Renal Dysfunction Following Elective Endovascular Aortic Aneurysm Repair

Incidence of Contrast-Induced Nephropathy and Post-Operative Outcomes in Patients Undergoing Chimney Endovascular Aortic Aneurysm Repair

Chimney endovascular aortic aneurysm repair (ch-EVAR) has become a valid alternative to treat complex aneurysms but the occurrence of contrast-induced kidney injury (CI-AKI) is poorly known. This study investigated the incidence and the impact of CI-AKI on post-operative outcomes after ch-EVAR. Consecutive patients who underwent ch-EVAR between July 2010 and 2021 were retrospectively included. CI-AKI was defined based on plasma creatinine levels within 7 days after the intervention according to the "Kidney Disease Improving Global Outcomes" (KDIGO) classification. Among 102 patients included, CI-AKI occurred in 14 cases (13.7%). The 30-day post-operative mortality and complications were significantly higher in patients who developed CI-AKI compared with those who did not (50 vs 9.1%, P = .001 and 57.1 vs 20.5%, P = .007). Over a median follow-up of 24 months (3-39), overall mortality was also significantly higher (78.6 vs 33.0%, P = .002). The pre-operative platelet-to-lymphocyte ratio (PLR) was significantly higher in patients who developed CI-AKI (224.5 vs 147.6, P = .008). CI-AKI is frequent after ch-EVAR and is associated with worse post-operative outcomes. This should increase awareness of clinicians to optimize preventive and therapeutic strategies.

Contrast-induced nephropathy in non-cardiac vascular procedures, a narrative review: Part 1

Contrast-induced nephropathy (CIN) is an important complication of iodinated contrast medium (CM) administration, which is associated with both short- and long-term adverse outcomes (e.g., cardiorenal events, longer hospital stay, and mortality). CIN has been mainly studied in relation to cardiac procedures, but it can also occur following non-cardiac vascular interventions. This is Part 1 of a narrative review summarizing the available literature on CIN after non-cardiac vascular diagnostic or therapeutic procedures for aortic aneurysm and carotid stenosis. We discuss the definition, pathophysiology, incidence, risk factors, biomarkers, and consequences of CIN in these settings, as well as preventive strategies and alternatives to limit iodinated CM use. Physicians and vascular surgeons should be aware of CM-related adverse events and the potential strategies to avoid them. Clearly, more research in this important field is required.

Partial Renal Coverage after Endovascular Aortic Aneurysm Repair with Suprarenal Fixation Seems Not to be Associated with Early Renal Impairment

BACKGROUND

Efforts to achieve optimal seal during endovascular aortic aneurysm repair (EVAR) may produce partial coverage of the lowest renal artery and in some cases even occlusion. This coverage might alter the renal ostial flow, which could finally affect renal function. We sought to evaluate the incidence of renal ostium coverage and its possible effects on renal function.

METHODS

All patients undergoing elective EVAR with suprarenal fixation devices between January 2014, and December 2017, at our institution were identified. Patients with preoperative and postoperative computed tomography angiography (CTA), as well as the preoperative, postoperative, and one year postintervention creatinine levels and estimated glomerular filtration rate (eGFR) were included in the present study. Patients in hemodialysis, with a preoperative eGFR <30 mL/min, urgent EVAR, neck adjunctive procedures, excessive aortic thrombus, or procedure-related reintervention were excluded.

RESULTS

A total of 127 patients received EVAR for aortoiliac aneurysmatic pathologies between January 2014, and December 2017. Forty-three of them met the inclusion criteria having a median follow-up of 18.8 months (range; 12.0-53.9). Twenty-six (60.5%) patients presented at least one criterion of hostile neck condition and 23 (53.5%) had a preoperative eGFR <60 mL/min. The average distance from the proximal endograft fabric to the lower renal artery was 1.5 mm (range, 0.0-6.0) while a total of 15 renal ostia (34.9%) suffered unintended partial coverage (range, 20 to 75% of the renal ostium) in the postoperative CTA. Nine of these patients (60%) had a hostile neck condition. Eight patients (18.6%) suffered significant deterioration (>20% of the eGFR), 27 patients (62.8%) maintained their renal function and 8 (18.6%) presented an improvement of the eGFR in the latest available blood sample. Renal function impairment showed no significant association with renal ostium coverage (P = 0.561), hostile neck condition (P = 0.973), or the diameter of the renal artery (P = 0.835). In the subgroup analysis, patients with the eGFR <60 mL/min did not show significantly greater renal function deterioration (P = 0.568).

CONCLUSIONS

Partial renal coverage is not an uncommon phenomenon occurring in one-third of the treated patients. However, it was not associated with renal function impairment in the early term. Further studies with longer follow-up are needed to confirm our results in the long haul.

Acute kidney injury after cardiac surgery: prevalence, impact and management challenges

Acute kidney injury (AKI) is a major medical problem that is of particular concern after cardiac surgery. Perioperative AKI is independently associated with an increase in short-term morbidity, costs of treatment, and long-term mortality. In this review, we explore the definition of cardiac surgery-associated acute kidney injury (CSA-AKI) and identify diverse mechanisms and risk factors contributing to the renal insult. Current theories of the pathophysiology of CSA-AKI and description of its clinical course will be addressed in this review. Data on the most promising renal protective strategies in cardiac surgery, from well-designed studies, will be scrutinized. Furthermore, diagnostic tools such as novel biomarkers of AKI and their potential utility will be discussed.