Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure

Abstract

Objective Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome. Methods Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients’ demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease. Results Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m2 (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001). Conclusions Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients’ risk factors that might contribute to postoperative ARF.

Risk Factors for Acute Renal Failure After Endovascular Aneurysm Repair

“…Our finding of a 2-fold increased risk has been seen in other studies though the mechanism for this has yet to be determined. 8,11 Clearly, future studies will be needed to both help delineate the risk factors for temporary vs permanent dialysis and mitigate this gender disparity.…”

“…4,5 Unfortunately, risk factors for AKI after EVAR are not often agreed upon, and most studies exclude patients undergoing EVAR for rupture. [6][7][8] In addition, there are variable definitions of AKI after EVAR, ranging from small increases in serum creatinine to decreased postoperative urine output, and change in glomerular filtration rates. [8][9][10][11][12][13] While some of these definitions are based on established criteria such as the RIFLE, AKIN, or KDIGO staging systems, there is still variability in how this affects clinical outcomes.…”

“…[6][7][8] In addition, there are variable definitions of AKI after EVAR, ranging from small increases in serum creatinine to decreased postoperative urine output, and change in glomerular filtration rates. [8][9][10][11][12][13] While some of these definitions are based on established criteria such as the RIFLE, AKIN, or KDIGO staging systems, there is still variability in how this affects clinical outcomes. 2,10,12,13 Previous studies have shown decreased renal function to negatively impact both shortand long-term survival after EVAR.…”

Predictors of in-hospital adverse events after endovascular aortic aneurysm repair

“…Suprarenal fixation, concomitant interventions, and renal artery stenting had been previously implicated in adverse renal outcomes. [38][39][40] The effect of contrast material is closely related to preoperative GFR. Nyman et al 41 proposed that a contrast material concentration to estimated GFR ratio can estimate the risk for development of contrast-induced nephropathy after interventional procedures.…”

Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference

“…Notably, concurrent treatment of RAS during endovascular aortic aneurysm repair is considered a high-risk procedure because of a high incidence of adverse kidney outcomes, including AKI, progressive kidney function decline, and stent occlusion. 81 , 82 …”