Renal Artery Coverage During Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm

Abstract

Coverage of one or both renal arteries may be required to facilitate endovascular aneurysm repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures. Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival. Overall, there were 2,278 patients presenting with ruptured aneurysms. Most patients had no renal artery coverage (n=2,230; 98%), followed by single renal artery coverage (n=30; 1.2%), and finally bilateral renal artery coverage (n=18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR]=5.7, ±4; P=0.030), permanent dialysis/30-day death (OR=9.5, ±7; P=0.016), and permanent dialysis (OR=47.5, ±47; P<0.001). Two patients with bilateral renal coverage did not suffer permanent dialysis/death. Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR=2.8, ±1.6; P=0.044) driven mainly by its effect on the outcome of permanent dialysis (OR=12.3, ±6; P<0.001). Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR]=3.4, P=0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR=3.5, P=0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models. Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.