A case-control study of intentional occlusion of accessory renal arteries during endovascular aortic aneurysm repair

Abstract

The purpose of this study was to evaluate outcomes of patients treated by intentional coverage of accessory renal artery (ARA) during endovascular abdominal aneurysm repair (EVAR). The clinical data of 119 patients (110 male and nine female; mean age, 75years) from a cohort of 811 patients treated by EVAR from 1998 to 2009 was reviewed. Patients who had intentional coverage of at least one ARA (group A) were compared with two control groups, which included patients with no ARA (group B) and those who had ARA preserved during EVAR (group C). All three groups of patients were matched for age, gender, hypertension, and preoperative estimated glomerular filtration rate (eGFR). Paired pre- and postoperative computed tomography angiography was analyzed for the presence and volume of kidney infarction. End points were changes in eGFR, chronic kidney disease (CKD) stage, blood pressure measurements, presence and volume of kidney infarction, freedom from reintervention, and endoleak. There were 42 patients in group A, 42 in group B, and 35 in group C. Demographics, cardiovascular risk factors, and CKD classification were similar in all three groups. Among patients in group A, 44 ARAs were intentionally covered with ARAs originating from the proximal neck in 22 patients, the aneurysm sac in 20, and the iliac arteries in two. There was one (1%) early death in the entire study. Early morbidity was similar in all three groups, including four patients (9%) in group A, four (9%) in group B, and four (11%) in group C (P= .9). Six (5%) patients had >25% decrease in eGFR, including two who had ARA coverage. None of the patients required dialysis. After a mean follow-up of 37months, there were no differences in late renal function deterioration, changes in eGFR, CKD stage, or blood pressure measurements among the three groups. Three of the 18 patients (17%) with ARA >3mm arising from the aneurysm sac developed a type II endoleak requiring coil embolization. Kidney infarction was noted in 28 patients (67%) in group A. Freedom from reintervention at 2years was similar in groups A (64%), B (80%), and C (96%; P= .09). Intentional ARA occlusion during EVAR was not associated with changes in renal function or blood pressure measurements, even when performed in patients with more advanced renal dysfunction. Type II endoleak may result from persistent outflow into large (>3mm) ARAs that arise from the aneurysm sac.