Impact of Chronic Kidney Disease and Acute Kidney Injury on Survival After Fenestrated-Branched Endovascular Aneurysm Repair for Thoracoabdominal Aortic Aneurysms

Abstract

Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) has extended the treatment of thoracoabdominal aortic aneurysms (TAAAs) to “high surgical risk” patients, including patients with chronic kidney disease (CKD). Previous studies have demonstrated that both CKD and acute kidney injury (AKI) are associated with decreased survival after open TAAA repair. The purpose of this study was to assess the impact of CKD and AKI on survival after F/B-EVAR. A total of 105 patients with TAAAs, enrolled in a prospective physician-sponsored investigational device exemption study (G130193) from 2014 to 2019, were analyzed. Data were collected prospectively and audited by an independent external monitor. All patients were treated with Cook manufactured patient-specific F/B-EVAR devices or the Cook t-Branch device (Cook Medical, Bloomington, Ind). CKD was defined as CKD stage 3 to stage 5 without hemodialysis, and a single patient receiving hemodialysis preoperatively was excluded. AKI was determined within 48 hours and at 30 days postoperatively using RIFLE criteria (“risk” or “injury”). Survival was analyzed using Kaplan-Meier analysis, and associated factors were identified using Cox proportional hazards model. Risk factors for AKI were analyzed using logistic regression. Of 105 patients who underwent F/B-EVAR, 46 (43.8%) had CKD. Overall 30-day mortality was 3.81% (4/105). Whereas freedom from 30-day mortality was significantly lower in CKD patients (91.4% vs 100%; P = .02), 2-year survival was not different between CKD and non-CKD patients (78.3% vs 91.5%; P = .12). AKI occurred in 34 patients (32.4%), and there was no difference in survival at 30 days (94.1% vs 97.2%; P = .47) or at 2 years (73.5% vs 91.5%; P = .08) in patients with and without AKI, respectively. CKD patients who developed AKI after F/B-EVAR (CKD + AKI) had significantly lower 2-year survival in comparison to patients without AKI (±CKD; 58.8% vs 90.9%; P = .008; Fig). Multivariable analysis identified CKD + AKI (hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.04-10.07; P = .04) and intraoperative blood loss (HR, 1.001; 95% CI, 1.00-1.001; P = .04) as risk factors for decreased 2-year survival. Increased procedure time was an independent risk factor for AKI (HR, 1.01; 95% CI, 1.00-1.001; P = .04). CKD, sex, renal artery diameter, renal artery stenosis ≥50%, contrast material volume, and intraoperative blood loss showed no significant correlation with AKI. Patients with CKD have increased perioperative mortality after F/B-EVAR but similar 2-year survival compared with patients without CKD. AKI occurs frequently after F/B-EVAR, and patients with pre-existing CKD who develop AKI after F/B-EVAR have markedly worse 2-year survival. Further studies focused on identification of risk factors for AKI and development of strategies to prevent AKI during F/B-EVAR are necessary and may significantly improve patient outcomes.