Abstract
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.All consecutive patients undergoing (elective and non-elective) F-BEVAR at a single centre (1 January 2011 - 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/1.73m2.Overall, 202 consecutive patients (mean age 72 ± 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 = .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 = .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 = .020). In a multivariable analysis CKD was independently associated with higher odds of peri-operative AKI (OR 2.8, 95% CI 1.9 - 5.8, p = .030), renal function decline (OR 4.9, 95% CI 1.7 - 9.2, p = .003), and all cause mortality (HR 3.2, 95% CI 1.2 - 8.6, p = .020).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.
Highlights
IntroductionEndovascular techniques have continued to gain popularity over the last two decades, mainly because of their reduced invasiveness compared with open surgical repair, and especially in high risk surgical candidates.[1,2] Fenestratedbranched endovascular aortic repair (F-BEVAR) is a lessMario D’Oria et al.invasive method to treat pararenal (PRAA) and thoracoabdominal (TAAA) aneurysms, which is regarded as the first line treatment for repair of complex aortic pathology in patients with suitable anatomy, even more so in those deemed unsuitable for open surgical repair because of high comorbidity burden and poor health status.[3,4] The avoidance of prolonged visceral and renal ischaemia during the procedure may reduce the morbidity that ensues from bowel ischaemia and acute kidney injury (AKI) after open surgical repair of extensive aortic disease, which will in turn substantially increase peri-operative morbidity.From prior studies, it is known that presence of preoperative chronic kidney disease (CKD) may significantly worsen the early and late outcomes after both open or endovascular treatment of aortic disease.5e7 Currently, there is a paucity of data that have examined the impact of pre-operative CKD on early and late morbidity and mortality after complex endovascular aortic procedures
Invasive method to treat pararenal (PRAA) and thoracoabdominal (TAAA) aneurysms, which is regarded as the first line treatment for repair of complex aortic pathology in patients with suitable anatomy, even more so in those deemed unsuitable for open surgical repair because of high comorbidity burden and poor health status.[3,4]
It is known that presence of preoperative chronic kidney disease (CKD) may significantly worsen the early and late outcomes after both open or endovascular treatment of aortic disease.5e7 Currently, there is a paucity of data that have examined the impact of pre-operative CKD on early and late morbidity and mortality after complex endovascular aortic procedures
Summary
Endovascular techniques have continued to gain popularity over the last two decades, mainly because of their reduced invasiveness compared with open surgical repair, and especially in high risk surgical candidates.[1,2] Fenestratedbranched endovascular aortic repair (F-BEVAR) is a lessMario D’Oria et al.invasive method to treat pararenal (PRAA) and thoracoabdominal (TAAA) aneurysms, which is regarded as the first line treatment for repair of complex aortic pathology in patients with suitable anatomy, even more so in those deemed unsuitable for open surgical repair because of high comorbidity burden and poor health status.[3,4] The avoidance of prolonged visceral and renal ischaemia during the procedure may reduce the morbidity that ensues from bowel ischaemia and acute kidney injury (AKI) after open surgical repair of extensive aortic disease, which will in turn substantially increase peri-operative morbidity.From prior studies, it is known that presence of preoperative chronic kidney disease (CKD) may significantly worsen the early and late outcomes after both open or endovascular treatment of aortic disease.5e7 Currently, there is a paucity of data that have examined the impact of pre-operative CKD on early and late morbidity and mortality after complex endovascular aortic procedures. Endovascular techniques have continued to gain popularity over the last two decades, mainly because of their reduced invasiveness compared with open surgical repair, and especially in high risk surgical candidates.[1,2] Fenestratedbranched endovascular aortic repair (F-BEVAR) is a less. Invasive method to treat pararenal (PRAA) and thoracoabdominal (TAAA) aneurysms, which is regarded as the first line treatment for repair of complex aortic pathology in patients with suitable anatomy, even more so in those deemed unsuitable for open surgical repair because of high comorbidity burden and poor health status.[3,4] The avoidance of prolonged visceral and renal ischaemia during the procedure may reduce the morbidity that ensues from bowel ischaemia and acute kidney injury (AKI) after open surgical repair of extensive aortic disease, which will in turn substantially increase peri-operative morbidity. Recent studies have suggested that a major contraindication for open surgical repair, baseline renal dysfunction may not be as prohibitive a risk factor for endovascular repair in patients with history of CKD.[8]
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