Fenestrated/Branched Endovascular Aortic Repair in Patients with Chronic Kidney Disease
Mitri Khoury, David Timaran-Montenegro, Marilisa Soto-Gonzalez, Carlos Timaran
Univ of Texas Southwestern Med Ctr, Dallas, TX
Renal function impairment is a common complication after open repair of complex abdominal aortic aneurysms (cAAAs) and thoracoabdominal aneurysms (TAAA). Fenestrated/ branched endovascular aneurysm repair (F-BEVAR) has emerged as an alternative to open repair with improved perioperative outcomes. The effects of chronic renal disease (CKD) on renal function after F-BEVAR has not been established. The purpose of this study was to assess renal perioperative outcomes and renal function deterioration after F-BEVAR in patients with CKD.
During a 6-year period, 186 patients (147 men [79%], and 39 women [21%]) underwent F-BEVAR using premanufactured devices, including the Zenith Fenestrated AAA Endovascular Grafts (78 [42%]), Zenith p-Branch (6 [3%]), investigational custom-made devices (87 [47%]) and off-the-shelf Zenith t-Branch device (15[8%]). Patients with suprarenal (49%), juxtarenal (22%), and type I-IV TAAAs (28%) were included. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) equation. Post-operative acute kidney injury (AKI) and CKD were defined using RIFLE criteria (Risk, Injury, Failure, Loss and End-stage renal disease) and the CKD stage system (CKD defined as stage >3, GFR < 60 ml/min/1.73m2), respectively. A GFR decline > 20% was considered as progression of CKD.
Median age of patients was 72 years (interquartile range [IQR], 67-77) with a median GFR of 77 ml/min/1.73m2 (IQR, 51-78 ml/min/1.73m2). CKD was present in 83 patients (45%), (21 women [25%] and 62 men [75%]. Among patients with CKD, median age was 72 years (IQR, 69-77 years) and the GFR was 49.8 ml/min/1.73m2 (IQR, 37-47 ml/min/1.73m2). Technical success was 100%. 30-day mortality was 0.5%. Post-operative AKI was diagnosed in 27 patients (14.5%); 13 (48%) had history of CKD and 14 (52%) had adequate renal function (p=0.8). None of these patients required permanent renal replacement therapy (RRT). Length of hospital stay among CKD patients was similar among patients with and without CKD (4 days [IQR, 2-56 days] versus 4 [IQR, 4-5 days] p=0.3). During a median follow-up time of 12 months (IQR 6-23 months), progression of CKD was observed in 38 patients (20%) with previous CKD and in 23 patients (12%) without CKD (p<0.01). Among patients with previous CKD, 18 patients (9%) progressed from stage 3 CKD to stage 4 whereas among patients without CKD, 18 patients (9%) progressed to stage 3 and 3 (6%) to stage 4. None required permanent RRT. In 2 patients (5%), renal stent stenosis required restenting. Among patients with progression of CKD, 13 had juxtarenal AAA (31%), 27 suprarenal (30%), 21 TAAA (29%)(p=0.4).
F-BEVAR is an effective and safe procedure for patients with CAAAs and TAAAs, even among patients with CKD. The frequency of AKI and length of stay was not affected by pre-existing CKD. Mid-term outcomes demonstrated that progression of CKD was more frequent among patients with preexisting CKD, but permanent RRT was not required. Anatomic extent of aneurysms did not affect CKD progression. Long-term effects of CKD after F-BEVAR remain to be elucidated.
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