Predictors of acute kidney injury after infrarenal abdominal aortic aneurysm repair in octogenarians

Maintenance of beta-blockers and cardiac surgery-related outcomes: a prospective propensity-matched multicentre analysis

BACKGROUND

We investigated the effects of maintaining beta-blockers on the day of surgery on the incidence of atrial fibrillation and postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery.

METHODS

We conducted a multicentre prospective observational study with propensity matching on patients treated with beta-blockers. We collected their baseline patient characteristics, comorbidities, and operative and postoperative outcomes. The endpoints were postoperative atrial fibrillation and AKI after cardiac surgery.

RESULTS

Of the 1789 included patients, propensity matching led to 583 patients in each group. Maintenance of beta-blockers was not associated with a reduced risk of atrial fibrillation (odds ratio: 0.86 [95% confidence interval 0.66-1.14], P=0.335; 141 patients [24.2%] vs 126 patients [21.6%]). Sensitivity analysis did not demonstrate association between beta-blocker maintenance and atrial fibrillation after cardiac surgery (odds ratio: 0.93 [95% confidence interval: 0.72-1.22], P=0.625). Maintenance of beta-blockers was associated with a higher rate of norepinephrine use (415 [71.2%] vs 465 [79.8%], P=0.0001) and postoperative AKI (124 [21.3%] vs 159 [27.3%], P=0.0127). No statistically significant difference was observed in ICU length of stay.

CONCLUSIONS

Maintenance of beta-blockers on the day of surgery was not associated with a reduced incidence of postoperative atrial fibrillation. However, maintenance of beta-blockers was associated with increased usage of vasopressors, potentially contributing to adverse postoperative renal events.

CLINICAL TRIAL REGISTRATION

NCT04769752.

Results of the Italian Collaborators for Evar Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm

OBJECTIVES

To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort.

MATERIALS AND METHODS

This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year.

RESULTS

The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042).

CONCLUSION

AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality.

CLINICAL IMPACT

This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.

Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair

BACKGROUND

Acute kidney injury (AKI) after endovascular aortic aneurysm repair (EVAR) is uncommon though carries significant morbidity. Procedural risk factors are not well established for acute renal failure (ARF) that requires initiation of dialysis. The goal of this study was to examine the impact of ARF on patients undergoing EVAR and identify risk factors for ARF using a large, national dataset.

METHODS

Patients undergoing EVAR were identified from the National Surgical Quality Improvement Program (NSQIP) database over 9 years, ending in 2019. Demographics, indication for repair, comorbidities, procedural details, complications, hospital and ICU LOS, and mortality were recorded. Patients were stratified by presence of ARF and compared. Patients were further stratified by indication for EVAR and presence of ARF. Multivariable logistic regression (MLR) analysis was performed to determine the independent predictors of ARF.

RESULTS

18 347 patients were identified. Of these 234 (1.3%) developed ARF requiring dialysis. Mortality (40 vs 1.8%, P < .0001), ICU LOS (5 vs 0 days, P < .0001), and hospital LOS (11 vs 2 days, P < .0001) were all significantly increased in patients with ARF. Multivariable logistic regression identified increasing diameter, creatinine, operative time, preoperative transfusions, ASA class, emergent repair, female gender, and juxtarenal/suprarenal proximal landing zone as predictors of ARF.

CONCLUSIONS

ARF after EVAR causes significant morbidity, prolongs hospitalizations, and increases mortality rates. Those patients at risk of ARF after EVAR should be closely monitored to reduce both morbidity and mortality.

Preoperative Anemia Is Associated With Postoperative Renal Failure After Elective Open Aortic Repair

INTRODUCTION

Preoperative anemia has been consistently shown to be a risk factor for acute kidney injury (AKI) after cardiac surgery. However, this association has not been examined in the open abdominal aortic aneurysm repair (OAR) population and is the subject of this analysis.

METHODS

Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing OAR from 2013 to 2019. Anemia was defined according to World Health Organization Guidelines: Hematocrit<36% for women or <39% for men. Primary endpoint was 30-day AKI. Anemia's effect on AKI was determined using inverse probability weighted logistic regression.

RESULTS

There were 2275 OAR; mean age was 70.9 ± 8.2 y; 24.0% were women. Anemia was present in 498 (26.3%) patients; 165 (7.6%) had a hematocrit<33% and 8 (0.35%) had a hematocrit<24%. Differences in patient factor were nonsignificant after weighting. Any degree of postoperative AKI was more common in the anemia group (11.2% vs 5.1%; unweighted P < 0.001), as was AKI requiring hemodialysis (7.7% vs 3.2%; unweighted P < 0.001). In the weighted multivariable analysis, anemia was independently associated with postoperative AKI (odds ratio 1.51; 95% confidence interval: 1.01-2.26; P = 0.042) while controlling for age and operative factors. Patients with postoperative AKI were significantly more likely to die postoperatively than those without (26.1% vs 1.9%; <0.001).

CONCLUSIONS

Preoperative anemia was independently associated with post-OAR AKI after propensity weighting and controlling for operative factors. AKI is a major source of morbidity and mortality in these patients, and, if time permits, preoperative correction of anemia or its underlying cause should be considered in high-risk patients.

Analysis of Early Death after Elective Open Abdominal Aortic Aneurysm Repair

BACKGROUND

Mortality after open abdominal aortic aneurysm repair is a quality measure and early death may represent a technical complication or poor patient selection. Our objective was to analyze patients who died in the hospital within postoperative day (POD) 0-2 after elective abdominal aortic aneurysm repair.

METHODS

The Vascular Quality Initiative was queried from 2003-2019 for elective open abdominal aortic aneurysm repairs. Operations were categorized as in-hospital death on POD 0-2 (POD 0-2 Death), in-hospital death beyond POD 2 (POD ≥3 Death), and those alive at discharge. Univariable and multivariable analyses were performed.

RESULTS

There were 7,592 elective open abdominal aortic aneurysm repairs with 61 (0.8%) POD 0-2 Death, 156 (2.1%) POD ≥3 Death, and 7,375 (97.1%) alive at discharge. Overall, median age was 70 years and 73.6% were male. Iliac aneurysm repair and surgical approach (anterior/retroperitoneal) were similar among groups. POD 0-2 Death, compared to POD ≥3 Death and those alive at discharge, had the longest renal/visceral ischemia time, more commonly had proximal clamp placement above both renal arteries, an aortic distal anastomosis, longest operative time, and largest estimated blood loss (all P < 0.05). Postoperative vasopressor usage, myocardial infarction, stroke, and return to the operating room were most frequent in POD 0-2 Death and extubation in the operating room was least frequent (all P < 0.001). Postoperative bowel ischemia and renal failure occurred most commonly among POD ≥3 Death (all P < 0.001).On multivariable analysis, POD 0-2 Death was associated with congestive heart failure, prior peripheral vascular intervention, female sex, preoperative aspirin use, lower center volume quartile, renal/visceral ischemia time, estimated blood loss, and older age (all P < 0.05).

CONCLUSIONS

POD 0-2 Death was associated with comorbidities, center volume, renal/visceral ischemia time, and estimated blood loss. Referral to high-volume aortic centers could improve outcomes.

Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study

BACKGROUND

Endovascular abdominal aortic repair (EVAR) is the main therapeutic option for repairing abdominal aortic aneurysms (AAAs). We aimed to determine the long-term outcomes of patients who underwent EVAR at our center.

METHODS

In this retrospective cohort study, patients who underwent EVAR for intact isolated AAA at Tehran Heart Center between 2007 and 2017 were included. Clinical outcomes and the frequency of mortality were analyzed for follow-up periods. We calculated the 5-year survival rate and its predictors for our patients using Kaplan-Meier estimation.

RESULTS

We included the data of all patients (154 patients, mean age = 70.7 [± 8.0] years, 96.1% men) who successfully underwent EVAR at our center. The most common risk factors were coronary artery disease (70.1%), hypertension (68.2%), smoking (64.9%), and dyslipidemia (39.6%). There was no mortality during the procedure. The median follow-up was 65.5 months. An average decrease of 9.07 mm (95% confidence interval: 6.9-11.2) occurred in the size of the AAA. During follow-up, 12 patients developed some complications, 49 died, and 7 did not complete the follow-up. The 5-year survival rate was 75% (3.9%). The independent predictors for 5-year survival were age (hazard ratio [HR] = 1.06, P = 0.002) and anemia (HR = 1.91, P = 0.029). Despite not being statistically significant, dyslipidemia (HR = 0.573, P = 0.078) and long intensive care unit/cardiac care unit stays (HR = 1.08, P = 0.070) were borderline mortality predictors.

CONCLUSIONS

This study depicted an acceptable survival rate for patients who underwent EVAR at our center. Age and anemia, 2 modifiable predictors of 5-year survival, can probably prolong the survival rate of patients, which requires evaluation later.

Incidence, risk factors and outcomes of acute kidney injury in surgical intensive care unit octogenarians at the Jordan University Hospital

BACKGROUND

Acute kidney damage (AKI) is among the most severe consequences observed in surgical intensive care units (SICUs). We aim to observe the incidence, risk factors, and outcomes of acute kidney injury in SICU octogenarians.

METHODS

A cross-sectional retrospective study was conducted at the SICU of Jordan University Hospital (JUH), a tertiary teaching hospital in a developing country, between January 2018 and December 2019. Patients who were 80 years or older at the time of data collection were included. The definition of AKI was based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Demographic, clinical, and laboratory data were reviewed.

RESULTS

A total number of 168 patients were included. The mean age was 84.0 ± 3.8 years, and 54.8% of the participants were women. Of those, 115 (68.5%) had surgery before or during ICU stay, and 28.7% of the patients' surgeries were an emergency surgery. Also, 47.8% of surgeries were considered by anesthesia to be high-risk surgeries. A total of 55 patients (32.7%) developed AKI during their SICU stay. The factors that were significantly associated with AKI in the ICU patients included use of beta blocker [AOR: 3.7; 95% CI: 1.2-11.8; p = 0.025], and inotropes [AOR:4.0; 95% CI: 1.2-13.3; p = 0.03]. The factors that were significantly associated with mortality in the ICU included using mechanical ventilation [AOR:18.7; 95% CI: 2.4-141.9; p = 0.005] and inotropes use [AOR: 12.3; 95% CI: 1.2-120.7; p = 0.031].

CONCLUSIONS

The incidence of AKI during SICU stay in this study was 32.7% and it was significantly associated with the use of beta blockers, mechanical ventilation, and inotropes. The mortality rate among octogenarians who developed AKI during SICU stay was 36.4%. Further studies are needed globally to assess the incidence of AKI in octogenarian surgical patients and identify risk factors to provide preventative measurements and strategies.

A simplified acute kidney injury predictor following endovascular aortic repair: ACEF score

OBJECTIVES

Treatment of abdominal aortic aneurysms (AAA) with endovascular aortic repair (EVAR) has become quite common in recent years. This method, which has many advantages compared to the open surgical procedure, also has some complications. One of these complications is acute kidney injury (AKI). ACEF (age, creatinine, and ejection fraction) score, which is gaining popularity, can be an easy-to-use and cost-effective method in detecting this condition that causes increased morbidity and mortality. We aimed to evaluate whether this ACEF score may predict a development of AKI in patients who underwent EVAR.

METHODS

A total of 133 consecutive patients with AAA who underwent EVAR were analyzed. The primary endpoint of the study was the development of AKI. The best cut-off value for the ACEF score to predict the development of AKI was calculated and according to this value, the patients were divided into two groups as those with high ACEF scores and those with low ACEF scores. ACEF score was calculated by the formula of age/EF + 1 (if baseline creatinine > 2 mg/dL).

RESULTS

After the exclusion criteria, a total of 118 patients were included in the study, and 20 (16.9%) of them developed AKI after EVAR. In the ROC curve analysis, a cut-off value of 1.34 was found for the ACEF score, and scores above this value were found to be independent predictors of AKI development after EVAR. In addition to the ACEF score, the contrast media volume was also found to be an independent predictor of the development of AKI.

CONCLUSION

In conclusion, ACEF is a simple and effective scoring system in patients undergoing EVAR. To the best our knowledge, our study is the first study which applies ACEF score to predict AKI in EVAR patients.

Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increases the risk of postoperative acute kidney injury after elective endovascular abdominal aortic aneurysm repair

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) is the major treatment for abdominal aortic aneurysm (AAA); however, EVAR still carries a considerable risk of acute kidney injury (AKI). The present study aimed to investigate the risk factors for AKI after elective EVAR procedures.

METHODS

This was a retrospective observational study. Eligible patients who underwent EVAR from September 2011 to March 2019 in West China Hospital were included. The primary outcome was the occurrence of AKI within two days after EVAR, which was defined by the Kidney Disease Improving Global Outcomes Clinical Practice Guideline. Demographics, comorbidities, medications, laboratory tests, anatomical parameters of AAA, and relative operative details were collected as variables. Univariable and multivariable logistic regression analyses were applied to identify the risk factors among variables, and covariate interactions were further assessed.

RESULTS

A total of 679 eligible patients were included. The incidence of postoperative AKI was 8.2% (56/679) in the whole cohort, and it was associated with a lower 5-year survival rate (63.5% vs . 80.9%; χ 2  = 4.10; P  = 0.043). The multivariable logistic regression showed that chronic kidney disease (OR, 5.06; 95% CI: 1.43-17.95; P  = 0.012), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) (OR, 2.60; 95% CI: 1.17-5.76; P  = 0.019), and short neck (OR, 2.85; 95% CI: 1.08-7.52; P  = 0.035) were independent risk factors for postoperative AKI. In the covariate interaction analysis, the effect of ACEIs/ARBs use on postoperative AKI was similar across all subgroups ( P  > 0.05), thereby suggesting a robust effect of ACEIs/ARBs use in all patients undergoing elective endovascular abdominal aortic aneurysm repair.

CONCLUSIONS

Postoperative AKI was associated with lower survival rate, and the use of ACEIs/ARBs was the only adjustable independent risk factor. Clinicians should consider withdrawing ACEIs/ARBs in high-risk patients undergoing elective endovascular abdominal aortic aneurysm repair to prevent postoperative AKI.

Acute Kidney Injury Risk and Contrast Volume in Intact Versus Ruptured Endovascular Aneurysm Repair in the Vascular Quality Initiative

Objective

Renal impairment after repair of ruptured abdominal aortic aneurysm has been associated with post-operative mortality. Acute kidney injury (AKI) risk specifically related to contrast administration in endovascular aneurysm repair (EVAR) for intact vs ruptured aneurysms has not been previously described. It was our objective to evaluate the risk of AKI and the association with contrast administration in EVAR for ruptured (rEVAR) and intact (iEVAR) aneurysm repair in the Vascular Quality Initiative (VQI).

Methods

Adult patients less than 90 years old undergoing EVAR in the VQI without prior abdominal aortic surgery or who were not actively on dialysis preoperatively were included. Patients immediately converted to an open repair were excluded. Patients were grouped by repair urgency, and patient and operative characteristics and outcomes compared. Univariable and multivariable analyses were performed to identify factors associated with the primary outcome of AKI. Survival was evaluated by Kaplan-Meier analysis.

Results

Of 38,775 EVAR patients identified, 86.5% underwent elective surgery for an intact aneurysm, 8.4% had urgent surgery for a symptomatic, intact aneurysm, and 5.1% had emergent repair for a ruptured aneurysm. Significant risk factors for AKI included contrast volume, a preoperative eGFR <30 mL/min, procedure urgency, COPD, congestive heart failure (CHF), and total procedure time. The factor most associated with AKI was aneurysm rupture prior to repair (OR 8.6, CI 7.2-10.3, P <.01). The association of contrast volume with the outcome was the least strong with a 4% increase in risk per 25 mL of contrast (OR 1.04, 95% CI 1.01-1.07). With the development of AKI, postoperative survival was reduced regardless of indication.

Conclusions

Of all factors assessed, aneurysm rupture was the most and contrast volume the least associated with AKI after EVAR. Further studies should evaluate methods of preventing post-EVAR AKI.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

Intra-arterial catheter-directed CT angiography for assessment of endovascular aortic aneurysm repair

OBJECTIVE

To compare the efficacy and safety as well as associated image quality of catheter-directed CT angiography (CCTA) with a low dose of iodine contrast agent compared to intravenous CTA in patients undergoing endovascular aortic aneurysm repair (EVAR).

METHODS

Retrospective data analysis of 92 patients undergoing EVAR between January 2009 and December 2017 was performed. Patients were divided in two groups; those receiving CTA (n = 59) after intravenous contrast agent application and those receiving CCTA (n = 33) via an intraarterial catheter placed in the descending aorta. Demographic and cardiovascular risk factors as well as renal function parameters before, immediately after and 6-60 months after EVAR were evaluated. As primary endpoint, changes in serum creatinine levels in the two groups were evaluated. Secondary endpoints encompassed complications associated with intraarterial catheter placement. Objective (signal-to-noise ratios) and subjective image quality (5-point Likert scale) were compared.

RESULTS

Amount of contrast medium was significantly lower in CCTA compared to i.v. CTA (23 ± 7 ml vs. 119 ± 15 ml, p<0.0001). Patients undergoing catheter-directed CTA had higher baseline creatinine values compared to the group with intravenous iodine application (1.9 ± 0.6 mg/dl vs. 1.3 ± 0.5 mg/dl; p<0.0001). Follow-up serum creatinine levels however did not show significant alterations between the two groups (1.9 ± 0.4 mg/dl vs. 1.3 ± 0.5 mg/dl). No major complications were detected in the CCTA group. Signal-to-noise ratio (SNR) was comparable between i.v. CTA and CCTA (8.5 ± 4.6 vs. 7.7 ± 4.0; p = 0.37) and subjective image similarly revealed no differences with a good interobserver agreement (ICC = 0.647).

CONCLUSIONS

Catheter-directed CTA is safe and provides comparable image quality with a substantial retrenchment of the needed amount of iodine-based contrast medium. However, no benefit of the reduced contrast medium protocol with respect to renal function was observed.