Impact of Aortic Wall Thrombus on Long-Term Changes in Renal Function Among Patients Treated by Fenestrated-Branched Endografts for Complex Aortic Aneurysms
Giuliano de A. Sandri, MD, Gustavo S. Oderich, MD, Mauricio Ribeiro, MD, PhD, Leonardo Reis de Souza, MD, Stephen Cha, MS, Thanila Macedo, MD, Stephen Textor, MD, Terri Vrtiska, MD.
Mayo Clinic, Rochester, MN, USA.
OBJECTIVES: Renal function deterioration (RFD) is an important determinant of mortality in patients treated for complex aortic aneurysms (CAAs). Catheter and guide-wire manipulations in diseased aortas during fenestrated-branched endovascular aortic repair (F-BEVAR) have been associated with risk of emboli leading to loss of renal function. The aim of this study was to describe the impact of atherosclerotic wall thrombus (AWT) on long-term RFD in patients treated by F-BEVAR for pararenal (PRA) and Extent IV thoracoabdominal aortic aneurysms (TAAAs).
METHODS: Clinical data of 212 patients treated for CAAs with F-BEVAR was entered into a prospectively maintained database (2007-2015). AWT was evaluated by computed tomography angiography (CTA) using volumetric measurements in non-aneurysmal aortic segments. AWT was classified as mild, moderate or severe using a score system based on thrombus extent, type, thickness, area and circumference. Patient survival and renal outcomes were assessed at dismissal, 6-8 weeks, 6 months and annually, including serum Creatinine, estimated Glomerular Filtration Rate (eGFR), Chronic Kidney Stage, RIFLE Criteria, need for renal replacement therapy (RRT) and presence of kidney infarction.
RESULTS: There were 169 male (80%) and 43 female (20%) patients with mean age of 75±7 years old. Aneurysm extent was PRA in 157 patients and Extent IV TAAA in 55. A total of 700 renal-mesenteric arteries were incorporated (3.1±1 vessels/patient). AWT was classified as mild in 98 patients (46%), moderate in 75 patients (35%) and severe in 39 patients (19%). At 30-days, 45 patients (21%) developed RFD (>30% decline in eGFR). Decline in eGFR and kidney infarction were associated with higher AWT volume index and severe AWT classification (P<0.05). There was no association of AWT with 30-day mortality, which was 0.5% for the entire cohort. Mean follow up was 29±23 months. Freedom from RFD was 73±6% for mild, 81±6% for moderate and 66±8% for severe AWT patients at 3-years (P=0.012). Patient survival was 73±5% for mild, 72±6% for moderate and 69±10% for severe AWT patients at 3-years (P=0.67)
CONCLUSIONS: Severe AWT is a significant predictor of kidney infarction, early and late decline in renal function among patients treated by F-BEVAR. Severe AWT had no impact on early and late patient survival. Pre-operative planning and decision-making should include careful assessment of AWT in patients with complex aortic aneurysms considered for F-BEVAR.
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