Impact Of Intentional Covered Of Accessory Renal Arteries On Renal Function Among Patients Treated By Fenestrated-branched Endografts
Emanuel R. Tenorio, MD, PhD, Keouna Pather, BSc, Jussi M. Kärkkäinen, MD, PhD, Bernardo C. Mendes, MD, Radall R. DeMartino, MD, MS, Thanila A. Macedo, MD, Peter Gloviczki, MD, Gustavo S. Oderich, MD.
Mayo Clinic, Rochester, MN, USA.
Purpose: To evaluate the impact of intentional accessory renal artery (ARA) coverage on renal function after fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) or thoracoabdominal aortic aneurysm (TAAAs).
Methods: We analyzed the clinical data of 289 patients enrolled in a prospectively non-randomized study to evaluate outcomes of F-BEVAR between 2013-2018. Thirty-two patients with solitary kidneys were excluded. Outcomes were analyzed in patients with intentional ARA coverage and controls who had preservation of all renal arteries, including patients with no ARAs and those who had preservation of ARAs. Acute kidney injury (AKI) was defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease) and renal function deterioration (RFD) was determined by >30% decline in estimated glomerular filtration rate (eGFR). End-points included 30-day mortality and major adverse events (MAEs), AKI and freedom from RFD.
Results: There were 257 patients (183 male, mean age 75±8 years old) included in the study, 51 (20%) with ARA coverage (Ø=2.6±0.7mm) and 206 controls (13 with ARA preservation, Ø=3.5±0.5mm). There were no difference in demographics, cardiovascular risk factors and aneurysm extent. Technical success was achieved in all patients with ARA coverage and in 99% of controls (P=1.0). None of the two technical failures were attributed to the ARA incorporation. There were 2 (1%) deaths within 30-days, both among controls. Patients with ARA coverage had more MAEs (35% vs. 22%, p=.04) due higher incidence of AKI (22% vs. 10%, p=.03). None of the 13 patients who had ARA preservation developed AKI. Mean follow up was 18±15 months. At 3-years, there was no significant difference in freedom from RFD for ARA coverage and controls (65±9% vs. 73±5%, p=.08), respectively. By multivariate analysis, ARA coverage (OR 2.4, p=.03) was a predictor for AKI, and renal re-intervention for stenosis (OR 2.7, p=.007), Extent II TAAA (OR 3.3, p=.001) and post-procedure AKI (OR 5.0, p<.001) were predictors for RFD.
Conclusion: Intentional ARA covered during F-BEVAR was associated with twofold higher incidence of AKI, with a non-significant trend towards lower freedom from RFD. Factors associated with RFD included renal reinterventions for stenosis, Extent II TAAA and post-procedure AKI. Incorporation of ARAs during F-BEVAR, when technically feasible, may help decrease risk of AKI.
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