Impact of chronic kidney disease and end stage renal disease on outcomes after Endovascular and Open Infrarenal Abdominal Aortic Aneurysm repair
Carla K Scott, Jesus Porras Colon, Alejandro Pizano Umana, Anna L Driessen, Tyler Miller, Carlos H Timaran, John G Modrall, Shirling Tsai, Melissa L Kirkwood, Bala Ramanan
UT Southwestern Medical Center, Dallas, TX
Objectives: Chronic kidney disease (CKD) and end stage renal disease (ESRD) are traditionally associated with worse outcomes after endovascular and open repair of abdominal aortic aneurysm (AAA). This study stratifies outcomes of AAA repair by CKD severity and dialysis dependence. Methods: All patients undergoing elective infrarenal open aneurysm repair (OAR) and endovascular aortic repair (EVAR) with preoperative renal function data captured by the Vascular Quality Initiative (VQI) between January 2003 and September 2020 were analyzed. Patients were stratified by CKD class as follows: normal/ mild (CKD 1 and 2), moderate (CKD class 3), severe (CKD class 4 and 5), ESRD. Primary outcomes were perioperative and 1-year mortality. Predictors of mortality were identified by cox multivariate regression models.Results: Out of 61,632 patients who underwent elective AAA repair, 13,685 had OAR and 47, 947 had EVAR. Table 1 demonstrates the distribution of patients, 30-day and 1-year mortality after OAR and EVAR. On Kaplan Meier analysis (Figure 1), 1-year survival favored the normal/mild CKD cohort compared to the moderate, severe CKD and ESRD groups after both OAR and EVAR. On cox regression analysis, when compared to normal/ mild CKD, worsening CKD stage (moderate CKD: HR, 5.15 [1.2-1.4], p <0.001, severe CKD: HR, 11.9 [2.5-3.5], p <0.001) and ESRD (HR, 12.11 [3.3-5.1], p <0.001) independently predicted 1-year mortality after EVAR. After OAR, worsening CKD stage but not ESRD was an independent predictor of 1- year mortality compared to normal/ mild CKD (moderate CKD: HR, 2.12 [1.02-1.8], p =0.034, severe CKD: HR, 4.68 [1.9-5.1], p <0.001). Conclusion: CKD severity is an important predictor of perioperative and 1-year mortality after infrarenal AAA repair irrespective of the treatment modality and may reflect the natural history of CKD. Open repair is associated with a prohibitive perioperative mortality risk in patients with severe CKD and ESRD. Consideration should be given to raising the threshold for elective AAA repair in these patients. 
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