patients with severe renal dysfunction, 256 consecutive patients who underwent both a nuclear stress test and noncardiac surgery were evaluated. We reclassified RCRI as fragmented RCRI (FRCRI) by integrating fQRS on electrocardiography. We defined postoperative major adverse cardiac event (MACE) as a composite of cardiac death, nonfatal myocardial infarction, and pulmonary edema.

Results

Twenty-eight patients (10.9%) developed postoperative MACE, and this was significantly frequent in patients with myocardial perfusion defect (41.4% vs. 28.0%, p = 0.031). fQRS was observed 84 (32.8%) patients, and it was proven to be an independent predictor of postoperative MACE after adjusting for the RCRI (odds ratio 3.279, 95% confidence interval (CI) 1.419–7.580, p = 0.005). Moreover, fQRS had an incremental prognostic value for the RCRI (chi-square = 7.8, p = 0.005), and to the combination of RCRI and age (chi-square = 9.1, p = 0.003). The area under curve for predicting postoperative MACE significantly increased from 0.612 for RCRI to 0.667 for FRCRI (p = 0.027) and 23 patients (32.4%) originally classified as RCRI 2 were reclassified as FRCRI 3.

Conclusions

A newly reclassified FRCRI that incorporates fQRS, is a valuable predictor of postoperative MACE in patients with severe renal dysfunction undergoing noncardiac surgery.

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair

OBJECTIVE

The objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms.

METHODS

We analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts.

RESULTS

There were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD.

CONCLUSIONS

Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.

Preoperative Glomerular Filtration Rate and Outcome Following Open Abdominal Aortic Aneurysm Repair

Estimated glomerular filtration rate (eGFR) can be readily calculated from serum creatinine values. It is a more sensitive prognostic indicator than serum creatinine alone in patients undergoing thoracoabdominal or endovascular abdominal aortic aneurysm repair. The value of eGFR in patients undergoing open abdominal aortic aneurysm repair remains unclear. The preoperative eGFR was calculated for patients undergoing elective open infrarenal aortic aneurysm repair. Postoperative complications, perioperative mortality, and long-term survival were compared across eGFR and serum creatinine quartiles. The eGFR identified preoperative renal dysfunction in 33% of patients, whereas serum creatinine identified renal impairment in only 11%. The eGFR correlated with perioperative morbidity and long-term survival. Serum creatinine did not correlate with perioperative mortality or long-term survival. However, it did correlate with postoperative morbidity. The eGFR is a more sensitive index of preoperative renal function than serum creatinine and correlates with survival. It should replace serum creatinine as the standard index of renal function before open abdominal aortic aneurysm repair.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience

BACKGROUND

Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies.

METHODS

Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated.

RESULTS

The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection.

CONCLUSIONS

Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Outcomes after thoracic endovascular aortic repair in patients with chronic kidney disease in the Medicare population

OBJECTIVE

Thoracic endovascular aortic repair has been increasingly performed in higher-risk patients with renal failure. The objective was to compare Medicare patients with preoperative chronic kidney disease with patients with normal renal function to determine differences in postoperative survival and complications.

METHODS

From 2000 to 2014, 27,079 Medicare fee-for service patients underwent thoracic endovascular aortic repair. Patients were stratified by kidney function, and 23,375 patients (86%) had no chronic kidney disease, 2957 patients (11%) had chronic kidney disease stage I/IV, and 747 patients (3%) had end-stage renal disease or hemodialysis. Groups were then compared with determined differences in adjusted all-cause mortality and rates of postoperative complications.

RESULTS

Overall survival was significantly worse among patients with chronic kidney disease and end-stage renal disease or hemodialysis compared with patients with no chronic kidney disease (1-year survival no chronic kidney disease: 78%; chronic kidney disease I/II: 77%; chronic kidney disease III: 67%; chronic kidney disease IV: 58%; and end-stage renal disease or hemodialysis: 48%, P < .001). Mortality was significantly increased among patients with chronic kidney disease III (hazard ratio [HR], 1.29; P < .001), chronic kidney disease IV (HR, 1.74; P < .001), and end-stage renal disease or hemodialysis (HR, 2.03; P < .001). No mortality difference was found between patients with no chronic kidney disease and patients with chronic kidney disease stage I/II. At 30 days after thoracic endovascular aortic repair, sepsis was increased for patients with chronic kidney disease stage III/IV (HR, 1.7; P < .001) and end-stage renal disease or hemodialysis (HR, 2.7; P < .001).

CONCLUSIONS

In this elderly Medicare population undergoing thoracic endovascular aortic repair, patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis had poor survival and increased morbidity compared with those with normal kidney function. These data may suggest that patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis should be more cautiously evaluated for thoracic endovascular aortic repair, weighing the benefits of the procedure against the high expected mortality.

Renal function after abdominal aortic aneurysm repair in patients with baseline chronic renal insufficiency: open vs. endovascular repair

BACKGROUND

The aim of this study is to analyze renal function impairment (RFI) after abdominal aortic aneurysm (AAA) repair in patients with preoperative chronic kidney disease (CKD).

METHODS

Retrospective cohort study of patients with CKD undergoing elective AAA repair between 2008-2015, dividing the sample into two groups: open repair (OR) and endovascular repair (EVAR). The primary outcome was RFI defined by the RIFLE scale, studying Risk (1.5-fold increase in Cr or GFR decline >25% compared to baseline) and kidney injury (doubling of Cr or GFR decline >50%).

RESULTS

Seventy-five patients (OR=29, EVAR=46). Baseline characteristics for OR and EVAR were similar except for age (70.4 vs. 77.2 years; P<0.001), coronary artery disease (31% vs. 56.5%; P=0.04), neck length (12.3 vs. 22.7 mm; P=0.001) and baseline GFR (40.6 vs. 36.9 mL/min; P=0.03). There were no inter-group differences in postoperative RFI: Risk of RFI 13.8% OR vs. 13% EVAR and kidney Injury 6.9% vs. 0% (P=0.19). There were also no differences in RFI at one year. Comparing GFR and Cr after surgery and at 12 months to baseline values, the OR group presented a significant postoperative decline in GFR compared to EVAR group (-3.8% vs. 11.1%; P=0.03), which had recovered at one-year follow-up (16.6% vs. 9.5%; P=0.43), while EVAR group presented with a tendency toward increased Cr during follow-up (-9.2% vs. 2.2%; P=0.08). Multivariate analysis did not identify independent RFI prognostic factors.

CONCLUSIONS

Both techniques can be used safely in patients with CKD and baseline CKD is not a limiting factor for either technique. RFI is rare and transient in both groups.

Impact of aortic wall thrombus on late changes in renal function among patients treated by fenestrated-branched endografts

OBJECTIVE

Renal function deterioration is an important determinant of mortality in patients treated for complex aortic aneurysms. We have previously determined that catheter and guidewire manipulation in diseased aortas during fenestrated-branched endovascular aneurysm repair (F-BEVAR) is associated with risk of renal function deterioration. The aim of this study was to describe the impact of atherothrombotic aortic wall thrombus (AWT) on renal function deterioration among patients treated by F-BEVAR for pararenal and extent IV thoracoabdominal aortic aneurysms.

METHODS

Clinical data of 212 patients treated for complex aortic aneurysms with F-BEVAR were entered into a prospectively maintained database (2007-2015). AWT was evaluated by computed tomography angiography using volumetric measurements in nonaneurysmal aortic segments. AWT was classified as mild, moderate, or severe using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Acute kidney injury (AKI) was defined using Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease (RIFLE) criteria, and renal function deterioration was defined by a decline in estimated glomerular filtration rate (eGFR) >30% from baseline. Patient survival and renal outcomes were assessed at dismissal, at 6 to 8 weeks, at 6 months, and annually, including AKI, serum creatinine concentration, eGFR, chronic kidney disease stage, need for renal replacement therapy, and presence of kidney infarction.

RESULTS

There were 169 male (80%) and 43 female (20%) patients with a mean age of 75 ± 7 years. Aneurysm extent was pararenal in 157 patients and extent IV thoracoabdominal aortic aneurysm in 55 patients. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%), moderate in 75 (35%), and severe in 39 (19%). At 30 days, 45 patients (21%) developed AKI. Decline in eGFR and kidney infarction were associated with higher AWT volume index and severe AWT classification (P < .05). There was no association of AWT with 30-day mortality, which was 0.5% for the entire cohort. Mean follow-up was 29 ± 23 months. Freedom from renal function deterioration was 73% ± 6% for mild, 81% ± 6% for moderate, and 66% ± 8% for severe AWT patients at 3 years (P = .012) and 46% ± 9% and 82% ± 4% for those with or without AKI after the initial procedure (P < .001). Overall, 41 patients (19%) had progression of chronic kidney disease stage, but none of the patients required renal replacement therapy. Survival was 73% ± 5% for mild, 72% ± 6% for moderate, and 69% ± 10% for severe AWT patients at 3 years (P = .67).

CONCLUSIONS

AWT is a significant predictor of AKI and continued decline in renal function after the initial F-BEVAR procedure. Longer follow-up time is needed to determine the actual impact of AWT on survival.

Chronic Kidney Disease Class Predicts Mortality After Abdominal Aortic Aneurysm Repair in Propensity-matched Cohorts From the Medicare Population

INTRODUCTION

Chronic kidney disease (CKD) predicts mortality after abdominal aortic aneurysm (AAA) repair. Few studies are adequately powered to stratify outcomes by CKD severity. This study assesses the effect of CKD severity on survival after AAA repair.

METHODS

Patients who underwent AAA repair from 2006 to 2007 were retrospectively identified in the Medicare database and stratified by CKD class as follows: normal (CKD class 1 and 2), moderate (CKD class 3), and severe (CKD class 4 and 5). Propensity matching (30:1) by clinical factors and procedure type was performed to derive well-matched comparative cohorts. Primary outcomes were 30-day and long-term mortality; secondary outcomes included hospital length of stay and cost.

RESULTS

A total of 47,715 patients were included (96.7% normal, 1.88% moderate, and 1.65% severe). Propensity matching was corrected for differences between cohorts. Thirty-day mortality was higher in moderate (5.7% vs normal 2.5%; P < 0.01) and severe (9.9% vs normal 1.8%; P < 0.01) groups. Hospital length of stay increased with CKD severity (4.4 ± 3.7 days normal vs 6.5 ± 4.2 days moderate CKD; P < 0.01/4.7 ± 3.8 days normal vs 9.1 ± 4.5 days severe CKD; P < 0.01) as did cost ($23 ± 14K normal vs $25 ± 16K moderate; P < 0.01 /$22 ± 11K normal vs $29 ± 22K severe; P < 0.01). Three-year survival favored the normal cohort (80% vs 64% moderate; log rank P < 0.01 /82% normal vs 44% severe; log rank P < 0.01).

CONCLUSIONS

CKD severity is an important predictor of perioperative mortality and long-term survival after AAA repair in propensity-matched cohorts. The 5-fold increase in 30-day mortality and 44% in 3-year survival suggest that elective AAA repair is contraindicated in most severe CKD patients.

Progression to stage 3 and 4 chronic kidney disease and risk factor stratification following endovascular aortic aneurysm repair

Background

Risk of progression to various stages of chronic kidney disease (CKD) after endovascular aortic aneurysm repair (EVAR) is unknown. This study estimates progression rates to stage 3 and 4 CKD after EVAR and identifies potential predictors for progression.

Methods

EVAR cases (2006–2012) were retrospectively reviewed. Freedom of progression to CKD was estimated using Kaplan–Meier analysis, and predictors for progression were identified using Cox proportional hazards model.

Results

Two hundred and twelve consecutive patients at a single academic institution underwent EVAR for infrarenal aneurysms. Estimated freedom from progression to stage 3 CKD was 80%, 76%, and 63% at 6, 12, and 18 months, respectively, and for stage 4, 97%, 96%, and 93% at 6, 12, and 18 months, respectively. Stage 3 CKD predictors of progression included age (odds ratio (OR): 1.106, p = 0.001), diabetes (OR: 3.052, p = 0.04), perioperative use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers (OR: 3.249, p = 0.02), and operative blood loss (OR: 1.002, p < 0.01). Stage 4 predictors included preoperative hemoglobin (OR: 0.473, p = 0.04) and baseline renal function (OR: 0.928, p = 0.001). Intraoperative contrast administration did not impact CKD development.

Conclusions

Progression to stage 3 CKD after EVAR occurs more frequently and at a higher rate compared with progression to stage 4. Different risk factors are associated with progression to each of those stages of CKD.

Preoperative Evaluation of the Renal Function before the Treatment of Abdominal Aortic Aneurysms

BACKGROUND

Chronic impaired renal function constitutes a major risk factor of morbi-mortality during the treatment of an abdominal aortic aneurism (AAA). The inflammatory state due to the AAA could result in a reduction in the muscular mass and an overestimation of the glomerular filtration rate (GFR) with the usual formulas. The objective of this study was to determine if the formulas used to evaluate the estimated GFR were adapted in patients with AAA.

MATERIALS AND METHODS

Between August 2013 and November 2014, we conducted an exploratory study to evaluate the renal function before surgery for AAA in 28 patients. The renal function was evaluated by (1) the dosage of plasmatic creatinine, (2) the GFR estimated with the Cockroft-Gault, Modification of Diet in Renal Disease (MDRD), and chronic kidney disease epidemiology collaboration (CKD-EPI) formulas, (3) the creatinine clearance (CC), and (4) the direct measurement of the GFR with a reference method (iohexol clearance). Statistical analysis was carried out to compare and correlate the GFR estimated by the various formulas with the GFR measured by the reference technique.

RESULTS

The study included 21 men (75%) and 7 women (25%), with a median age of 76 years (58-89). The measured GFR was correlated with the GFR estimated from the CKD-EPI (rho = 0.78, P < 0.0001), the MDRD (rho = 0.78, P < 0.0001), the Cockroft-Gault (rho = 0.65, P = 0.0002), and CC (rho = 0.86, P < 0.0001). However, there were important individual variations between estimated and measured GFR. As regards the detection of the patients presenting a GFR <60 mL/min/1.73 m², the sensitivities of the CKD-EPI, MDRD, Cockroft-Gault formulas and CC were 64%, 64%, 71%, and 70%, respectively. Specificities were 71%, 79%, 57%, and 100%, respectively. The estimation of the GFR by the CKD-EPI formula had the lowest bias (-3.0). Bland-Altman plots indicated that the estimation of the GFR by the CKD-EPI formula had the best performance in comparison with the other methods.

CONCLUSIONS

This study found a statistical correlation between the measurement of the GFR and the various formulas available to estimation the GFR among AAA patients. The CKD-EPI formula is most appropriate. However, there were important individual variations between the measurement and the estimations of the GFR. A larger scale study is necessary to determine the profile of the patients with a risk of error in the estimation of the GFR. The French recommendations on the evaluation of the renal function before AAA treatment remain based on serum creatinine and should be revalued.

Risk factors for early renal dysfunction following endovascular aortic aneurysm repair and its effect on the postoperative outcome

PURPOSE

Renal insufficiency is associated with increased morbidity and death after endovascular aortic aneurysm repair (EVAR). However, the effect of postoperative acute kidney dysfunction on patient outcome has not been fully determined. This study aimed to determine the risk factors of early postoperative renal function decline using chronic kidney disease (CKD) staging and its effect on the clinical outcome.

METHODS

A retrospective analysis was performed on a prospectively maintained EVAR database. Pre- and postoperative CKD stages were determined for all patients according to the estimated glomerular filtration rate values.

RESULTS

We identified 135 patients who were treated with elective EVAR. CKD stage decline was observed in 25 (19 %) of the patients. Freedom from aneurysm-related death was significantly lower in patients with postoperative CKD progression compared with those with unchanged CKD stage. A shaggy aorta without oral beta-blocker administration and higher preoperative serum creatinine levels (>1.4 mg/dL) were found to be independent predictors of an early postoperative CKD stage decline.

CONCLUSIONS

Patients with postoperative CKD progression have an increased frequency of aneurysm-related death. The presence of a shaggy aorta, absence of oral beta-blocker administration and an increased preoperative creatinine level are independent predictors of early postoperative CKD progression.

Prevalent cardiac, renal and cardiorenal damage in patients with advanced abdominal aortic aneurysms

Chronic kidney disease (CKD), cardiac damage (CD) and the combination of the two are associated with increased morbidity and death in patients admitted to vascular surgery units. We assessed the prevalence of cardiac and renal damage and cardiorenal syndrome (CRS) in 563 patients with abdominal aortic aneurysms (AAA) who underwent cardiac screening before either an endovascular procedure (EVAR) or open surgery (OS) for aneurysm repair. CD was defined by ≥stage B as per the ACC/AHA classification of congestive heart failure (CHF), while CKD was defined by estimated GFR <60 mL/min/1.73 m(2) (CKD-EPI). Anemia [World Health Organization (WHO) guidelines] and iron deficiency (ID) (criteria for CHF patients) were also calculated. AAA patients were stratified into the following groups: CD, CKD, CRS or none of these conditions [no risk factors (NoRF)]. The prevalence of isolated cardiac and renal structural damage, of combined cardiorenal damage and of ID was 24.1, 15.0, 20.6 and 23.4 %, respectively. The frequency of anemia (mostly unrecognized) among the groups increased from NoRF (12.8 %)/CKD (19 %)/CD (25 %) up to CRS (38.8 %). This large-scale observational study provides clues for the increased CD/CKD risk profiles of unselected AAA patients, and underlines the need for better identification of ID/anemia and for appropriate treatment of CKD and CD before these patients undergo EVAR/OS.

Moderate Increase of Indoxyl Sulfate Promotes Monocyte Transition into Profibrotic Macrophages

OBJECTIVE

The uremic toxin Indoxyl-3-sulphate (IS), a ligand of Aryl hydrocarbon Receptor (AhR), raises in blood during early renal dysfunction as a consequence of tubular damage, which may be present even when eGFR is normal or only moderately reduced, and promotes cardiovascular damage and monocyte-macrophage activation. We previously found that patients with abdominal aortic aneurysms (AAAs) have higher CD14+CD16+ monocyte frequency and prevalence of moderate chronic kidney disease (CKD) than age-matched control subjects. Here we aimed to evaluate the IS levels in plasma from AAA patients and to investigate in vitro the effects of IS concentrations corresponding to mild-to-moderate CKD on monocyte polarization and macrophage differentiation.

METHODS

Free IS plasma levels, monocyte subsets and laboratory parameters were evaluated on blood from AAA patients and eGFR-matched controls. THP-1 monocytes, treated with IS 1, 10, 20 μM were evaluated for CD163 expression, AhR signaling and then induced to differentiate into macrophages by PMA. Their phenotype was evaluated both at the stage of semi-differentiated and fully differentiated macrophages. AAA and control sera were similarly used to treat THP-1 monocytes and the resulting macrophage phenotype was analyzed.

RESULTS

IS plasma concentration correlated positively with CD14+CD16+ monocytes and was increased in AAA patients. In THP-1 cells, IS promoted CD163 expression and transition to macrophages with hallmarks of classical (IL-6, CCL2, COX2) and alternative phenotype (IL-10, PPARγ, TGF-β, TIMP-1), via AhR/Nrf2 activation. Analogously, AAA sera induced differentiation of macrophages with enhanced IL-6, MCP1, TGF-β, PPARγ and TIMP-1 expression.

CONCLUSION

IS skews monocyte differentiation toward low-inflammatory, profibrotic macrophages and may contribute to sustain chronic inflammation and maladaptive vascular remodeling.

Is Endovascular Aneurysm Repair a Relative Contraindication for Patients with Preoperative Renal Dysfunction?

Whether endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is a relative contraindication in patients with preoperative renal dysfunction (Pre-RD), remains controversial because the contrast medium may induce nephrotoxicity. In this study 1658 patients were treated at ten Japanese medical centers between January 2005 and March 2011 (Open surgery (OS) vs. EVAR: n = 1270 vs. n = 388). They were retrospectively analyzed. Multiple logistic regression analysis (MLRA) with pre- and intra-operative variables was applied to all patients. The endpoints induced onset of new dialysis and postoperative renal dysfunction (Post-RD), were defined as a 50% decrease or more from the preoperative estimated glomerular filtration rate (eGFR) level.

RESULTS

Early mortality, Post-RD, incidence of new dialysis in all patients were 1.6% (OS: EVAR = 1.9%:0.8%), 6% (OS: EVAR = 8%:2.3%) and 1.4% (OS: EVAR = 1.5%:1.0%) respectively. MLRA identified operation time, clamp of renal artery as risk factors for Post-RD, and operation time and Pre-eGFR level as risk factors for new dialysis.

CONCLUSION

Although Post-RD was more frequently observed in the OS group, MLRA showed that the choice of OS or EVAR was not a risk factor for Post-RD and new dialysis. It was strongly suggested that using contrast medium during EVAR is not a contraindication to AAA repair in patients with Pre-RD. (This article is a translation of J Jpn Coll Angiol 2014; 54: 13-18.).

Endovascular treatment of renal artery occlusion caused by aortic stentgraft migration

Renal function impairment during interventional procedures became a real clinical problem. Contrast related nephropathy is the most common cause of renal failure, however, the procedure-related technical troubles may cause unexpected renal dysfunction.Technical failure of EVAR resulting in acute renal dysfunction is presented. The postprocedural occlusion of the right renal artery was treated in chimney technique. Early reintervention allowed the kidney preservation and renal function restoration. It is impossible to avoid all the complications following treatment of aortic aneurysm, but they can be anticipated and comprehensively treated in collaboration with other specialists.

A systematic review and meta-analysis indicates underreporting of renal dysfunction following endovascular aneurysm repair

Deterioration in renal function has been described after endovascular repair of abdominal aortic aneurysms (EVRs). The etiology is multifactorial and represents an important therapeutic target. A need exists to quantitatively summarize incidence and severity of renal dysfunction after EVR to allow better-informed attempts to preserve renal function and improve life expectancy. Here a systematic search was performed using Medline and Embase for renal function after EVR applying PRISMA statements. Univariate and multivariate random-effects meta-analyses were performed to estimate pooled postoperative changes in serum creatinine and creatinine clearance at four time points after EVR. Clinically relevant deterioration in renal function was also estimated at 1 year or more after EVR. Pooled probability of clinically relevant deterioration in renal function at 1 year or more was 18% (95% confidence interval of 14-23%, I2 of 82.5%). Serum creatinine increased after EVR by 0.05 mg/dl at 30 days/1 month, 0.09 mg/dl at 1 month to 1 year, and 0.11 mg/dl at 1 year or more (all significant). Creatinine clearance decreased after EVR by 5.65 ml/min at 1 month-1 year and by 6.58 ml/min at 1 year or more (both significant). Thus, renal dysfunction after EVR is common and merits attention.

The impact of chronic renal insufficiency on vascular surgery patient outcomes

Renal insufficiency is associated with an increased incidence of poor outcomes, including cardiovascular events and death, in the general population. Renal dysfunction appears to have a particularly negative impact in patients undergoing vascular surgery and endovascular therapy. Although the exact mechanism is unknown, increased levels of inflammatory and biochemical modulators associated with adverse cardiovascular outcomes, as well as endothelial dysfunction, appear to play a role in the association between renal insufficiency and adverse outcomes. Outcomes after the surgical and endovascular treatment of abdominal aortic aneurysms, carotid disease, and peripheral arterial disease are all negatively affected by renal insufficiency. Patients with renal dysfunction may warrant intervention for the treatment of critical limb ischemia and symptomatic carotid stenosis, given the comparatively worse outcomes associated with medical management. Open repair of aortic aneurysms and carotid intervention for asymptomatic disease in patients with severe renal dysfunction should be performed with significant caution, as the risks of repair may outweigh the benefits in this population. Further study is needed to better delineate the risks of medical management for these conditions in patients with coexisting severe renal dysfunction. Lastly, current guidelines for the management of vascular diseases, including objective performance goals for critical limb ischemia, are likely not applicable in patients with severe renal insufficiency.

Outcomes and Management Considerations in Patients on Dialysis Undergoing Laparoscopic Radical Nephrectomy for Renal-Cell Carcinoma

PURPOSE

To analyze the perioperative outcomes and management considerations in patients with dialysis-dependent end-stage renal disease (ESRD) undergoing laparoscopic radical nephrectomy for renal-cell carcinoma (RCC).

METHODS

There were 224 consecutive laparoscopic radical nephrectomies reviewed. Of those, 37 patients with ESRD were identified and compared with 187 patients with sporadic RCC. Evaluable parameters included age, sex, race, side of surgery, medical comorbidities, body mass index, American Society of Anesthesiologist (ASA) scoring, and age adjusted Charlson Comorbidity Index. All complications occurring intraoperatively and within the first 30 days were classified as per the Clavien classification system. Presurgical workup and transplant considerations were evaluated. Demographic and clinical characteristics were compared using Student t tests and chi-square tests for categoric variables.

RESULTS

Compared with non-ESRD patients, those with ESRD were younger and had smaller tumors. ASA was significantly higher in the ESRD group (P<0.001). Mean blood loss was similar between ESRD patients and non-ESRD patients. Overall complication rates were higher in patients with ESRD. Pathologic characteristics of ESRD renal masses included a higher proportion of papillary RCC.

CONCLUSION

Patients with RCC associated with ESRD tend to have a higher ASA class and lower grade tumors. In addition, this population is at increased risk of surgical complications and more likely to need transfusions. Careful preoperative preparation and intraoperative anesthetic management are crucial to minimize patient morbidity and improve outcomes.

Comparable mid-term survival in patients undergoing elective fenestrated endovascular aneurysm repair and endovascular aneurysm repair for abdominal aortic aneurysm

Objective:

To evaluate mid-term survival in patients undergoing elective fenestrated endovascular aneurysm repair and standard endovascular aneurysm repair for abdominal aortic aneurysm.

Methods:

Consecutive patients treated from 2007 to 2011 with elective fenestrated endovascular aneurysm repair (n = 81) and endovascular aneurysm repair (n = 201) were evaluated concerning age, cardiovascular medication, comorbidities, and mid-term mortality.

Results:

Patients in the elective fenestrated endovascular aneurysm repair group were younger than the endovascular aneurysm repair group (p = 0.006). In comparison with the endovascular aneurysm repair group, a lower proportion of patients in the elective fenestrated endovascular aneurysm repair group had diabetes (p = 0.013) and anemia (p = 0.003), and a higher proportion had arterial hypertension (p = 0.009). When entering age, endovascular aneurysm repair or fenestrated endovascular aneurysm repair operation, diabetes, anemia, and hypertension in a Cox regression model, only age (hazard ratio: 1.07; 95% confidence interval: 1.03–1.11; p < 0.001) was a risk factor for mid-term mortality.

Conclusion:

Careful patient selection and medical optimization resulted in comparable mid-term survival in patients undergoing elective fenestrated endovascular aneurysm repair and endovascular aneurysm repair.

Preoperative estimates of glomerular filtration rate as predictors of outcome after surgery: a systematic review and meta-analysis

BACKGROUND

Kidney dysfunction is a strong determinant of prognosis in many settings.

METHODS

A systematic review and meta-analysis was undertaken to explore the relationship between estimated glomerular filtration rate (eGFR) and adverse outcomes after surgery. Cohort studies reporting the relationship between eGFR and major outcomes, including all-cause mortality, major adverse cardiovascular events, and acute kidney injury after cardiac or noncardiac surgery, were included.

RESULTS

Forty-six studies were included, of which 44 focused exclusively on cardiac and vascular surgery. Within 30 days of surgery, eGFR less than 60 m l · min · 1.73 m(-2) was associated with a threefold increased risk of death (multivariable adjusted relative risk [RR] 2.98; 95% confidence interval [CI] 1.95-4.96) and acute kidney injury (adjusted RR 3.13; 95% CI 2.22-4.41). An eGFR less than 60 ml · min · 1.73(-2) m was associated with an increased risk of all-cause mortality (adjusted RR 1.61; 95% CI 1.38-1.87) and major adverse cardiovascular events (adjusted RR 1.49; 95% CI 1.32-1.67) during long-term follow-up. There was a nonlinear association between eGFR and the risk of early mortality such that, compared with patients having an eGFR more than 90 ml · min · 1.73m(-2) the pooled RR for death at 30 days in those with an eGFR between 30 and 60 ml · min · 1.73 m(-2) was 1.62 (95% CI 1.43-1.80), rising to 2.85 (95% CI 2.49-3.27) in patients with an eGFR less than 30 ml · min · 1.73 m(-2) and 3.75 (95% CI 3.44-4.08) in those with an eGFR less than 15 ml · min · 1.73 m(-2).

CONCLUSION

: There is a powerful relationship between eGFR, and both short- and long-term prognosis after, predominantly cardiac and vascular, surgery.

Endovascular aneurysm repair: a perioperative perspective

Endovascular aneurysm repair (EVAR), has surpassed open repair as the technique of choice in many centres in response to several large studies which showed significantly improved 30-day mortality. While several multicentre EVAR trials looked at surgical outcomes, very few have specifically investigated the effect of anaesthetic techniques or perioperative care of these patients. The purpose of this review to is to present some of the current evidence for the different aspects of perioperative management of patients undergoing EVAR. This includes surgical considerations, pre-operative assessment, and choice of anaesthetic technique as well as pharmacological protective strategies.

Impact of chronic kidney disease on outcomes after abdominal aortic aneurysm repair

OBJECTIVE

Chronic kidney disease (CKD) is associated with increased morbidity and death after open abdominal aortic aneurysm (AAA) repair (OAR). This study highlights the effect of CKD on outcomes after endovascular AAA (EVAR) and OAR in contemporary practice.

METHODS

The National Surgical Quality Improvement Program (NSQIP) Participant Use File (2005-2008) was queried by Current Procedural Terminology (American Medical Association, Chicago, Ill) code to identify EVAR or OAR patients, who were grouped by CKD class as having mild (CKD class 1 or 2), moderate (CKD class 3), or severe (CKD class 4 or 5) renal disease. Propensity score analysis was performed to match OAR and EVAR patients with mild CKD with those with moderate or severe CKD. Comparative analysis of mortality and clinical outcomes was performed based on CKD strata.

RESULTS

We identified 8701 patients who were treated with EVAR (n = 5811) or OAR (n = 2890) of intact AAAs. Mild, moderate, and severe CKD was present in 63%, 30%, and 7%, respectively. CKD increased (P < .01) overall mortality, with rates of 1.7% (mild), 5.3% (moderate), and 7.7% (severe) in unmatched patients undergoing EVAR or OAR. Operative mortality rates in patients with severe CKD were as high as 6.2% for EVAR and 10.3% for OAR. Severity of CKD was associated with increasing frequency of risk factors; therefore, propensity matching to control for comorbidities was performed, resulting in similar baseline clinical and demographic features of patients with mild compared with those with moderate or severe disease. In propensity-matched cohorts, moderate CKD increased the risk of 30-day mortality for EVAR (1.9% mild vs 3.2% moderate; P = .013) and OAR (3.1% mild vs 8.4% moderate; P < .0001). Moderate CKD was also associated with increased morbidity in patients treated with EVAR (8.3% mild vs 12.8% moderate; P < .0001) or OAR (25.2% mild vs 32.4% moderate; P = .001). Similarly, severe CKD increased the risk of 30-day mortality for EVAR (2.6% mild vs 5.7% severe; P = .0081) and OAR (4.1% mild vs 9.9% severe; P = .0057). Severe CKD was also associated with increased morbidity in patients treated with EVAR (10.6% mild vs 19.2% severe; P < .0001) or OAR (31.1% mild vs 39.6% severe; P = .04).

CONCLUSIONS

The presence of moderate or severe CKD in patients considered for AAA repair is associated with significantly increased mortality and therefore should figure prominently in clinical decision making. The high mortality of AAA repair in patients with severe CKD is such that elective repair in such patients is not advised, except in extenuating clinical circumstances.

Systematic review and meta-analysis of sex differences in outcome after intervention for abdominal aortic aneurysm

Background

The aim of this study was to assess possible differences in mortality between men and women with an abdominal aortic aneurysm (AAA) treated either by elective repair or following aneurysm rupture.

Methods

A systematic literature search was performed using the MEDLINE, Cochrane and Embase databases. Data were analysed by means of bivariate random-effects meta-analysis. Data were pooled and odds ratios (ORs) calculated for women compared with men.

Results

Sixty-one studies (516 118 patients) met the predetermined inclusion criteria. Twenty-six reported on elective open AAA repair, 21 on elective endovascular repair, 25 on open repair for ruptured AAA and one study on endovascular repair for ruptured AAA. Mortality rates for women compared with men were 7·6 versus 5·1 per cent (OR 1·28, 95 per cent confidence interval (c.i.) 1·09 to 1·49) for elective open repair, 2·9 versus 1·5 per cent (OR 2·41, 95 per cent c.i. 1·14 to 5·15) for elective endovascular repair, and 61·8 versus 42·2 per cent (OR 1·16, 95 per cent c.i. 0·97 to 1·37) in the group that had open repair for rupture. The group that had endovascular repair for ruptured AAA was too small for meaningful analysis.

Conclusion

Women with an AAA had a higher mortality rate following elective open and endovascular repair.

Surgery in the patient with renal dysfunction

Preoperative evaluation of patients with renal dysfunction often requires the collaborative efforts of the primary care physician, nephrologist, surgeon, and anesthesiologist. Renal dysfunction is typically a spectrum of disease with multisystem effects. Optimization of preexisting medical issues is the key, as is a thorough understanding of the potential perioperative risks for further renal injury. Surgical or anesthetic techniques may require alteration for the patient with significant renal dysfunction. Identification of those at risk for renal injury may allow for preventative therapies in the perioperative period. This article focuses on defining the population at risk, a framework for preoperative evaluation, and developments in the area of perioperative renal protection.