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Comparative analysis of open and endovascular abdominal aortic aneurysm repair by chronic kidney disease severity
Nathan J. Aranson, M.D.1, Robert T. Lancaster, M.D.1, Emel Ergul, M.A.1, Shermerhorn L. Marc, M.D.2, Daniel J. Bertges, M.D.3, Mark F. Conrad, M.D.1, Richard P. Cambria, M.D.1, Patel I. Virendra, M.D.1.
1Massachusetts General Hospital, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Fletcher Allen, Burlington, VT, USA.

Introduction: Chronic kidney disease (CKD) has been shown to increase post-operative mortality, complications, and length of stay following abdominal aortic aneurysm (AAA) repair, however impact of repair type in patients with CKD is unknown. This study evaluated the outcomes of endovascular AAA (EVAR) and open AAA repair (OAR) in patients of varying CKD severity.
Methods: Patients in the Vascular Study Group of New England (VSGNE) registry who underwent EVAR or OAR for non-ruptured AAA from 2003 to 2013 were stratified by National Kidney Foundation CKD staging as having MILD (CKD class 0-1), MODERATE (CKD class 2-4), or SEVERE (CKD class 5-6) CKD. Comparative analysis was conducted with mortality as a primary endpoint as well as pre-operative factors and postoperative clinical outcomes as secondary endpoints.
Results: We identified 5101 patients who were treated with EVAR (n=3760; 74%) and OAR (n=1341; 26%). Distribution of MILD, MODERATE, and SEVERE CKD across the cohort was 70%, 26%, and 2% respectively; similar in both repair types (P=0.72). Variables associated with increasing CKD severity included age, ASA class 4/5, hypertension, diabetes, CAD, CHF, COPD, PVD, larger AAA, and urgent cases(P≤0.01; all variables). Post-operative death, renal failure, and 5-year survival rates are presented. (Table 1) Univariate outcomes were worse in patients with MILD or SEVERE CKD undergoing OAR, whereas outcomes were comparable for EVAR and OAR in patients with MODERATE CKD. Multivariable modeling however found that MODERATE(OR1.9[95%CI:1.04-3.6];P=0.02), SEVERE(OR4.9[95%CI:1.6-15.5];P=0.02), and OAR(OR2.3[95%CI:1.2-4.5];P<0.01) independently predicted operative mortality. Independent risk of renal failure was associated with MODERATE(OR3.0[95%CI:2.1-4.4];P<0.01), SEVERE(OR13.4[95%CI:6.8-26];P<0.01), and OAR(OR3.4[95%CI:2.3-4.9];P<0.01). Other independent predictors of operative mortality and acute renal failure included ASA class 4/5, CAD, and CHF. Cox proportional hazards modeling showed that MODERATE(HR1.2[95%CI:1.05-1.4];P<0.01) and SEVERE(HR2.6[95%CI:1.9-3.6];P<0.01)CKD increased risk of late death whereas procedure type did not affect survival (HR0.9[95%CI:0.7-1.3];P=0.8). Other independent predictors of late death included age, CAD, CHF, and COPD.
Conclusion: MODERATE and SEVERE CKD adversely impact early and late mortality following AAA repair therefore should be prominently considered in surgical decision making. In patients with CKD and AAA, EVAR is associated with lower morbidity and comparable late survival and should be the treatment of choice if anatomically feasible.
Post-operative Outcomes
MILD30-Day Mortality (%)0.71.5<0.05
Acute Renal Failure (%)0.20.6<0.05
5-year Survival (%; SE)78 (1.2)81 (1.5)0.5
MODERATE30-Day Mortality (%)
Acute Renal Failure (%)
5-year Survival (%; SE)65 (2.4)75 (2.6)<0.05
SEVERE30-Day Mortality (%)
Acute Renal Failure (%)1.425<0.05
5-year Survival (%; SE)44 (1.1)42 (1.3)0.7

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