Editor's Choice – Pre-Operative Moderate to Severe Chronic Kidney Disease is Associated with Worse Short-Term and Mid-Term Outcomes in Patients Undergoing Fenestrated-Branched Endovascular Aortic Repair

Abstract

WHAT THIS PAPER ADDS Analysis of 202 consecutive patients treated with fenestrated-branched endovascular repair (F-BEVAR) for pararenal and thoraco-abdominal aortic aneurysms showed that, despite similarly low peri-operative mortality, subjects with a history of moderate to severe chronic kidney disease (CKD) have higher rates of acute kidney injury than those with unimpaired renal function. Prior CKD was independently associated with renal function decline and poorer survival at midterm follow up. Presence of pre-operative moderate to severe CKD must be considered during decision making for complex endovascular aortic interventions, and efforts made to optimise outcomes in the immediate peri-operative period as well as in the long term.Objective: To review experience of fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal/ thoraco-abdominal aortic aneurysms (PRAA/TAAA) and to assess the association between pre-operative moderate to severe chronic kidney disease (CKD) and post-operative outcomes. Methods: All consecutive patients undergoing (elective and non-elective) F-BEVAR at a single centre (1 January 2011 e 1 July 2019) were identified. Renal function was calculated as the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. Accordingly, presence of moderate to severe CKD was defined as eGFR < 60 mL/min/1.73m 2 . Results: Overall, 202 consecutive patients (mean age 72 AE 8 years; 25% women) underwent F-BEVAR for the treatment of PRAA/TAAA during the study period. Of these, 51 had a history of moderate to severe CKD (none on chronic haemodialysis). No statistically significant differences were found in demographics and major comorbidities between patients with or without a history of CKD. The overall peri-operative mortality rate was 2%, without statistically significant differences between study groups (p ¼ .26). Patients with prior CKD had statistically significantly higher rates of acute kidney injury (AKI) (37% vs. 12%, p < .001). At three years, overall survival was statistically significantly lower in patients with history of CKD compared with those without pre-operative CKD (57% vs. 82%, p ¼ .010). Similarly, freedom from renal function decline at three years was statistically significantly poorer in patients with prior history of CKD compared with those without pre-operative CKD (43% vs. 80%, p ¼ .020). In a multivariable analysis CKD was independently associated with higher odds of peri-operative AKI (OR 2.8, 95% CI 1.9 e 5.8, p ¼ .030), renal function decline (OR 4.9, 95% CI 1.7 e 9.2, p ¼ .003), and all cause mortality (HR 3.2, 95% CI 1.2 e 8.6, p ¼ .020). Conclusion: Despite low peri-operative mortality rates that are comparable to patients with unimpaired renal function, occurrence of AKI was statistically significantly higher in subjects with pre-existing moderate to severe CKD. History of CKD was independently associated to renal function decline and poorer midterm survival.

European Multicentric Experience With Fenestrated-branched ENDOvascular Stent Grafting After Previous FAILed Infrarenal Aortic Repair

“…Indeed, the pooled rate of perioperative morbidity is comparatively low in light of some of the contemporary series of surgical conversion after EVAR, [18][19][20] as well as recent series of complex endovascular repair for native aortic aneurysms. 21,22 This supports the adoption of F-BEVAR as the first-line treatment for rescue of postinfrarenal AAA repair failures, provided the anatomy is suitable, although open surgical conversion may still be needed in selected circumstances including cases of graft infection as suggested by contemporary experts opinion and clinical practice guidelines. 23,24 The similar rates of technical success and 5-year survival rates between study groups in the present report would suggest an analogous undertaking, but there are differences that deserve further consideration.…”

“…In that sense, the presented cohort is the largest of its kind to date, and the inclusion of an almost equal number of pEVAR and pOAR patients offers important insights in future treatment considerations. Indeed, the pooled rate of perioperative morbidity is comparatively low in light of some of the contemporary series of surgical conversion after EVAR, 18–20 as well as recent series of complex endovascular repair for native aortic aneurysms 21,22 . This supports the adoption of F-BEVAR as the first-line treatment for rescue of postinfrarenal AAA repair failures, provided the anatomy is suitable, although open surgical conversion may still be needed in selected circumstances including cases of graft infection as suggested by contemporary experts opinion and clinical practice guidelines 23,24 …”

Role of CTA Surveillance for Management of Endovascular Repair of Aortic Dissection

“…Patients suffering from severe impairment of renal function (GFR<30 ml/min) showed significantly higher rates of all-cause mortality compared with patients with preserved kidney function. The relationship between increased mortality and severity of renal impairment is widely established and has been proven in several studies [Grundmann 2021;Blumenfeld 2022;D'Oria 2021]. The link between renal impairment and survival also underlines the importance of reducing the amount of potentially nephrotoxic contrast agent applications by e.g., avoiding less relevant CTA examinations.…”

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

“…The revascularization of the renal and visceral arteries during complex aortic surgery entails arterial reconstruction and periods of inherent ischemia until the repair is completed; this can contribute to a variety of complications, whose severity may range from mild to life or organ threatening events with fatal consequences [ 81 ]. Prior studies have shown that the overall incidence of ischemic complications may be intrinsically higher in F/BEVAR procedures as compared with standard EVAR, owing to the higher complexity of such procedures [ 82 ]. The incidence of acute kidney injury (AKI) has been shown to be higher for patients with pre-existing chronic kidney disease (CKD), as defined by eGFR <60 mL/min/1.73 m 2 , compared to those patients with unimpaired renal function (12% vs. 37%, p < 0.001).…”