Risk of renal failure and death when renal arteries are involved in endovascular aortic aneurysm repair

Postoperative renal complications following open juxtarenal aortic aneurysm repair adversely impact midterm survival

OBJECTIVE

Juxtarenal aortic aneurysms present a challenge for endovascular treatment. Although renal dysfunction after open repair has been associated with lower short-term survival, the relationship between postoperative kidney function and midterm outcomes such as rupture, reintervention, and mortality remains unclear. This study investigates the association between postoperative renal function and these outcomes.

METHODS

We conducted a retrospective cohort study using data from the Society for Vascular Surgery Vascular Quality Initiative linked to Medicare claims through the Vascular Implant Surveillance and Interventional Outcomes Network (VISION). Patients who underwent elective open repair of juxtarenal aortic aneurysms between January 2003 and December 2018 (N = 1925) were included. Patients were stratified based on postoperative renal function: stable renal function; acute kidney injury (AKI), as defined by a ≥0.5 mg/dL increase in baseline serum creatinine level; or need for renal replacement therapy (RRT). Primary outcomes included 5-year mortality, rupture, and reintervention, and secondary outcomes were immediate postoperative complications. Multivariable logistic regression, Kaplan-Meier analysis, and Cox regression modeling were used.

RESULTS

Among the 1925 patients, 74% had stable postoperative renal function, 21% developed AKI, and 4.9% required RRT. Worse renal outcomes were associated with longer renal ischemia times, higher proximal aortic clamping, and renal artery bypass. Postoperative, 30-day mortality was highest in the RRT group, along with higher rates of cardiac, respiratory, and intestinal ischemic complications (P < .001). Patients requiring RRT had higher risks of subsequent aortic aneurysm-related reintervention (adjusted hazard ratio [aHR]: 2.4; 95% confidence interval [CI]: 1.1-5.1; P = .03) and midterm (1-, 3-, and 5-year follow-up) mortality (aHR: 2.2; 95% CI: 2.1-5.1; P < .001) compared with those with stable renal function. Patients with AKI also had higher midterm mortality (aHR: 1.5; 95% CI: 1.1-2.0; P = .01). No significant differences in aneurysm rupture were observed between groups.

CONCLUSIONS

Postoperative patients who required RRT were associated with increased midterm aortic reinterventions and mortality after open juxtarenal aneurysm repair. Patients demonstrating any degree of renal impairment were associated with higher midterm mortality risk, though rupture rates and rates of reintervention demonstrated no difference.

A prospective randomized trial of remote renal ischemic preconditioning for reducing nephropathy risk following fenestrated endovascular aortic aneurysm repair

OBJECTIVES

We sought to evaluate whether remote renal ischemic preconditioning is effective for reducing postoperative acute kidney injury (AKI) and mid-term renal function decline in patients undergoing elective fenestrated endovascular aneurysm repair (FEVAR) of juxtarenal aortic aneurysms.

METHODS

We performed a single-site, blinded, prospective randomized trial of a renal ischemic preconditioning intervention using arm ischemia via manual inflation of arm blood pressure cuff. We evaluated 30-day AKI, determined using the Risk, Injury, Failure, loss of Function, and End-stage (RIFLE) classification and 2-year freedom from renal function decline, defined as a >30% decrease in baseline estimated glomerular function rate. The study was powered to detect a >25% difference in renal injury incidence.

RESULTS

We enrolled 80 patients (80% male; mean aneurysm diameter, 6.1 cm) who were undergoing elective FEVAR using Cook ZFEN devices between July 2018 and August 2023. The 30-day follow-up rate was 95.0%, and mean follow-up duration was 20.2 ± 14.6 months. Although there was a trend to older patient age in the treatment group (77.4 ± 7.8 years vs 74.1 ± 7.0 years), this difference did not reach statistical significance (P = .05). The mean baseline estimated glomerular function rate and creatinine were 69.8 ± 21.0 mL/min/1.73 m2 and 1.1 ± 0.4 mg/dL respectively, and 30.0% had chronic kidney disease stage ≥3. There were no differences in any other baseline or operative metrics between the groups. The rate of AKI at 30 days was 11.3% overall (risk, 7.5%; injury, 2.5%; failure, 1.3%) and did not differ between groups. There were no 30-day deaths. There was no difference in 2-year freedom from renal function decline between treatment groups (56.2% vs 81.1%; log-rank P = .12).

CONCLUSIONS

Renal ischemic preconditioning using arm ischemia did not confer a 30-day AKI or mortality or long-term renal protection benefit in patients undergoing elective FEVAR.