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DeJong M, Peterson L, Zielke T, Simone A, Penton A, Blecha M. Investigation of Renal Decline and New Onset Dialysis Following Endovascular Aneurysm Repair in the Vascular Quality Initiative. Vasc Endovascular Surg 2023; 57:203-214. [PMID: 36906859 DOI: 10.1177/15385744221141229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The purpose of this study is to identify variables significantly associated with renal function decline after elective endovascular infra-renal abdominal aortic aneurysm repair and to identify the rate and risks of subsequent progression to dialysis. Specifically, we investigate the long-term impact of supra-renal fixation, female gender, and physiologically stressful perioperative events on renal function following endovascular aneurysm repair (EVAR). METHODS Review of all EVAR cases in the Vascular Quality Initiative between 2003 and 2021 was conducted to investigate variable associations with three primary outcomes: postoperative acute renal insufficiency (ARI); greater than 30% decline in glomerular filtration rate (GFR) in patients beyond 1 year of follow up; and new onset dialysis requirement at any point in follow up. Binary logistic regression analysis was performed for the events of acute renal insufficiency and new onset dialysis requirement. Cox proportional hazard regression was performed regarding long term GFR decline. RESULTS Postoperative ARI occurred in 3.4% (1692/49 772) of patients. Significant (P < .05) association with postoperative ARI was noted for: age (OR 1.014/year, 95% CI 1.008-1.021); female gender (OR 1.44, 95% CI 1.27-1.67); hypertension (OR 1.22, 95% CI 1.04-1.44); chronic obstructive pulmonary disease (OR 1.34, 95% CI 1.20-1.50); anemia (OR 4.24, 95% CI 3.71-4.84); reoperation at index admission (OR 7.86, 95% CI 6.47-9.54); baseline renal insufficiency (OR 2.29, 95% CI 2.03-2.56); larger aneurysm diameter; increased blood loss; and higher volumes of intra-operative crystalloid. Risk factors (P < .05) correlating with a decline of 30% in GFR at any time beyond 1 year were: female gender (HR 1.43, 95% CI 1.24-1.65); body mass index (BMI) less than 20 (HR 1.34, 95% CI 1.03-1.74); hypertension (HR 1.38, 95% CI 1.15-1.64); diabetes (HR 1.34, 95% CI 1.17-1.53); COPD (HR 1.21, 95% CI 1.07-1.37); anemia (HR 1.92, 95% CI 1.52-2.42); baseline renal insufficiency (HR 1.31, 95% CI 1.15-1.49); absence of discharge ace-inhibitor (HR 1.27, 95% CI 1.13-1.42); long term re-intervention (HR 2.43, 95% CI 1.84-3.21) and larger AAA diameter. Patients who experienced long term GRF decline had a significantly higher long-term morality. New onset dialysis following EVAR occurred in .47% (234/49 772) of those meeting inclusion criteria. Higher rate (P < .05) of new onset dialysis was associated with age (OR 1.03/year, 95% CI 1.02-1.05); diabetes (OR 1.376, 95% CI 1.005-1.885); baseline renal insufficiency (OR 6.32, 95% CI4.59-8.72); Reoperation at index admission (OR 2.41, 95% CI 1.03-5.67); postoperative ARI (OR 23.29, 95% CI 16.99-31.91); absence of beta blocker (OR 1.67, 95% CI 1.12-2.49); long term graft encroachment on renal arteries (OR 4.91, 95% CI 1.49-16.14). CONCLUSIONS New onset dialysis following EVAR is a rare event. Perioperative variables influencing renal function following EVAR include blood loss, arterial injury, and reoperation. Supra-renal fixation is not associated with postoperative acute renal insufficiency or new onset dialysis in long term follow up. Renal protective measures are recommended for patients with baseline renal insufficiency undergoing EVAR as acute renal insufficiency following EVAR portends a 20-fold increased risk of new onset dialysis in long term follow up.
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Affiliation(s)
- Matthew DeJong
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Laelle Peterson
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Tara Zielke
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Avital Simone
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Ashley Penton
- Department of Surgery, 25815Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
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Hahl T, Kurumaa T, Uurto I, Protto S, Väärämäki S, Suominen V. The effect of suprarenal graft fixation during EVAR on short- and long-term renal function. J Vasc Surg 2022; 76:96-103.e1. [PMID: 35074412 DOI: 10.1016/j.jvs.2021.12.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The effect of suprarenal fixation (SR) compared to infrarenal fixation (IR) on renal function during endovascular aneurysm repair (EVAR) remains controversial. This study aims to compare the renal outcomes between fixation types in short- and long-term follow-up. METHODS Patients undergoing EVAR for infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. Estimated glomerular filtration rate (eGFR) was measured at baseline and during a follow-up of 5 years. A decline in renal function was defined as a ≥ 20% decrease in eGFR. Changes in eGFR were compared between SR and IR groups at 1-7 days, 30 days, and 1-5 years postoperatively. Preoperative renal insufficiency was defined as eGFR < 60mL/min/1.73m2, and those patients were included in the subanalyses. RESULTS A total of 358 patients were included. Among these, 267 (74.6%) had SR and 91 (25.4%) had IR fixation. A decline in renal function occurred more commonly after SR than after IR in 1-7 days postoperatively (p = .009), but no difference was noticed at 30 days and 1-5 years. Regardless of the fixation method, renal function steadily decreased steadily over time after EVAR (estimate -3.13 per a year, 95% confidence interval -3.40- -2.85, p < .001). Patients with pre-existing renal insufficiency were included in subgroup analyses, and those with SR were more often found to have a decline in eGFR 5 years postoperatively than their counterparts with IR (59.5% vs 20.0%, p = .036). CONCLUSION An immediate postoperative decline in renal function was seen more often after SR fixation than IR fixation but this difference was transient. SR fixation is a safe method for patients with normal renal function. Long-term results seems to favor IR over SR in patients with pre-existing renal insufficiency.
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Affiliation(s)
- Tilda Hahl
- Centre for vascular surgery and interventional radiology, Tampere University Hospital, Central hospital, P.O. BOX 2000, FI-33521 Tampere, Finland.
| | - Tiiu Kurumaa
- Tampere University, FI-33014 Tampere University, Tampere, Finland
| | - Ilkka Uurto
- Centre for vascular surgery and interventional radiology, Tampere University Hospital, Central hospital, P.O. BOX 2000, FI-33521 Tampere, Finland; Tampere University, FI-33014 Tampere University, Tampere, Finland
| | - Sara Protto
- Centre for vascular surgery and interventional radiology, Tampere University Hospital, Central hospital, P.O. BOX 2000, FI-33521 Tampere, Finland
| | - Suvi Väärämäki
- Centre for vascular surgery and interventional radiology, Tampere University Hospital, Central hospital, P.O. BOX 2000, FI-33521 Tampere, Finland
| | - Velipekka Suominen
- Centre for vascular surgery and interventional radiology, Tampere University Hospital, Central hospital, P.O. BOX 2000, FI-33521 Tampere, Finland; Tampere University, FI-33014 Tampere University, Tampere, Finland
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Blecha M, Malach L, Dickens B, Decicco E, D'Andrea M, DeJong M, Bechara CF. Predictors of Decline in Renal Function 5 Years after EVAR. Vasc Endovascular Surg 2021; 56:166-172. [PMID: 34694174 DOI: 10.1177/15385744211054283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While there exists copious short-term data regarding renal function following infra-renal endovascular abdominal aortic aneurysm repair (EVAR), long-term analysis is sparse. This is a single institution retrospective review of predictors of renal function decline 5 years after elective EVAR. METHODS All EVAR between 2007 and 2015 were queried. Patients in whom renal function was documented 5 years postoperatively were included in analysis. Exclusion criteria were ruptured aneurysm, mortality before 56 months, lack of follow-up, ESRD status, and concomitant renal intervention. The primary outcome investigated was a 20% or greater drop in glomerular filtration rate (GFR) 5 years postoperatively. The following variables at the time of surgery were investigated as potential predictors: age, gender, hypertension, hyperlipidemia, diabetes, CAD or prior MI, COPD, prior stroke, baseline eGFR under 60 mL/min/1.73 m2, supra-renal fixation, infra-renal fixation, neck diameter, neck length, and number of contrast CT. RESULTS 354 EVAR were identified of which 143 met inclusion criteria (211 excluded). Univariate analysis revealed female gender (OR 2.7), hypertension (OR 9.4), baseline renal insufficiency (OR 3.8), larger neck diameter, and supra-renal fixation (OR 2.32) all predictive (P < .05) of GFR drop at 5 years. Multivariate binary logistic regression analysis found female gender (multivariate OR 3.9, P = .023) and baseline renal insufficiency (multivariate OR 3.0, P = .029) as significant predictors of greater than 20% GFR drop at 5 years. Only 2 patients of the 143 progressed to dialysis requirement at 5 years. CONCLUSIONS Females and patients with baseline renal insufficiency are more vulnerable to significant decline in renal function 5 years following EVAR. Consistent with analogous literature, supra-renal fixation appears moderately deleterious toward renal function with no clinical significance in those with baseline normal renal function. The potential benefit of avoidance of supra-renal fixation in female patients with baseline renal insufficiency is worth further investigation in a more robust multi-center study.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
| | - Lillian Malach
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Brooke Dickens
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Emily Decicco
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Melissa D'Andrea
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Matthew DeJong
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Carlos F Bechara
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
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Singh B, Resch T, Sonesson B, Abdulrasak M, Dias NV. Simple diameter measurements with ultrasound can be safely used to follow the majority of patients after infrarenal endovascular aneurysm repair. INT ANGIOL 2021; 40:425-434. [PMID: 34282856 DOI: 10.23736/s0392-9590.21.04706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal imaging follow-up after infrarenal EVAR is still undefined. The objective was to study the outcome of a personalized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements for low-risk patients. METHODS All consecutive patients followed-up locally after elective and acute infrarenal EVAR between 2010 and 2015 were retrospectively reviewed. Patients underwent CTA at 1 month post-EVAR whereby the attending surgeon defined the subsequent follow-up. Patients considered at low risk were followed with ultrasound only assessing AAA diameter at 1, 2, 3 and every 5 years postoperatively (group A). Low-risk required a favourable preoperative anatomy especially regarding the aneurysm neck, satisfactory intraoperative result and uneventful 1 month CTA (type 2 endoleaks acceptable). Patients not fulfilling the criteria for group A were followed with yearly 3-phase-CTAs (group B). RESULTS 222 patients with a AAA median diameter of 58 (54-68) mm were included. 191 were allocated into group A and 31 in group B. Median follow-up time was 36 (24-59) months. Five year primary and primary assisted success was 82 ± 5 % and 93 ± 3 % for group A and 70 ± 13% and 93 ± 5% for group B, respectively (P= 0.042 and P= 0.504, respectively). 16 late aneurysm-related re-interventions were performed in 12 patients (7 in group A and 9 in group B). In group A, 5 re-interventions were rupture-preventing and 2 were symptomatic. All late re-interventions in group B were performed following findings on follow-up imaging. Five-year late re-intervention-free survival was 95 ± 2 % and 84 ± 7 % for groups A and B, respectively (P=0.046). Five-year survival was 80 ± 3 % and 63 ± 10 % for group A and B, respectively (P= 0.024). CONCLUSIONS A customized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements in low-risk patients seems to be effective in maintaining a very high mid-term clinical success rate.
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Affiliation(s)
- Bharti Singh
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden - .,Clinical Sciences Malmö, Lund University, Malmö, Sweden -
| | - Timothy Resch
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Mohammed Abdulrasak
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Nuno V Dias
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Time-to-Event Analysis of the Impact of Endovascular Aortic Aneurysm Repair on Chronic Renal Decline. Ann Vasc Surg 2021; 74:165-175. [PMID: 33823250 DOI: 10.1016/j.avsg.2021.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/11/2021] [Accepted: 02/11/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although randomized studies have revealed the long-term outcomes of the endovascular repair (ER) of abdominal aortic aneurysm (AAA) compared to open repair (OR), there is controversy surrounding chronic renal decline (CRD) after ER. This study reviewed our propensity-matched cohorts of ER and OR to compare CRD rates using a time-to-event analysis. The ER groups undergoing suprarenal (SR) or infrarenal (IR) proximal fixation were also compared with the OR group. METHODS This retrospective review of infrarenal AAA repair was conducted from June 2007-December 2017. Patients with ≥1 year of follow-up were included. Cases of supra/pararenal AAAs, infectious AAAs, rupture, or severe chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2 or dependence on renal replacement therapy) were excluded. CRD was defined as eGFR decline of >20% or de novo hemodialysis during follow-up. Patients treated with ER (ER group) and OR (OR group) were propensity-score matched for age, sex, comorbidities, ejection fraction, respiratory function, and baseline eGFR. Kaplan-Meier analysis compared the freedom from CRD rates of the matched cohorts (mER and mOR groups). Patients treated with SR and IR fixation devices (SR and IR groups) were also separately matched to the OR group, followed by analysis. RESULTS In total, 1087 patients underwent elective AAA repair. Among them, 944 (512 ER and 432 OR) were enrolled. The ER group was older than the OR group (median age 79 vs 71; P<0.001). The ER group had significantly lower baseline eGFR and more comorbidities than the OR group. Among 187 propensity-score matched pairs (187 mER and 187 mOS patients), background characteristics, including age and baseline eGFR, were comparable, but median renal function follow-up was significantly longer in the mER group than in the mOR group (48 vs 26 months; P<0.001). CRD was observed in 57 patients in the mER group and 30 patients in the mOR group. Kaplan-Meier analysis of the freedom from CRD showed no significant difference between the matched groups (P=0.268); however, in the later follow-up of >4 years, CRD was more common in the mER group. The matched analyses between the OR group and specific fixation groups, comprising 102 OR-SR and 73 OR-IR pairs, demonstrated no significant differences in CRD. CONCLUSIONS Compared to OR, there was no significant impact of ER on CRD at up to 4 years, supporting the safety of ER in terms of the mid-term renal outcome of our present clinical practice.
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Pasqui E, de Donato G, Giannace G, Panzano C, Setacci C, Palasciano G. Management of abdominal aortic aneurysm in nonagenarians: A single-centre experience. Vascular 2020; 29:27-34. [PMID: 32611281 DOI: 10.1177/1708538120936831] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In the last decades, life expectancy has increased worldwide considerably. Traditionally, very elderly patients have been considered too frail to undergo major vascular interventions. Considering that abdominal aortic aneurysm is an age-related disease, there is an increasing need of a correct management of the disease even in nonagenarians, but data are still scarce. The purpose of this single-centre study is to report early and mid-term outcomes of all-comer abdominal aortic aneurysm patients in their 10th decades of age. METHODS A retrospective review of our prospectively maintained database identified a total of 33 patients aged ≥ 90 presenting with abdominal aortic aneurysm between 2014 and 2019. Elective and emergency repairs were both considered. Early technical success and mortality rate at 30 days were considered as primary outcomes. Mid-term clinical success was reported, and overall survival, freedom from aneurysm-related death, re-interventions and endoleaks were estimated with the Kaplan-Meier method, stratified for elective of emergency repair and type of treatment. RESULTS The mean age was 91.7 (range 90-96), and 63.6% were male. Mean abdominal aortic aneurysm diameter was 67.4 ± 16.8 mm. Sixteen patients were admitted for rupture abdominal aortic aneurysm: three untreated, five underwent open and seven underwent endovascular aneurysm repair (EVAR), with an early mortality rate of 100, 100 and 42.8%, respectively. Eighteen (60%) patients were asymptomatic, and all underwent elective EVAR, with an early mortality rate of 0%. At one-month follow-up, clinical success was 84% in EVAR group. At a median follow-up of 22.4 ± 14.5 months, no abdominal aortic aneurysm-related death was registered. Freedom from all cause of mortality was 77.3, 59.4 and 40.7% at one, two and three years. Freedom from endoleaks was 95.4% at one month and 61.7% at one and three years. Freedom from reintervention was 85.8% at three years. CONCLUSION Elective EVAR in nonagenarians is associated with acceptable early and mid-term outcomes. Age by itself should not be considered an exclusion criterion for treatment.
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Affiliation(s)
- Edoardo Pasqui
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Gianmarco de Donato
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Giovanni Giannace
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Claudia Panzano
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Carlo Setacci
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
| | - Giancarlo Palasciano
- Department of Medicine, Surgery and Neuroscience, Vascular Surgery Unit, 9313University of Siena, Siena, Italy
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Banno H, Ikeda S, Kawai Y, Fujii T, Akita N, Takahashi N, Sugimoto M, Kodama A, Komori K. Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation. J Vasc Surg 2020; 71:450-456. [DOI: 10.1016/j.jvs.2019.03.061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/28/2019] [Indexed: 10/26/2022]
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Bannazadeh M, Beckerman WE, Korayem AH, McKinsey JF. Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution. J Vasc Surg 2019; 71:15-22. [PMID: 31718954 DOI: 10.1016/j.jvs.2019.03.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 03/02/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Despite numerous recent pivotal and small-scale trials, real-world endovascular management of juxtarenal aneurysms (JRA), suprarenal aneurysms (SRA), and thoracoabdominal aortic aneurysms (TAAA) remains challenging without consensus best practices. This study evaluated the mortality, graft patency, renal function, complication, and reintervention rates for fenestrated and parallel endografts in complex aortic aneurysms repairs. METHODS This retrospective review of consecutive included patients with JRA, SRA, or TAAA who underwent complex endovascular repair from August 2014 to March 2017 at one high-volume institution. Treatment modality was a single surgeon decision based on patients anatomy and the urgency of the repair. Patient demographics, hospital course, and follow-up visits inclusive of imaging were analyzed. Ruptured aneurysms were excluded. Survival rates and outcomes were determined using the Kaplan-Meier method with log-rank tests. RESULTS Seventy complex endovascular aortic repairs were performed; 38 patients with TAAA were treated with snorkel/sandwich parallel endografts (21 celiac, 28 superior mesenteric arteries, 58 renal arteries) and 32 patients with JRA/SRA were treated by fenestrated endovascular aneurysm repair (FEVAR) with 94 total fenestrations (2 celiac, 30 SMA, 62 renal). The mean patient age was 74.8 ± 10.0 years. Sixty percent were male, and the mean aortic aneurysm diameter was 6.0 ± 1.4 cm. Perioperative mortality was 3.1% (1/32) for FEVAR compared with 2.6% (1/38) for parallel endografts (P = .9). All-cause reintervention rates were 15.6% in FEVAR (5/32) vs 23.6% with parallel endografts (9/38; P = .4). Branch reintervention rates per each branch endograft were 4.3% for FEVAR (4/94; 2 renal stent occlusions, 1 colonic ischemia without technical issue found on reintervention, 1 perinephric hematoma) vs 3.7% for parallel endografts (4/107; 2 renal and 1 celiac stent thromboses, and 1 renal stent kink; P = .41). The endograft branch thrombosis rate was 2.1% in FEVAR (2/94) vs 2.7% in parallel endografts (3/109; P = .77). Reinterventions owing to endoleaks were performed in five patients (2 type I, 2 type III, and 1 gutter endoleak; 13.1%) with parallel grafts vs no endoleak reinterventions in FEVAR. The overall survival and freedom from aneurysm-related mortality at 24 months was 78% and 96.9% in FEVAR vs 73% and 93.4% for parallel endografts (P = .8 and P = .6). The median follow-up was 12 months (range, 1-32 months). CONCLUSIONS Parallel and fenestrated endografts have acceptable and comparable mortality and patency rates in endovascular treatment of JRA, SRA, and TAAA. This study reaffirms that parallel endografts are a safe and viable alternative to fenestrated devices for complex aortic aneurysmal disease despite often treating more urgent patients and more complicated anatomy unable to be treated with FEVAR.
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Affiliation(s)
- Mohsen Bannazadeh
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY
| | - William E Beckerman
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY
| | - Adam H Korayem
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY
| | - James F McKinsey
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Medical Center, New York, NY.
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Taneva GT, Reyes Valdivia A, Pitoulias GA, El Amrani Joutey M, Donas KP, Ocaña Guaita J, Gandarias Zúñiga C. Partial Renal Coverage after Endovascular Aortic Aneurysm Repair with Suprarenal Fixation Seems Not to be Associated with Early Renal Impairment. Ann Vasc Surg 2019; 64:124-131. [PMID: 31634594 DOI: 10.1016/j.avsg.2019.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Efforts to achieve optimal seal during endovascular aortic aneurysm repair (EVAR) may produce partial coverage of the lowest renal artery and in some cases even occlusion. This coverage might alter the renal ostial flow, which could finally affect renal function. We sought to evaluate the incidence of renal ostium coverage and its possible effects on renal function. METHODS All patients undergoing elective EVAR with suprarenal fixation devices between January 2014, and December 2017, at our institution were identified. Patients with preoperative and postoperative computed tomography angiography (CTA), as well as the preoperative, postoperative, and one year postintervention creatinine levels and estimated glomerular filtration rate (eGFR) were included in the present study. Patients in hemodialysis, with a preoperative eGFR <30 mL/min, urgent EVAR, neck adjunctive procedures, excessive aortic thrombus, or procedure-related reintervention were excluded. RESULTS A total of 127 patients received EVAR for aortoiliac aneurysmatic pathologies between January 2014, and December 2017. Forty-three of them met the inclusion criteria having a median follow-up of 18.8 months (range; 12.0-53.9). Twenty-six (60.5%) patients presented at least one criterion of hostile neck condition and 23 (53.5%) had a preoperative eGFR <60 mL/min. The average distance from the proximal endograft fabric to the lower renal artery was 1.5 mm (range, 0.0-6.0) while a total of 15 renal ostia (34.9%) suffered unintended partial coverage (range, 20 to 75% of the renal ostium) in the postoperative CTA. Nine of these patients (60%) had a hostile neck condition. Eight patients (18.6%) suffered significant deterioration (>20% of the eGFR), 27 patients (62.8%) maintained their renal function and 8 (18.6%) presented an improvement of the eGFR in the latest available blood sample. Renal function impairment showed no significant association with renal ostium coverage (P = 0.561), hostile neck condition (P = 0.973), or the diameter of the renal artery (P = 0.835). In the subgroup analysis, patients with the eGFR <60 mL/min did not show significantly greater renal function deterioration (P = 0.568). CONCLUSIONS Partial renal coverage is not an uncommon phenomenon occurring in one-third of the treated patients. However, it was not associated with renal function impairment in the early term. Further studies with longer follow-up are needed to confirm our results in the long haul.
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Affiliation(s)
- Gergana T Taneva
- Vascular and Endovascular Surgery Department, University Hospital Ramón y Cajal, Ctra, Colmenar Viejo, Madrid, Spain.
| | - Andrés Reyes Valdivia
- Vascular and Endovascular Surgery Department, University Hospital Ramón y Cajal, Ctra, Colmenar Viejo, Madrid, Spain
| | - Georgios A Pitoulias
- Second Department of Surgery, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mehdi El Amrani Joutey
- Vascular and Endovascular Surgery Department, University Hospital Ramón y Cajal, Ctra, Colmenar Viejo, Madrid, Spain
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, St. Franziskus Hospital, Muenster, Germany
| | - Julia Ocaña Guaita
- Vascular and Endovascular Surgery Department, University Hospital Ramón y Cajal, Ctra, Colmenar Viejo, Madrid, Spain
| | - Claudio Gandarias Zúñiga
- Vascular and Endovascular Surgery Department, University Hospital Ramón y Cajal, Ctra, Colmenar Viejo, Madrid, Spain
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de Mik SML, Geraedts ACM, Ubbink DT, Balm R. Effect of Imaging Surveillance After Endovascular Aneurysm Repair on Reinterventions and Mortality: A Systematic Review and Meta-analysis. J Endovasc Ther 2019; 26:531-541. [PMID: 31140361 PMCID: PMC6630065 DOI: 10.1177/1526602819852085] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose: To study the effects of imaging surveillance after endovascular aortic repair (EVAR) on reintervention and mortality. Materials and Methods: A systematic review was conducted comparing complication rates in EVAR patients compliant with the imaging surveillance protocol vs partially or noncompliant patients. Two authors independently selected articles and performed quality assessment and data extraction. Risk differences for reintervention and mortality between compliant and partially/noncompliant patients were meta-analyzed. The pooled risk difference (RD) is reported with the 95% confidence interval (CI). The review protocol is registered at Prospero (CRD42017080494). Results: A total of 11 cohort studies involving 21,838 patients were included. Studies differed in imaging, their surveillance protocols, and definitions of compliance subgroups. Median follow-up was 31.7 months (interquartile range 29.8, 49.3). The overall reintervention rate was 5%, while the overall mortality was 31%. The RD for the reintervention rate was 4% (95% CI 1% to 7%) in favor of partial/noncompliance [number needed to harm 25 (95% CI 14 to 100)], while mortality showed a nonsignificant RD of 12% (95% CI −2% to 26%) in favor of partial/noncompliance. Two studies reported that 41% to 53% of reinterventions were performed for complications detected through imaging surveillance; the other events were detected through patient symptoms. Conclusion: Patients who are compliant with imaging surveillance appear to undergo more reinterventions than those who are partially or noncompliant. However, imaging surveillance does not seem to protect against mortality. This suggests that the recommended yearly imaging surveillance may not be beneficial for all EVAR patients.
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Affiliation(s)
- Sylvana M L de Mik
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
| | - Anna C M Geraedts
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
| | - Dirk T Ubbink
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
| | - Ron Balm
- 1 Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Department of Surgery, Amsterdam, the Netherlands
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Ahmad W, Hasselmann HC, Galas N, Majd P, Brunkwall S, Brunkwall JS. Image fusion using the two-dimensional-three-dimensional registration method helps reduce contrast medium volume, fluoroscopy time, and procedure time in hybrid thoracic endovascular aortic repairs. J Vasc Surg 2019; 69:1003-1010. [DOI: 10.1016/j.jvs.2018.07.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/12/2018] [Indexed: 11/26/2022]
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12
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Radiation doses for endovascular aortic repairs performed on mobile and fixed C-arm fluoroscopes and procedure phase-specific radiation distribution. J Vasc Surg 2018; 68:1889-1896. [DOI: 10.1016/j.jvs.2018.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 05/15/2018] [Indexed: 12/21/2022]
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13
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Abstract
Perioperative acute kidney injury is associated with morbidity and mortality. Several definitions have been proposed, incorporating small changes of serum creatinine and urinary output reduction as diagnostic criteria. In the surgical patient, comorbidities, type and timing of surgery, and nephrotoxins are important. Patient comorbidities remain a significant risk factor. Urgent or emergent surgery and cardiac or transplantation procedures are associated with a higher risk of acute kidney injury. Nephrotoxic drugs, contrast dye, and diuretics worsen preexisting kidney dysfunction or act as an adjunctive insult to perioperative injury. This review includes preoperative, intraoperative, and postoperative issues that can be mitigated.
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Affiliation(s)
- Sheela Pai Cole
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, 300 Pasteur Dr, H3580, Stanford, CA 94305, USA.
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14
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The Impact of Suprarenal Fixation on Renal Function Following Endovascular Abdominal Aortic Aneurysm Repair: Meta-analysis Based on Estimated Glomerular Filtration Rate. Eur J Vasc Endovasc Surg 2018; 56:497-506. [DOI: 10.1016/j.ejvs.2018.02.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 02/10/2018] [Indexed: 01/11/2023]
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15
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Ahmad W, Obeidi Y, Majd P, Brunkwall JS. The 2D-3D Registration Method in Image Fusion Is Accurate and Helps to Reduce the Used Contrast Medium, Radiation, and Procedural Time in Standard EVAR Procedures. Ann Vasc Surg 2018. [PMID: 29522869 DOI: 10.1016/j.avsg.2018.01.098] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aimed to evaluate the accuracy and the effectiveness of 2D-3D registration method of image fusion (IF) technology in endovascular aneurysm repair (EVAR). METHODS We performed a review of our institutional endovascular aortic database of patients who had undergone EVAR between 2011 and 2015 before and after the installation of a 3D IF computed tomography system in our hybrid operating room. RESULTS The accuracy was assessed in 14 endovascular procedures and showed a median registration error of 1.8 mm at the origin of the right renal artery and 1.0 mm at the origin of the left renal artery and a complete visual accuracy in 42% of the cases. EVAR was performed using the intraoperative IF technique with a 2D-3D registration method in 105 patients (group IF), whereas 47 patients done without served as controls. The IF group had a significantly reduced amount of used contrast compared with controls with a median of 58 mL and P < 0.0001. The intraoperative exposition to radiation was similar between the 2 groups with a median dose area product of 2,343.7 cGy cm2 in the IF group and 3,219 cGy cm2 among the controls (P = 0.457). The radiation dose in the sub group IF (including patients operated by the 2 most experienced surgeons) was lower than that in sub controls (median, 1,087 cG cm2 vs. 2,705.3 cG cm2, P = 0.012). The procedure time and the time of intraoperative radiation did not differ between the study groups (P = 0.117 and 0.106, respectively), as did not fluoroscopy time in the sub group IF (median, 6.3 min, vs. 9.5 min, P = 0.067), but for the 2 most experienced surgeons, the procedural time was shortened when using IF (P = 0.002). CONCLUSIONS The 2D-3D registration method of IF guidance is accurate to delineate the vessels of interest and could help the execution of the EVAR procedures with a significantly reduced amount of contrast medium and also with reduced radiation and shorter procedural duration when surgeons are more familiar with EVAR and IF.
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Affiliation(s)
- Wael Ahmad
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany.
| | - Youssra Obeidi
- Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Payman Majd
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
| | - Jan Sigge Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Cologne, Germany
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16
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Stather PW, Ferguson J, Awopetu A, Boyle JR. Meta-analysis of Renal Function Following Infrarenal EVAR using Suprarenal or Infrarenal Fixation Devices. Eur J Vasc Endovasc Surg 2018; 56:486-496. [PMID: 29506944 DOI: 10.1016/j.ejvs.2018.01.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/27/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE/BACKGROUND The effect of suprarenal (SR) as opposed to infrarenal (IR) fixation on renal outcomes post-endovascular aneurysm repair (EVAR) remains controversial. This meta-analysis aims to update current understanding of this issue. METHODS A prior meta-analysis was updated through a Preferred Reporting Items for Systematic reviews and Meta-Analyses search for additional studies published in the last 3 years reporting on renal dysfunction or related outcomes post-EVAR. Random effects meta-analysis was undertaken using SPSS. RESULTS A total of 25 non-randomised studies comparing SR with IR fixation were included, totalling 54,832 patients. In total, 16,634 underwent SR and 38,198 IR. Baseline characteristics, including age, baseline estimated glomerular filtration rate, diabetes, cardiac disease, and smoking, were similar between the groups. There was a small but significant difference in outcomes for renal dysfunction at the study end point (SR 5.98% vs. IR 4.83%; odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.40 [p < .001]); however, at 30 days and 12 months there was no significant difference, and this did not hold up to sensitivity analysis. Incidence of renal infarcts (SR 6.6% vs. IR 2.3%; OR 2.78, 95% CI 1.46-5.29 [p = .002]), renal stenosis (SR 2.4% vs. IR 0.8%; OR 2.89, 95% CI 1.00-8.38 [p = .05]), and renal artery occlusion (SR 2.4% vs. IR 1.2%; OR 2.21, 95% CI 1.15-4.25 [p = 0.02]) favoured IR fixation; however, there was no difference in haemodialysis rates. CONCLUSION This meta-analysis has identified small but significantly worse renal outcomes in patients having SR fixation devices compared with IR; however, there was no difference in dialysis rates and a small effect on renal dysfunction, which did not stand up to rigorous sensitivity analysis. This should be taken into consideration during graft selection, and further studies must assess renal outcomes in the longer term, and in those with pre-existing renal dysfunction.
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Affiliation(s)
- Philip W Stather
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK.
| | - James Ferguson
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK
| | - Ayoola Awopetu
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK
| | - Jonathan R Boyle
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK
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Majd P, Ahmad W, Becker I, Brunkwall JS. Ten-Year Single-Center Results of Abdominal Aortic Aneurysm Treatment: Endovascular versus Open Repair. Ann Vasc Surg 2017; 44:113-118. [DOI: 10.1016/j.avsg.2017.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
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