Impact of chronic kidney disease and end stage renal disease on outcomes after Complex Endovascular and Open 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 aortic aneurysms (AAA). However, there is paucity of data in complex aortic aneurysm repair that involves the visceral segment of the aorta. This study stratifies outcomes of complex aortic aneurysm repair by CKD severity and dialysis dependence. Methods: All patients undergoing elective complex open aneurysm repair (OAR) and fenestrated/branched endovascular aortic repair (F-BEVAR) 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) and ESRD. For OAR, only patients with clamp site at least above one of the renal arteries were included. For F-BEVAR, patients with proximal landing zone below zone 5 were included and distal landing zones between zone 1 to 5 were excluded. Primary outcomes were perioperative and 1- year mortality. Predictors of mortality were identified by cox multivariate regression models.Results: Out of 6,980 patients who underwent elective complex aortic aneurysm repair, 4230 had OAR and 2750 had F-BEVAR. The 30-day and 1-year mortality for all CKD stages and ESRD are represented in Table 1. Patients with moderate CKD had better mortality at 1 year with OAR than with FEVAR. Of note however, patients undergoing FEVAR in this group were older, and had higher incidence of comorbidities such as COPD, diabetes, coronary artery disease and congestive heart failure. On Kaplan Meier analysis (Figure 1), 1-year survival favored the normal cohort compared to the moderate CKD, severe CKD and ESRD groups after both OAR and F-BEVAR. Factors independently associated with increased mortality at 1 year in the F-BEVAR group were moderate CKD (OR, 3.56 [1.2-2.1]; p<0.001), severe CKD (OR, 2.13 [1.05-3.6]; p=0.03), ESRD (OR, 3.32 [1.7-7.5]; p=0.001), female gender (OR, 2.09 [1.0-1.7]; p=0.03), oxygen dependent COPD (OR, 4.8 [1.8-4.1]; p=0.000) and previous myocardial infarction (MI) (OR, 2.2 [1.5-7.8]; p=0.025). Factors independently associated with increased mortality at 1 year in the OAR group were severe CKD (OR, 4.04 [1.6-4.5]; p<0.001), older age (OR, 7.92 [1.05-1.08]; p<0.001) and oxygen dependent COPD (OR, 3.2 [1.4-4.1]; p=0.001).
Conclusion: CKD severity is an important predictor of perioperative and 1-year mortality after complex AAA repair irrespective of the treatment modality and this may reflect the natural history of CKD. Consideration should be given to raising the threshold for elective AAA repair in patients with moderate to severe CKD and ESRD given the high 1-year mortality rate.
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