Risk factors for Late Renal Insufficiency Following Open and Endovascular Repair of Juxtarenal and Short-neck Infrarenal Aortic Aneurysms
Valerie Mai, MS, David Dexter, MD, Gordon Stokes, MD, Sadaf Ahanchi, MD, Sarah Ongstad, MD, Brandon Cain, MD, Obie Powell, MD, Niraj Parikh, MD, Jean Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
Objective: To determine factors influencing long-term renal function following open repair (OR) and endovascular aortic repair (EVAR) of primary juxtarenal and short-neck infrarenal Abdominal Aortic Aneurysms (AAA).
Methods: Records of patients who underwent OR and EVAR of juxtarenal and short-neck (<10mm) infrarenal AAA between January 2009 and October 2015 were evaluated. Late renal insufficiency was defined by an increase in creatinine >50% or a decrease in GFR by 25% measured preoperatively to the most recent follow-up. Variables influencing late renal insufficiency were evaluated by univariate chi-square analysis, independent sample t-tests, and Kaplan-Meier analysis.
Results: We identified 70 patients fitting our inclusion criteria with more than 6 months of follow-up. Of those, 27 received OR and 43 received EVAR. The average follow-up time was 27.36 months (6-62.6 months). Within the EVAR group, 20 were sealed in a short neck, 12 were fenestrated, and 11 received a renal chimney stent. The mean age was 74.5 years, 71% were men. The aneurysm was juxtarenal in 39 patients (55.7%) and infrarenal with short-neck in 31 (44.3%). Following repair, 51.9% of patients who underwent OR developed Acute Kidney Injury in contrast to 16.3% who received EVAR (p = 0.008). The rates of late renal insufficiency were 29.6% and 58.1% for the OR and EVAR groups respectively (p = 0.045). The need for hemodialysis was temporary for 3 patients (4%) and permanent for 6 (9%). Persistent renal insufficiency was significantly associated with preoperative chronic kidney disease (70% w and 30% w/o, p = 0.015), the presence of neck thrombus (57% vs 43%, p = 0.008), neck calcium (62% vs 38%, p = 0.008), and snorkel-chimney endovascular repair (91% vs 9%, p = 0.011). There was a significant correlation between long-term renal deterioration to postoperative renal artery occlusion (100% 7/7 vs 0% 0/63, p = 0.003) and the number of aortic-related re-interventions (mean 0.45 w/ and 0.16 w/o, p = 0.002). Long-term renal insufficiency was significantly related to mortality (p = 0.022).
Conclusions: Patients undergoing EVAR had lower rates of early renal insufficiency, however a higher rate of late renal insufficiency. Preoperative CKD, renal chimney stents, neck thrombus/calcium, postoperative renal artery occlusion, and multiple interventions also predicted long-term renal insufficiency. Incorporating these factors into the planning phase may decrease long-term renal dysfunction.
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