Impact of Intentional Coverage of Accessory Renal Arteries on Renal Function Among Patients Treated by Fenestrated-Branched Endografts

Abstract

The objective of this study was to evaluate the impact of intentional accessory renal artery (ARA) coverage on renal function after fenestrated-branched endovascular aneurysm repair (F-BEVAR) for pararenal aneurysm or thoracoabdominal aortic aneurysm (TAAA). We analyzed the clinical data of 289 patients enrolled in a prospectively nonrandomized study to evaluate outcomes of F-BEVAR between 2013 and 2018. Thirty-two patients with solitary kidneys were excluded. Outcomes were analyzed in patients with intentional ARA coverage and controls who had preservation of all renal arteries, including patients with no ARAs and those who had preservation of ARAs. Acute kidney injury (AKI) was defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease), and renal function deterioration (RFD) was determined by >30% decline in estimated glomerular filtration rate. End points included 30-day mortality and major adverse events, AKI, and freedom from RFD. There were 257 patients (183 male; mean age, 75 ± 8 years) included in the study, 51 (20%) with ARA coverage (Ø = 2.6 ± 0.7 mm) and 206 controls (13 with ARA preservation; Ø = 3.5 ± 0.5 mm). There were no differences in demographics, cardiovascular risk factors, and aneurysm extent. Technical success was achieved in all patients with ARA coverage and in 99% of controls (P = 1.0). Neither of the two technical failures was attributed to the ARA incorporation. There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (35% vs 22%; P = .04) due to higher incidence of AKI (22% vs 10%; P = .03). None of the 13 patients who had ARA preservation developed AKI. Mean follow-up was 18 ± 15 months. At 3 years, there was no significant difference in freedom from RFD for ARA coverage and controls (65% ± 9% vs 73% ± 5%; P = .08), respectively. By multivariate analysis, ARA coverage (odds ratio [OR], 2.4; P = .03) was a predictor for AKI, and renal reintervention for stenosis (OR, 2.7; P = .007), extent II TAAA (OR, 3.3; P = .001), and postprocedure AKI (OR, 5.0; P < .001) were predictors for RFD. Intentional ARA covered during F-BEVAR was associated with twofold higher incidence of AKI, with a nonsignificant trend toward lower freedom from RFD. Factors associated with RFD included renal reinterventions for stenosis, extent II TAAA, and postprocedure AKI. Incorporation of ARAs during F-BEVAR, when technically feasible, may help decrease risk of AKI.