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LaFontaine S, Goriacko P, Carnevale M, Shukla H, Phair J, Indes J, Lipsitz E, Koleilat I. Acute Kidney Injury Risk and Contrast Volume in Intact Versus Ruptured Endovascular Aneurysm Repair in the Vascular Quality Initiative. Vasc Endovascular Surg 2022; 56:581-589. [DOI: 10.1177/15385744221098820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Samantha LaFontaine
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pavel Goriacko
- Department of Pharmacy, Montefiore Medical Center, Bronx, NY, USA
| | - Matthew Carnevale
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Harshal Shukla
- Department of Pharmacy, Montefiore Medical Center, Bronx, NY, USA
| | - John Phair
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey Indes
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Evan Lipsitz
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Issam Koleilat
- Department of Surgery, Community Medical Center, RWJ/Barnabas Health, Tom’s River, NJ, USA
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Gu N, Grab JG, Moore RD. Rapid endovascular bailout revascularization of the renal arteries with a steerable guiding sheath after endovascular abdominal aortic aneurysm repair. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:572-576. [PMID: 34485780 PMCID: PMC8408573 DOI: 10.1016/j.jvscit.2021.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/22/2021] [Indexed: 10/28/2022]
Abstract
Advancements in endovascular therapy have made it increasingly available for patients with complex cases but not without complications. Unintentional coverage of the renal arteries is a rare occurrence during endovascular aortic aneurysm repair. Given the potentially devastating repercussions, it is important that surgeons understand the suitability and the risks and benefits of the available revascularization options. We have described two cases of unintentional renal coverage, with subsequent successful bailout via direct manipulation of the stent-graft with a steerable sheath. We also conducted a review of the reported data, discussed the breadth of management options and their technical aspects, and provided several distinct solutions.
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Affiliation(s)
- Ningzhi Gu
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeffery G Grab
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Randy D Moore
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Nana P, Kouvelos G, Brotis A, Spanos K, Giannoukas A, Matsagkas M. The effect of Endovascular Aneurysm Repair on Renal Function in Patients Treated for Abdominal Aortic Aneurysm. Curr Pharm Des 2020; 25:4675-4685. [DOI: 10.2174/1381612825666191129094923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/25/2020] [Indexed: 12/21/2022]
Abstract
Aim:
The effect of endovascular aneurysm repair in patients treated for abdominal aortic aneurysm has
not been clearly defined. The objective of the present article was to provide a contemporary literature review and
perform an analysis to determine the effect of EVAR on renal function in the early post-operative period and
during follow-up.
Methods:
A systematic review of the literature was undertaken to identify all studies reporting the effect of
EVAR on renal function. Outcome data were pooled and combined overall effect sizes were calculated using
fixed or random-effects models.
Results:
Thirty-two studies reporting on 24846 patients were included. Acute renal failure after EVAR occurred
with an estimated frequency of 9% (95%CI: 5-16%; I2=97%). Median follow-up period was 19.5 months (range
1-60 months). The estimated frequency of chronic renal failure during follow-up was 7% (95%CI: 3-17%;
I2=98%). Hemodialysis was required in 2% (1-3%; I2=97%) of the cases.
Conclusion:
High-level evidence demonstrating the effect of EVAR on the incidence of acute and chronic renal
failure is lacking. Based on the current available data, nearly 10% of patients undergoing EVAR for AAA have an
increased risk for renal dysfunction after the procedure. Whether this deterioration may lead to a worse outcome
has not been adequately proved.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Medical School, University of Thessaly, Larissa, Greece
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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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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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A systematic review of surveillance after endovascular aortic repair. J Vasc Surg 2018; 67:320-331.e37. [DOI: 10.1016/j.jvs.2017.04.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 04/23/2017] [Indexed: 11/17/2022]
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Buck DB, Soden PA, Deery SE, Zettervall SL, Ultee KHJ, Landon BE, O'Malley AJ, Schermerhorn ML. Comparison of Endovascular Stent Grafts for Abdominal Aortic Aneurysm Repair in Medicare Beneficiaries. Ann Vasc Surg 2017; 47:31-42. [PMID: 28890065 DOI: 10.1016/j.avsg.2017.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/07/2017] [Accepted: 08/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Increased renal complications have been suggested with suprarenal stent grafts, but long-term analyses have been limited. Therefore, the purpose of this study was to evaluate the effect of endograft choice on perioperative and long-term outcomes. METHODS We compared Medicare beneficiaries undergoing endovascular abdominal aortic aneurysms repair from 2005 to 2008 with endografts with infrarenal fixation and a single docking limb (AneuRx, Excluder) to those with suprarenal fixation and 2 docking limbs (Zenith), or a unibody configuration (Powerlink). Propensity score weighting accounted for differences in patient characteristics among the different graft formations, and perioperative mortality, complications, and length of stay and 4-year rates of survival, rupture, and reintervention were compared. RESULTS Forty-six thousand one hundred seventy-one Medicare beneficiaries were identified including 11,002 (24%) with suprarenal fixation, 32,909 (71%) with infrarenal fixation, and 2,260 (5%) with a unibody graft. After propensity score weighting, there were no significant differences in patients' baseline clinical and demographic characteristics. The suprarenal fixation patients had higher rates of perioperative mortality (1.7% vs. 1.3%, P < 0.01), renal failure (6.0% vs. 4.7%, P < 0.001), and mesenteric ischemia (0.7% vs. 0.4%, P < 0.01) and longer length of stay (3.4 days vs. 3.0 days, P < 0.001) compared with patients with infrarenal fixation. Unibody grafts had higher rates of renal failure (5.9% vs. 4.7%, P < 0.001), mesenteric ischemia (1.0% vs. 0.4%, P < 0.001), and conversion to open repair (0.7% vs. 0.1%, P < 0.001) compared to those with infrarenal fixation and single docking limbs. At 4 years, mortality remained slightly higher with suprarenal compared to infrarenal fixation (30% vs. 29%, P = 0.047), although these patients had fewer conversions to open repair (0.6% vs. 0.9%, P = 0.03) and aneurysm-related reinterventions (10% vs. 12%, P < 0.01). At 4 years, unibody grafts had more aneurysm-related interventions compared to infrarenal fixation grafts (15% vs. 12%, P < 0.01) but fewer conversions to open repair (0.4% vs. 0.9%, P = 0.02). Late rupture did not differ among the groups. CONCLUSIONS Compared to infrarenal fixation devices, patients who underwent EVAR with suprarenal fixation had higher perioperative mortality and renal complications but fewer reinterventions including conversion, while the unibody graft had more perioperative complications and aneurysm-related reinterventions, but fewer conversions to open repair. Although these differences could be explained by selection bias, these data suggest that further comparative effectiveness analyses should be performed to understand the outcomes following EVAR with suprarenal fixation and unibody grafts.
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Affiliation(s)
- Dominique B Buck
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Peter A Soden
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah E Deery
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sara L Zettervall
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Klaas H J Ultee
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Bruce E Landon
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - A James O'Malley
- Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Marc L Schermerhorn
- Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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8
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Zettervall SL, Deery SE, Soden PA, Shean K, Siracuse JJ, Alef M, Patel VI, Schermerhorn ML. Editor's Choice - Renal complications after EVAR with suprarenal versus infrarenal fixation among all users and routine users. Eur J Vasc Endovasc Surg 2017; 54:287-293. [PMID: 28779856 PMCID: PMC5659342 DOI: 10.1016/j.ejvs.2017.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 05/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Previous studies comparing endografts with suprarenal and infrarenal fixation for endovascular abdominal aortic aneurysm repair (EVAR) have found conflicting results and did not account for differences in patient selection. This study aims to evaluate the differences in outcomes among surgeons who routinely use either suprarenal or infrarenal fixation, as well as all surgeons in the Vascular Study Group of New England (VSGNE). METHODS All patients undergoing EVAR in the VSGNE from 2003 to 2014 were identified. All ruptured aneurysms, repairs with concomitant procedures, and infrequently used stent grafts (<50) were excluded. Suprarenal endografts included Talent, Zenith, and Endurant; infrarenal endografts included AneuRx and Excluder. Grafts were compared among surgeons who used only one type of endograft (suprarenal or infrarenal) for >80% of cases, as well as all surgeons. Multivariate regression and Cox hazard models were utilised to account for patient demographics, comorbidities, operative differences, and procedure year. RESULTS This study identified 2574 patients (suprarenal, 1264; infrarenal, 1310) with 888 endografts placed by routine users (suprarenal, 409; infrarenal, 479). There were no differences in baseline comorbidities, including the estimated glomerular filtration rate, between suprarenal and infrarenal fixation, or between patients with endografts placed by routine and non-routine users. Patients treated with suprarenal endografts received more contrast than all users (102 mL vs. 100 mL, p = .01) and routine users (110 mL vs. 88 mL, p < .01), but other vascular and operative details were similar. Among all users, patients treated with suprarenal grafts had higher rates of creatinine increase >.5 mg/dL (3.7% vs. 2.0%, p = .01), length of stay >2 days (27% vs. 19%, p < .01), and discharge to a skilled nursing facility (9.2% vs. 6.7%, p = .02). There were no differences in 30 day or 1 year mortality. Following adjustment, suprarenal stent grafts remained associated with an increased risk of renal deterioration (OR 2.0; 95% CI 1.2-3.4) and prolonged length of stay (OR 1.8; 95% CI 1.4-2.2). Among routine users, suprarenal fixation was also associated with higher rates of renal dysfunction (3.7% vs. 1.3%, p = .02; OR 2.9; 95% CI 1.1-7.8). CONCLUSION Despite potential differences in patient selection, endografts with suprarenal fixation among all users and routine users were associated with higher rates of renal deterioration and longer length of hospital stay. Longer-term data are needed to determine the duration and severity of renal function decline and to identify potential benefits of decreased migration or endoleak.
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Affiliation(s)
- S L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Surgery, George Washington University, Washington, DC, USA
| | - S E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - P A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA
| | - M Alef
- Department of Surgery, Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT, USA
| | - V I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - M L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Ilic NS, Opacic D, Mutavdzic P, Koncar I, Dragas M, Jovicic S, Markovic M, Davidovic L. Evaluation of the renal function using serum Cystatin C following open and endovascular aortic aneurysm repair. Vascular 2017; 26:132-141. [DOI: 10.1177/1708538117717348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Controversies regarding renal function impairment after open and endovascular aortic aneurysm repair still exist. The purpose of this study was to evaluate the renal function following open repair and endovascular aneurysm repair using Cystatin C. Methods This prospective, observational case–control study was conducted in tertiary referral centre over 3 years, starting from 2012. In total, 60 patients operated due to infrarenal AAA either by means of open repair (30 patients) or endovascular aneurysm repair (30 patients) were included in the study. Biochemical markers of renal function (sCr, urea, potassium) were recorded pre-operatively and at these specific time points, immediately after the operation and at discharge, home (third postoperative day, endovascular aneurysm repair group) or from intensive care unit (third postoperative day, open repair group). Multivariate and propensity score adjustments were used to control for the baseline differences between the groups. Results Creatinine levels in serum remained unchanged during the hospital stay in both groups without significant differences at any time point. Cystatin C levels in endovascular aneurysm repair patients significantly increased postoperatively and restored to values comparable to baseline at the discharge (0.865 ± 0.319 vs. *0.962 ± 0.353 vs. 0.921 ± 0.322, * p < 0.001). Cystatin C levels in patients treated with the open surgery was decreasing over time but not statistically significant comparing to Cystatin C values at the admission. However, decrease in Cystatin C serum levels in patients treated with conventional surgery resulted in statistically significant lower values compared to endovascular aneurysm repair patients both postoperatively and at the time of discharge (0.760 ± 0.225 vs. 0.962 ± 0.353, p < 0.05; 0.750 vs. 0.156, p < 0.05). Both multivariate linear regression models and propensity score adjustment confirm that, even after correction for previously observed intergroup differences, type of surgery, i.e. endovascular aneurysm repair is independently associated with the higher levels of Cystatin C both postoperatively and at the discharge. Conclusions Dynamics of Cystatin C levels have been proven as a more vulnerable marker of renal dysfunction. Endovascular aneurysm repair is associated with higher levels of kidney injury markers.
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Affiliation(s)
- Nikola S Ilic
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
- Medical Faculty, University of Belgrade, Serbia
| | - Dragan Opacic
- Department of Physiology, Maastricht University, The Netherlands
| | - Perica Mutavdzic
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
| | - Igor Koncar
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
- Medical Faculty, University of Belgrade, Serbia
| | - Marko Dragas
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
- Medical Faculty, University of Belgrade, Serbia
| | - Snezana Jovicic
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
- Department of Medical Biochemistry, University of Belgrade, Serbia
| | - Miroslav Markovic
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
- Medical Faculty, University of Belgrade, Serbia
| | - Lazar Davidovic
- Clinic of Vascular Surgery and Endovascular Surgery, Clinical Center of Serbia, Serbia
- Medical Faculty, University of Belgrade, Serbia
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Zettervall SL, Soden PA, Deery SE, Ultee K, Shean KE, Shuja F, Amdur RL, Schermerhorn ML. Comparison of Renal Complications between Endografts with Suprarenal and Infrarenal Fixation. Eur J Vasc Endovasc Surg 2017; 54:5-11. [PMID: 28279653 PMCID: PMC5482762 DOI: 10.1016/j.ejvs.2017.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Surgeons have multiple grafts options available for the endovascular treatment of abdominal aortic aneurysm (EVAR), and some hypothesize that suprarenal fixation endografts may result in higher rates of renal complications than infrarenal endografts. This study aimed to compare the outcomes of contemporary suprarenal and infrarenal endografts. METHODS The Targeted Vascular Module of the National Surgical Quality Improvement Project was utilised to identify patients undergoing EVAR for infrarenal aneurysm from 2011 to 2013. Pre-operative and operative variables and 30 day outcomes were compared among suprarenal (Zenith and Endurant) and infrarenal fixation devices (Excluder). Renal complications included creatinine increase > 2 mg/dL or new dialysis, as defined by NSQIP. Multivariate regression was completed to account for patient demographics, comorbidities, and operative characteristics. RESULTS A total of 3587 patients were evaluated including 2273 (63%) with suprarenal grafts and 1314 (37%) with infrarenal grafts. Patients with suprarenal grafts were less commonly white (84% vs. 88%, p < .01) and more commonly male (83% vs. 80%, p = .03). There were no differences in age or comorbidities. Renal complications (1.1% vs. 0.1%, p < .01) and length of stay more than 2 days (34% vs. 25%, p < .01) occurred more commonly after suprarenal fixation. After adjustment, suprarenal grafts had significantly higher rates of renal complications (OR, 12.0; 95% CI, 1.6-91) and length of stay more than 2 days (OR, 1.4; 95% CI, 1.2-1.7). CONCLUSION Overall rates of renal complications following EVAR are low. Patients selected for suprarenal stent grafts are at increased risk of renal complications and prolonged length of stay, which may be due to selection bias, deployment techniques, or the presence of a bare stent overlying the renal arteries. Further studies are necessary to evaluate the mechanism and duration of renal dysfunction and important long-term outcomes of interest.
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Affiliation(s)
- S L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Department of Surgery, George Washington University, Washington, DC, USA
| | - P A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - S E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K Ultee
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA; Erasmus University Medical Center, Rotterdam, The Netherlands
| | - K E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - F Shuja
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - R L Amdur
- Department of Surgery, George Washington University, Washington, DC, USA
| | - M L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Agag G, Salomon du Mont L, Leclerc B, Behr J, Rinckenbach S. Is Suprarenal Fixation of Aortic Stent Grafts Really without Consequence on the Renal Function? Ann Vasc Surg 2017; 39:90-98. [DOI: 10.1016/j.avsg.2016.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/22/2016] [Accepted: 04/26/2016] [Indexed: 12/23/2022]
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12
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Gray DE, Eisenack M, Gawenda M, Torsello G, Majd P, Brunkwall J, Osada N, Donas KP. Repeated contrast medium application after endovascular aneurysm repair and not the type of endograft fixation seems to have deleterious effect on the renal function. J Vasc Surg 2017; 65:46-51. [DOI: 10.1016/j.jvs.2016.05.088] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/26/2016] [Indexed: 11/17/2022]
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13
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Waasdorp E, van't Hullenaar C, van Herwaarden J, Kelder H, van de Pavoordt E, Overtoom T, Moll F, de Vries JP. Renal Function after Endovascular Aortic Aneurysm Repair: A Single-Center Experience with Transrenal versus Infrarenal Fixation. J Endovasc Ther 2016; 14:130-7. [PMID: 17484527 DOI: 10.1177/152660280701400203] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To describe the short-term consequences of endovascular aortic aneurysm repair (EVAR) on renal function after infrarenal (IR) versus transrenal (TR) stent-graft fixation. Methods: Between December 1996 and January 2006, 369 consecutive patients were treated with EVAR. All patients had an AneuRx or a Talent stent-graft implanted using IR (AneuRx) or transrenal (Talent) fixation. Post-EVAR, a standardized follow-up scheme included computed tomography (CT) scanning and serum creatinine measurements at 2 days, 3 months, and 12 months. Postoperative renal dysfunction was defined as a >20% decrease in serum creatinine clearance compared to baseline, the presence of new-onset dialysis, or both. Of the 369 patients, 309 (291 men; mean age 71±7 years, range 63–82) had complete 1-year follow-up and were included in this study. An IR stent-graft was placed in 190 patients, and a TR stent-graft was placed in the remaining 119 patients. Results: At discharge, renal dysfunction occurred in 3.7% of the patients in the IR group versus 5.9% in the TR group (p=NS) and rose significantly to 13.7% in the IR group (p=0.001) and 15.1% in the TR group (p=0.02) at the 1-year follow-up. However, no significant difference was noted between the IR and TR groups at either time point. At the 1-year follow-up, at least 50% of renal dysfunction was caused by obstructions of (accessory) renal arteries and renal infarctions. During the follow-up interval, 3 (0.97%) of 309 patients underwent new-onset dialysis. Conclusion: Both infrarenal and transrenal fixation techniques in EVAR will lead to a significant rise in renal dysfunction during the first year. A few patients with dysfunction will require dialysis.
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Affiliation(s)
- Evert Waasdorp
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Boules TN, Stanziale SF, Chomic A, Selzer F, Tublin ME, Makaroun MS. Predictors of Diffuse Renal Microembolization Following Endovascular Repair of Abdominal Aortic Aneurysms. Vascular 2016; 15:18-23. [PMID: 17382050 DOI: 10.2310/6670.2007.00006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We evaluated the incidence, risk factors, and clinical consequences of renal microembolic events following endovascular aneurysm repair using suprarenal or infrarenal fixation. Pre- and postoperative (1 month) computed tomographic angiograms were reviewed for new renal perfusion defects. Suprarenal aortic and infrarenal neck thrombus load was classified by circumference involved and thrombus thickness. Serum creatinine was measured preoperatively, on the first postoperative day, and 1 month postoperatively. Among 136 patients, 8 (5.9%) had bilateral microembolic cortical defects. Patients with moderate or severe suprarenal thrombus were more likely to have renal microemboli than those with no or mild suprarenal thrombus (17% vs 0%; p < .001). Similarly, patients with moderate or severe infrarenal neck thrombus were more likely to have renal microemboli than those with no or mild infrarenal thrombus (9.6% vs 1.5%; p = .08). Severe infrarenal thrombus was independently predictive of microembolization (odds ratio 15.0; 95% confidence interval 1.6–142; p = .018). There was no statistically significant difference in the incidence of renal microembolization when comparing suprarenal and infrarenal fixation (8.2% vs 4.0%; p = .47). Changes in creatinine from baseline were not different in those with or without renal microemboli. Renal microembolization is an uncommon but distinct radiographic finding that is more associated with significant neck thrombus than fixation level.
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Affiliation(s)
- Tamer N Boules
- Division of Vascular Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA
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15
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Yang B, Fung A, Pac-Soo C, Ma D. Vascular surgery-related organ injury and protective strategies: update and future prospects. Br J Anaesth 2016; 117:ii32-ii43. [DOI: 10.1093/bja/aew211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Nguyen BN, Sidawy AN. Which Is Best for Abdominal Aortic Aneurysms Treatment with Chronic Renal Insufficiency: Endovascular Aneurysm Repair or Open Repair? Adv Surg 2015; 49:65-77. [PMID: 26299490 DOI: 10.1016/j.yasu.2015.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Bao-Ngoc Nguyen
- Department of Surgery, George Washington University, 2150 Pennsylvania Avenue, Washington, DC 20037, USA.
| | - Anton N Sidawy
- Department of Surgery, George Washington University, 2150 Pennsylvania Avenue, Washington, DC 20037, USA
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Stanišić MG, Majewska N, Romanowski M, Kulesza J, Juszkat R, Makałowski M, Majewski W. Endovascular treatment of renal artery occlusion caused by aortic stentgraft migration. POLISH JOURNAL OF SURGERY 2015; 87:181-4. [PMID: 26146117 DOI: 10.1515/pjs-2015-0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 11/15/2022]
Abstract
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.
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19
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Miller LE, Razavi MK, Lal BK. Suprarenal versus infrarenal stent graft fixation on renal complications after endovascular aneurysm repair. J Vasc Surg 2015; 61:1340-9.e1. [DOI: 10.1016/j.jvs.2015.01.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/19/2015] [Indexed: 10/23/2022]
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20
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Acute renal infarction presenting with acute abdominal pain secondary to newly discovered atrial fibrillation: a case report and literature review. Case Rep Emerg Med 2015; 2014:981409. [PMID: 25614841 PMCID: PMC4295136 DOI: 10.1155/2014/981409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/09/2014] [Indexed: 11/24/2022] Open
Abstract
We report an 85-year-old female with known history of recurrent diverticulitis presented with abdominal pain. It was believed that the patient again needed to be treated for another diverticulitis and was started on the routine treatment. The initial CT scan of abdomen showed renal infarcts bilaterally that were confirmed by a CT with and without intravenous contrast secondary to unknown cause. An ECG found accidentally that the patient was in atrial fibrillation, which was the attributed factor to the renal infarctions. Subsequently, the patient was started on the appropriate anticoagulation and discharged.
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Mills JL, Duong ST, Leon LR, Goshima KR, Ihnat DM, Wendel CS, Gruessner A. Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate. J Vasc Surg 2008; 47:1141-9. [PMID: 18514831 DOI: 10.1016/j.jvs.2008.01.039] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Revised: 01/13/2008] [Accepted: 01/20/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE It has been suggested that endovascular aneurysm repair (EVAR) in concert with serial contrast-enhanced computed tomography (CT) surveillance adversely impacts renal function. Our primary objectives were to assess serial renal function in patients undergoing EVAR and open repair (OR) and to evaluate the relative effects of method of repair on renal function. METHODS A thorough retrospective chart review was performed on 223 consecutive patients (103 EVAR, 120 OR) who underwent abdominal aortic aneurysm (AAA) repair. Demographics, pertinent risk factors, CT scan number, morbidity, and mortality were recorded in a database. Baseline, 30- and 90-day, and most recent glomerular filtration rate (GFR) were calculated. Mean GFR changes and renal function decline (using Chronic Kidney Disease [CKD] staging and Kaplan-Meier plot) were determined. EVAR and OR patients were compared. CKD prevalence (>or=stage 3, National Kidney Foundation) was determined before repair and in longitudinal follow-up. Observed-expected (OE) ratios for CKD were calculated for EVAR and OR patients by comparing observed CKD prevalence with the expected, age-adjusted prevalence. RESULTS The only baseline difference between EVAR and OR cohorts was female gender (4% vs 12%, P = .029). Thirty-day GFR was significantly reduced in OR patients (P = .047), but it recovered and there were no differences in mean GFR at a mean follow-up of 23.2 months. However, 18% to 39% of patients in the EVAR and OR groups developed significant renal function decline over time depending on its definition. OE ratios for CKD prevalence were greater in AAA patients at baseline (OE 1.28-3.23, depending upon age group). During follow-up, the prevalence and severity of CKD increased regardless of method of repair (OE 1.8-9.0). Deterioration of renal function was independently associated with age >70 years in all patients (RR 2.92) and performance of EVAR compared with OR (RR 3.5) during long-term follow-up. CONCLUSIONS Compared with EVAR, OR was associated with a significant but transient fall in GFR at 30 days. Renal function decline after AAA repair was common, regardless of method, especially in patients >70 years of age. However, the renal function decline was significantly greater by Kaplan-Meier analysis in EVAR than OR patients during long-term follow-up. More aggressive strategies to monitor and preserve renal function after AAA repair are warranted.
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Affiliation(s)
- Joseph L Mills
- The University of Arizona Health Sciences Center, University Medical Center, Tucson, AZ 85724, USA.
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22
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Walsh SR, Boyle JR, Lynch AG, Sadat U, Carpenter JP, Tang TY, Gaunt ME. Suprarenal endograft fixation and medium-term renal function: systematic review and meta-analysis. J Vasc Surg 2008; 47:1364-1370. [PMID: 18280095 DOI: 10.1016/j.jvs.2007.11.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Revised: 11/05/2007] [Accepted: 11/11/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Suprarenal fixation is widely used in endovascular aneurysm repair. Numerous small, underpowered studies have concluded that it does not increase the risk of renal impairment compared with infrarenal fixation. A recent meta-analysis demonstrated that renal infarction is more common with suprarenal fixation, but the effect on renal function remains unclear. METHODS Electronic abstract databases, article reference lists, and conference proceedings were searched for series reporting renal function data after suprarenal fixation. There was considerable study heterogeneity with respect to key factors such as pre-existing renal dysfunction and length of follow-up. Authors were contacted to obtain individual patient data for a pooled reanalysis using standardized criteria. RESULTS Of 46 potentially relevant citations, only 11 were eligible for inclusion in the meta-analysis. Complete data sets were available for four studies (1065 patients), with a median follow-up of 33 months. Kaplan-Meier curves were constructed for postoperative renal impairment in the suprarenal fixation and infrarenal fixation groups and compared by the log-rank test. Median time free of renal impairment was 38.5 months in the infrarenal fixation group compared with 32.4 months in the suprarenal fixation group (P = .0038). However, to account for significant methodologic differences, further analysis was required using a Weibull regression model fitted in open Bayesian inference using Gibbs sampling (BUGS). The pooled hazard ratio for deterioration of renal function after suprarenal fixation was 0.6 (95% confidence interval, 0.3-10). CONCLUSION Currently available data are insufficient to determine the precise effect of suprarenal fixation on medium-term renal function. Conventional Kaplan-Meier analysis of the pooled data set suggested that suprarenal fixation increased the risk of renal dysfunction; however, the effect disappeared when sophisticated statistical modelling was performed to account for study heterogeneity. A randomised controlled trial of suprarenal fixation may resolve this issue.
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Affiliation(s)
- Stewart R Walsh
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom.
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23
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Walsh SR, Tang TY, Boyle JR. Renal Consequences of Endovascular Abdominal Aortic Aneurysm Repair. J Endovasc Ther 2008; 15:73-82. [PMID: 18254679 DOI: 10.1583/07-2299.1] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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24
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Hedayati N, Lin PH, Lumsden AB, Zhou W. Prolonged renal artery occlusion after endovascular aneurysm repair: Endovascular rescue and renal function salvage. J Vasc Surg 2008; 47:446-9. [PMID: 17950560 DOI: 10.1016/j.jvs.2007.08.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2007] [Revised: 08/10/2007] [Accepted: 08/10/2007] [Indexed: 10/22/2022]
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25
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Choke E, Munneke G, Morgan R, Belli AM, Dawson J, Loftus IM, McFarland R, Loosemore T, Thompson MM. Visceral and Renal Artery Complications of Suprarenal Fixation during Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2007; 30:619-27. [PMID: 17401761 DOI: 10.1007/s00270-007-9008-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The effect of suprarenal fixation of endovascular grafts on renal and visceral artery function remains undefined. This study aimed to determine renal and visceral artery complications following suprarenal fixation during endovascular aneurysm repair (EVR). METHODS Prospectively collected data from 112 patients who received suprarenal fixation (group SF) and 36 patients who received infrarenal fixation (group IF) in a single institution from December 1997 to April 2005 were reviewed retrospectively. Median follow-up was 26 months (range 0.1-101 months). RESULTS Stent struts extended to or above the level of 106 (94.6%) right renal arteries, 104 (92.9%) left renal arteries, 49 (43.8%) superior mesenteric arteries (SMA), and 7 (6.3%) celiac arteries in group SF. This group had 2 (1.8%) unintentional main renal artery occlusions, of which 1 was successfully treated at the first procedure with a renal stent. There was 1 (0.9%) SMA occlusion which resulted in bowel infarction and death. Group IF had no renal or visceral artery complications. There were no late-onset occlusions or infarcts. There was no significant difference in median serum creatinine between groups SF and IF at 1 month (p = 0.18) and 6 months to 12 months (p = 0.22) follow-up. The change in serum creatinine over time was also not significantly different within each group (SF, p = 0.09; IF, p = 0.38). CONCLUSIONS In this study, suprarenal fixation was associated with a very small incidence of immediate renal and visceral artery occlusion. There did not appear to be any medium-term sequelae of suprarenal fixation.
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Affiliation(s)
- Edward Choke
- St. George's Vascular Institute, Blackshaw Road, London, SW17 0QT, UK
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26
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Waasdorp E, van't Hullenaar C, van Herwaarden J, Kelder H, van de Pavoordt E, Overtoom T, Moll F, de Vries JP. Renal Function After Endovascular Aortic Aneurysm Repair:A Single-center Experience with Transrenal Versus Infrarenal Fixation. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[130:rfaeaa]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Durability of renal artery stents in patients with transrenal abdominal aortic endografts. J Vasc Surg 2007; 45:915-20; discussion 920-1. [PMID: 17391902 DOI: 10.1016/j.jvs.2007.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2006] [Accepted: 01/05/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The management of renal artery stenosis in patients with abdominal aortic aneurysms continues to be complex and technically challenging despite advances in endovascular therapy. There is growing concern about the durability of renal artery stents in the setting of transrenal abdominal aortic endografts. This study reports a single-center experience of renal artery stenting with transrenal abdominal aortic endografts for patients with renal artery stenosis. METHODS All patients undergoing endovascular abdominal aortic aneurysm repair preceded or followed by renal artery stent placement between January 1999 and December 2005 were retrospectively reviewed from a prospectively gathered endovascular database. Patients were surveyed after renal stent procedures with multidetector computed tomography angiography or duplex sonography. The surveillance data were analyzed for primary patency of the renal artery stent at 6 months, incidence of complications, need for secondary interventions, and changes in creatinine clearance (CrCl). RESULTS Sixty-two renal artery stents were placed in 56 patients (44 men, 12 women) with a mean age of 77.3 years (range, 61 to 94 years). Forty-one were placed before the endograft procedure, eight were placed during the endograft procedure, and 13 were placed postoperatively. There were no major or minor complications related to the renal artery stent procedures. Transrenal aortic endografts were used in 44 of the 56 patients, and 12 had devices with infrarenal fixation. The mean follow-up was 18.5 months (range, 1 to 73 months). The 6-month primary patency, which could be evaluated for 51 renal artery stents, was 97.4% (37/38) in patients with transrenal fixation and 84.6% (11/13) in patients with infrarenal fixation. The overall rate of in-stent restenosis was 8.5% (4/47) in the transrenal fixation group and 20.0% (3/15) in the infrarenal fixation group. The overall occlusion rate was 2.1% (1/47) in the transrenal fixation group and 0% (0/15) in infrarenal fixation group. Five (83.3%) of six patients underwent successful treatment of in-stent restenosis with placement of a new stent in all five cases. CrCl decreased in the total group by 4.2 +/- 11.8 mL/min, by 4.7 +/- 12.0 mL/min in patients with transrenal fixation, and by 2.2 +/- 11.0 mL/min in patients with infrarenal fixation. CONCLUSION The presence of a transrenal aortic endograft did not affect the outcome of the renal artery revascularization procedure in this cohort. Renal artery stenting in the presence of transrenal abdominal aortic endografts appears to be a safe procedure without adverse effect on renal artery stent patency or renal function.
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Influence of Suprarenal Stentgraft Fixation on Renal Function in Patients After Abdominal Aortic Aneurysm Endovascular Exclusion. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0002-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Forbes TL, Harding GEJ, Lawlor DK, Derose G, Harris KA. Comparison of renal function after endovascular aneurysm repair with different transrenally fixated endografts. J Vasc Surg 2006; 44:938-42. [PMID: 17098524 DOI: 10.1016/j.jvs.2006.07.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Accepted: 07/19/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Transrenal fixation of abdominal aortic endografts may provide a more secure proximal attachment with few deleterious effects with respect to renal function. This study's purpose was to determine whether different metals used in two commercially available endografts (Cook Zenith and Medtronic Talent) result in different effects on renal function when placed across renal ostia. METHODS A total of 140 consecutive patients, between August 2003 and April 2005, who underwent elective endovascular repair of an aortic aneurysm with a nitinol or stainless steel-based endograft with transrenal fixation were reviewed with a mean follow-up period of 5.5 months (range, 1-22 months). The main outcome variable was the percentage change in creatinine clearance (CrCl), which was determined before surgery and at the most recent follow-up. Multiple regression analysis was performed to analyze the contribution of various factors to any deterioration in renal function. RESULTS The 140 patients were predominantly male (86%), with a mean age of 75 years (range, 56-92) and a mean aneurysm diameter of 62 mm (range, 42-110 mm). The mean intraoperative contrast use was 67 mL (range, 45-160 mL), and after surgery these patients received a mean of 3 surveillance computed tomographic scans (range, 1-7). Nineteen cases (13.6%) required deliberate accessory renal artery coverage. CrCl did not change significantly after surgery; the mean change in CrCl at the end of follow-up was a 2.5% decrease. There was no difference in the reduction in CrCl between endograft types. Only 14.3% of patients experienced a greater than 20% decrease in CrCl. Multiple regression analysis failed to show a relationship between change in renal function and age, sex, aneurysm diameter, infrarenal neck dimensions, endograft type, coverage of accessory renal arteries, intraoperative contrast volume, preoperative CrCl, and postoperative computed tomographic scans. Length of follow-up was an independent predictor (P = .04). CONCLUSIONS Transrenal endograft fixation results in little deterioration in renal function during intermediate follow-up. The few patients who do experience a decline in renal function do so independently of any features related to the initial endovascular repair, and there is no difference in renal deterioration between endografts with nitinol and stainless steel transrenal bare metal stents.
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Affiliation(s)
- Thomas L Forbes
- Division of Vascular Surgery, London Health Sciences Centre and The University of Western Ontario, London, ON, Canada.
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Lalka S, Johnson M, Namyslowski J, Dalsing M, Cikrit D, Sawchuk A, Shafique S, Nachreiner R, O'Brien E. Renal interventions after abdominal aortic aneurysm repair using an aortic endograft with suprarenal fixation. Am J Surg 2006; 192:577-82. [PMID: 17071187 DOI: 10.1016/j.amjsurg.2006.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 08/06/2006] [Accepted: 08/06/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our aim was to determine whether suprarenal fixation in endografts compromises renal artery (RA) flow and whether subsequent RA intervention is precluded by the stent struts. METHODS Prospectively acquired data from 104 patients with endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm using the Zenith endograft (Cook, Inc., Bloomington, IN) were analyzed. The Zenith device uses a 26-mm, uncovered, barbed Z stent for suprarenal function. RESULTS No RA stenosis, occlusion, or infarction resulted from the suprarenal stent. In 3 of 104 (2.9%) patients, RA compromise (2 stenoses, 1 occlusion) was caused by impingement of graft material on the lowermost RA. The 2 RA stenoses were stented successfully at 1 and 7 months post-EVAR. Six of 104 (5.8%) patients developed late stenoses unrelated to the endograft: all were stented successfully from 19 to 36 months after EVAR. One patient with severe RA stenosis had balloon angioplasty pre-EVAR and then was stented electively 6 weeks post-EVAR. CONCLUSIONS Our data show that the suprarenal fixation of the Zenith aortic endograft does not cause RA stenosis, occlusion, or infarction, nor does it preclude post-EVAR renal artery intervention.
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Affiliation(s)
- Stephen Lalka
- Section of Vascular Surgery, Richard L. Roudebush Veterans Affairs Medical Center and Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Parmer SS, Fairman RM, Karmacharya J, Carpenter JP, Velazquez OC, Woo EY. A comparison of renal function between open and endovascular aneurysm repair in patients with baseline chronic renal insufficiency. J Vasc Surg 2006; 44:706-11. [PMID: 16930930 DOI: 10.1016/j.jvs.2006.05.049] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Accepted: 05/22/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) is rapidly becoming the predominant technique for repair of abdominal aortic aneurysms. Results from current studies, however, are conflicting on the effect of EVAR on renal function compared with standard open repair. Furthermore, data for open repair in patients with baseline renal insufficiency suggests worse outcomes, including renal function. This analysis compared the effects of open repair vs EVAR on renal function in patients with baseline renal insufficiency. METHODS We reviewed our records for patients with preoperative chronic renal insufficiency (serum creatinine, 1.5 mg/dL) who underwent open repair or EVAR between 1999 and 2004. The same group of vascular surgeons at a single institution performed aneurysm repair on 98 patients: 46 open (37 men, 9 women) and 52 EVAR (50 men, 2 women). Preoperative, postoperative, and follow-up serum creatinine and creatinine clearance were compared, as was the development of postoperative renal impairment (increase in serum creatinine >30%). RESULTS Serum creatinine and creatinine clearance were not statistically different between the open and EVAR groups during any time period studied. Likewise when comparing the magnitude of change in serum creatinine in patients between the postoperative and follow-up times with preoperative values, no significant differences existed between the open and EVAR groups. When the change in serum creatinine over time within each group was compared, however, the open group had a significant increase in serum creatinine postoperatively (2.43 +/- 1.20 vs 2.04 +/- 0.64, P = .012), which returned to baseline during follow-up (1.96 +/- 0.94, P = .504). Although serum creatinine in the EVAR group increased compared with preoperative values of 2.04 +/- 0.55 (postoperative, 2.27 +/- 1.04; follow-up, 2.40 +/- 1.37), this failed to reach statistical significance for the postoperative (P = .092) or follow-up (P = .081) periods. A similar pattern was noted in creatinine clearance. Postoperative renal impairment was noted in 13 open (28%) and 15 EVAR patients (29%) and was not statistically different between groups. Overall, two patients (4.3%) from the open group and four (7.7%) from the EVAR group required hemodialysis; one in the EVAR group required permanent hemodialysis. This difference was not statistically significant (P = .681). CONCLUSIONS Open and endovascular repair of abdominal aortic aneurysms in patients with pre-existent renal insufficiency can be performed safely with preservation of renal function. In contrast to previous reports, no significant differences existed between open repair and EVAR in postoperative alterations in renal function. Although a significant increase in serum creatinine develops in patients with renal insufficiency postoperatively with open repair, this appears to be transient, and preoperative renal dysfunction alone should not exclude either approach. After EVAR, patients with pre-existing renal insufficiency continue to be at risk for progressive renal dysfunction, and protective measures should be taken to preserve renal function in this patient population.
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Affiliation(s)
- Shane S Parmer
- Division of Vascular Surgery, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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Parmer SS, Carpenter JP. Endovascular aneurysm repair with suprarenal vs infrarenal fixation: A study of renal effects. J Vasc Surg 2006; 43:19-25. [PMID: 16414382 DOI: 10.1016/j.jvs.2005.09.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 09/13/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Although suprarenal fixation may be of benefit during endovascular aneurysm repair (EVAR), its safety with regards to renal effects remains uncertain. To date, there has been no controlled study of the topic, with most reports relying upon single-center experiences that use heterogeneous patient populations and devices from different manufacturers. The purpose of this analysis was to evaluate the effect of suprarenal fixation on renal function by comparing homogeneous patient populations receiving EVAR grafts from a single manufacturer that are identical in design and delivery method, except for utilizing either suprarenal (SR) or infrarenal (IR) fixation. METHODS During two pivotal US Food and Drug Administration trials, 283 patients underwent EVAR with the Powerlink bifurcated graft. The trials' inclusion and exclusion criteria and grafts were identical except for fixation scheme. Clinical, laboratory, and computed tomographic (CT) data were retrospectively reviewed. A comparison of preoperative, perioperative (1 to 7 days), and postoperative (>7 days) alterations in serum creatinine (SCr), creatinine clearance (CrCl), and blood pressure was performed. Renal adverse events were determined by CT scan and clinical chart review and included renal infarction, renal artery stenosis (either progressive or requiring renal stent placement), and renal artery occlusion. RESULTS Both SR and IR groups demonstrated a significant increase in SCr and a decrease in CrCl over time. No significant difference in SCr or CrCl existed between groups during any time period. There were no differences in postoperative renal impairment (IR, 10.2%; SR, 7.6%, P = .634), the need for hemodialysis (IR, 0.7%; SR, 0%, P = 1.00), or systolic and diastolic blood pressure during subsequent follow-up between treatment groups. There was no significant difference in the number of renal adverse events detected by CT between the IR (10, 6.8%) and SR (3, 3.8%) groups (P = .550). CONCLUSION Suprarenal fixation does not lead to a significant increase in acute renal events, renal impairment, or alteration in blood pressure compared with infrarenal fixation. Patients undergoing aneurysm repair with devices that use either suprarenal or infrarenal fixation develop progressive renal dysfunction over time. Further studies are needed to determine the long-term effects of suprarenal fixation on renal function and progression of renal artery stenosis.
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Affiliation(s)
- Shane S Parmer
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Linsen MAM, Vos AWF, Diks J, Rauwerda JA, Wisselink W. Fenestrated and Branched Endografts: Assessment of Proximal Aortic Neck Fixation. J Endovasc Ther 2005; 12:647-53. [PMID: 16363893 DOI: 10.1583/05-1639r.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate proximal fixation characteristics of different aortic endograft designs: a suprarenally placed fenestrated endograft, a modular branched endograft, an infrarenal endograft with suprarenal bare stent fixation, and the gold standard, a conventional hand-sewn anastomosis. METHODS Ten human cadaveric aortas were obtained at autopsy and transected 20 mm below the renal arteries to mimic an infrarenal aneurysm neck. In random order, the infrarenal, fenestrated, and branched endografts were deployed into the aorta. Using a hydraulic material testing machine, longitudinal load was applied to the distal end of each endograft until migration occurred, thus defining the displacement force (DF). Subsequently, a hand-sewn infrarenal anastomosis was tested in a similar manner. RESULTS The median DF was 4.67 N (3.82-6.37) for the infrarenal endograft, 9.17 N (8.03- 10.81) for the fenestrated endograft, and 16.95 N (14.78-19.67) for the branched endograft. The differences in DF between the infrarenal and fenestrated endografts and between the fenestrated and branched designs were statistically significant (both p=0.005). The median force to dislodge the graft from the conventional anastomosis was 89.16 N (71.24-105.23). CONCLUSIONS Suprarenally placed endografts, especially with additional branch grafts, provide improved proximal fixation compared to an infrarenal endograft with suprarenal bare stent fixation. However, none of the tested endografts approached the optimal, time-proven fixation, the hand-sewn anastomosis.
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Affiliation(s)
- Matteus A M Linsen
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
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Alsac JM, Zarins CK, Heikkinen MA, Karwowski J, Arko FR, Desgranges P, Roudot-Thoraval F, Becquemin JP. The impact of aortic endografts on renal function. J Vasc Surg 2005; 41:926-30. [PMID: 15944586 DOI: 10.1016/j.jvs.2005.02.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the impact on late postoperative renal function of suprarenal and infrarenal fixation of endografts used to treat infrarenal abdominal aortic aneurysm (AAA). METHODS Retrospective analysis of 277 patients treated from 2000 to 2003 with three different endografts at two clinical centers. Five patients on dialysis for preoperative chronic renal failure were excluded. Group IF of 135 patients treated with an infrarenal device (Medtronic AneuRx) was compared with group SF of 137 patients treated with a suprarenal device (106 Cook Zenith and 31 Medtronic Talent). Renal function was evaluated by calculating preoperative and latest postoperative creatinine clearance (CrCl) using the Cockcroft formula. Patients who developed a >20% decrease in CrCl were considered to have significantly impaired renal function. RESULTS There were no significant differences in patient age, sex, aneurysm size, preoperative risk factors, dose of intra- and postoperative contrast, or baseline CrCl (IF: 69.3 mL/min, SF: 71.7 mL/min, P = .4). Follow-up time of 12.2 months was the same in both groups. CrCl decreased significantly during the follow-up period in both groups (IF: 69.3 mL/min to 61.7 mL/min, P < .01; SF: 71.7 mL/min to 64.9 mL/min, P < .03). Postoperative CrCl (IF: 61.7 mL/min, SF: 64.9 mL/min, P = .3), and the rate of CrCl decrease during the follow-up period (IF: -10.9%, SF: -9.5%, P = .2) was not different between the two groups. The number of patients with a >20% decrease in CrCl was not different between the two groups (IF: n = 35 [25.9%], SF: n = 41 [29.9%], P = .46). However, the magnitude of decrease in CrCl in patients with renal impairment was greater in patients treated with suprarenal fixation endografts (SF: -39%) compared with those treated with infrarenal endografts (IF: -31%, P = .005). This greater degree of renal impairment was not due to identifiable differences in preoperative risk factors, age, or baseline CrCl. No patients in these series required dialysis. CONCLUSIONS Regardless the type of endograft used, there is a 10% decrease in CrCl in the first year after endovascular aneurysm repair. Suprarenal fixation does not seem to increase the likelihood of postoperative renal impairment. Decline in renal function over time after endovascular aortic repair is probably due to multiple factors, and measures known to be effective in protecting kidneys should be considered for these patients. Long-term follow-up with measurement of CrCl, along with renal imaging and regular blood pressure measurements, should be performed to detect possible late renal dysfunction. Prospective studies comparing suprarenal versus infrarenal fixation are needed to confirm those results.
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Affiliation(s)
- Jean-Marc Alsac
- Department of Vascular Surgery, Stanford University Hospital, Calif, USA.
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Krämer SC, Görich J, Bachmann R, Fuge D, Kuhnt B, Scharrer-Pamler R. Incidence of Renal Infarctions After Transrenal Stent Placement in an Animal Model. J Endovasc Ther 2005; 12:312-7. [PMID: 15943506 DOI: 10.1583/04-1486mr.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the incidence and appearance of renal infarctions after transrenal stent placement in an animal model. METHODS An aortic stent was placed via a femoral approach in 20 female Merino sheep. Ten animals had intentional coverage of one renal ostium with the bare struts, 1 sheep had both renal artery ostia covered, and the other 9 sheep had no stent impingement on the renal orifices. Animals were sacrificed after 3 to 12 months (mean 6) for gross pathological and histological evaluation. Infarction locations and patterns were evaluated and correlated to stent placement. RESULTS Of the 40 renal arteries, coverage was proven at autopsy in 12 cases; the remaining 28 arteries were free of any stent overlay. Overall, 14 (35%) renal infarctions were detected; 7 were found in the 12 arteries with a transrenal stent (58.3% incidence in covered renal arteries). By comparison, the other 7 infarctions were found in the 28 unaffected arteries (25% incidence in noncovered renal arteries; p = 0.04). All infarctions appeared to be well-defined punctate lesions. CONCLUSIONS A transrenal stent position in the abdominal aorta is related to increased renal infarctions in an animal model.
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Affiliation(s)
- Stefan C Krämer
- Department of Clinical Radiology, University of Münster, Germany.
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Sun Z. Transrenal fixation of aortic stent-grafts: current status and future directions. J Endovasc Ther 2005; 11:539-49. [PMID: 15482027 DOI: 10.1583/04-1212.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aortic stent-graft repair has been widely used in clinical practice for more than a decade, achieving satisfactory results compared to open surgical techniques. Transrenal fixation of stent-grafts is designed to obtain secure fixation of the proximal end of the stent-graft to avoid graft migration and to prevent type I endoleak. Unlike infrarenal deployment of stent-grafts, transrenal fixation takes advantage of the relative stability of the suprarenal aorta as a landing zone for the uncovered struts of the proximal stent. These transostial wires have sparked concern about the patency of the renal arteries, interference with renal blood flow, and effects on renal function. Although short to midterm results with suprarenal stent-grafts have not shown significant changes in renal function, long-term effects of this technique are still not fully understood. This review will explore the current status of transrenal fixation of aortic stent-grafts, potential risks of stent struts relative to the renal ostium, alternative methods to preserve blood flow to the renal arteries, and future directions or developments in stent-graft design to prevent myointimal proliferation around the stent struts.
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Affiliation(s)
- Zhonghua Sun
- School of Applied Medical Sciences and Sports Studies, University of Ulster, Newtownabbey, Northern Ireland, UK.
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Fairman RM, Velazquez OC, Carpenter JP, Woo E, Baum RA, Golden MA, Kritpracha B, Criado F. Midterm pivotal trial results of the Talent Low Profile System for repair of abdominal aortic aneurysm: Analysis of complicated versus uncomplicated aortic necks. J Vasc Surg 2004; 40:1074-82. [PMID: 15622358 DOI: 10.1016/j.jvs.2004.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study was undertaken to determine whether a complicated aortic neck is associated with unfavorable outcome after abdominal aortic aneurysm (AAA) endografting. METHODS In a prospective pivotal clinical trial, 237 consecutive patients underwent implantation of the bifurcated Talent Low Profile System. Patients were divided into 2 groups, those with complicated aortic necks (short, <15 mm; very short, < or =10 mm; dilated, >28 mm; angulated, >45 degrees; calcified; and thrombus-lined) versus those with uncomplicated neck anatomy. Major outcome parameters included procedure time, operative blood loss, transfusion requirements, volume of contrast medium used during the implant procedure, endoleaks, migration, limb patency, AAA regression, conversion to open repair, morbidity, and mortality. Mean follow-up was 620.5 days. RESULTS Overall, 32% of aortic necks were short, 19% were very short, 20% were dilated, 18% were calcified, 8.5% were thrombus-lined, and 19.9% were angulated. Thirty percent and 70% of patients, respectively, were stratified to the uncomplicated and complicated groups ( P < .01. Procedure time, operative blood loss, transfusions, volume of contrast medium used in the implant procedure, migration, endograft patency, AAA sac regression, conversion to open repair, and mortality were not significantly different in necks with complicated versus uncomplicated anatomy. At 21 months, sacs were regressing or stable in 98% (complicated) versus 96% (uncomplicated). Primary graft limb patency was 100% in both groups. The endoleak rate was 4.3% (complicated) versus 17% (uncomplicated) at 18 months, but this difference was not statistically significant. Adverse renal events, however, occurred in 27.5% (complicated) versus 13.6% (uncomplicated; P = .04). CONCLUSIONS Complicated aortic neck is not associated with unfavorable outcome at midterm follow-up after AAA endografting. However, statistically more adverse renal events occur in patients with complicated neck anatomy.
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Affiliation(s)
- Ronald M Fairman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia 19003, USA.
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