Late outcomes of endovascular aortic stent graft therapy in patients with chronic kidney disease

Outcomes of Thoracic and Complex Endovascular Aortic Repair in Patients with Renal Insufficiency

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (cEVAR) are effective and minimally invasive treatment options for preventing rupture and decreasing mortality of aortic aneurysms. Patients with renal insufficiency are prone to worse postoperative cardiovascular morbidity and mortality due to the atherosclerosis burden as well as increased levels of angiotensin II. Nonetheless, knowledge about the outcomes of aortic stent graft therapy in patients with chronic kidney disease (CKD) or dialysis is scarce. This study aimed to examine outcomes after TEVAR and cEVAR in patients on CKD and dialysis.

METHODS

Utilizing data from the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database, we retrospectively evaluated patients who underwent TEVAR or cEVRA from 2010 to 2018. Patients were divided into patients with no CKD or dialysis, CKD patients, and dialysis patients. Outcomes were in-hospital stroke, myocardial infarction (MI), spinal cord ischemia (SCI), 30-day mortality, one-year mortality, aneurysmal rupture, and reintervention. In-hospital outcomes were assessed using multivariable logistic regression analysis and one-year outcomes were evaluated using kaplan Meier Survival and Cox regression analyses.

RESULTS

A total of 4,867 patients were included in the study, 2,694 had no CKD or dialysis, 2,047 had CKD, and 126 were on dialysis. Dialysis patients were significantly younger, and more likely to be non-white and of Hispanic/Latino origin. They were also more likely to have medical comorbidities. CKD patients had higher odds of in-hospital MI (OR: 2.02, 95%CI (1.43-2.86), P<0.001) and 30-day mortality (OR: 1.56, 95%CI (1.18-2.07), P<0.001) compared to patients with no CKD or dialysis. Dialysis patients had higher odds of 30-day mortality (OR: 3.31, 95%CI (1.73-6.35), P<0.001). At one year, dialysis was associated with a higher risk of mortality (HR: 3.48, 95%CI (2.39-5.07), P<0.001) and reintervention (HR: 1.72, 95%CI (1.001-2.94), P<0.049). CKD was associated with a higher risk of mortality (HR: 1.45, 95%CI (1.21-1.75), P<0.001) compared to patients with no CKD or dialysis.

CONCLUSIONS

Among patients undergoing TEVAR or cEVAR, there was no significant difference in the risk of in-hospital stroke, SCI, and one-year aneurysmal rupture among dialysis and CKD patients compared to patients with no CKD or dialysis. However, CKD patients had twice the risk of in-hospital MI. Dialysis patients had a higher risk of 1-year reintervention. Both dialysis and CKD patients had a higher risk of 30-day and 1-year mortality.

Outcomes of Endovascular Treatment for Infective Aortic Aneurysms - A Multicenter Retrospective Study

BACKGROUND

In Taiwan, infective native aortic aneurysms (INAAs) are relatively common, so the aim of present study was to demonstrate the comparative outcomes of endovascular repair for thoracic and abdominal INAAs.

METHODS AND RESULTS

Patients with naïve thoracic or abdominal INAAs managed with endovascular repair between 2001 and 2018 were included in this multicenter retrospective cohort. The confounding factors were adjusted with propensity score (PS). Of the 39 thoracic and 43 abdominal INAA cases, 41 (50%) presented with aneurysmal rupture, most of which were at the infrarenal abdominal (n=35, 42.7%) or descending thoracic aorta (n=25, 30.5%). Salmonella spp. was the most frequently isolated pathogen. The overall in-hospital mortality rate was 18.3%. The risks of in-hospital death and death due to rupture were significantly lower with thoracic INAAs (12.8% vs. 23.3%; PS-adjusted odds ratio (OR) 0.24, 95% confidence interval (CI) 0.06-0.96; 0.1% vs. 9.3%; PS-adjusted OR 0.11, 95% CI 0.01-0.90). During a mean follow-up of 2.5 years, the risk of all-cause death was significantly higher with thoracic INAAs (35.3% vs. 15.2%; PS-adjusted HR 6.90, 95% CI 1.69-28.19). Chronic kidney disease (CKD) was associated with death.

CONCLUSIONS

Compared with thoracic INAAs, endovascular repair of abdominal INAAs was associated with a significantly higher in-hospital mortality rate. However, long-term outcomes were worse for thoracic INAAs, with CKD and infections being the most important predictor and cause of death, respectively.

Selection criterion for endovascular aortic repair in those with chronic kidney disease

OBJECTIVE

Endovascular aortic repair (EVAR) is the preferred method of repair for abdominal aortic aneurysms (AAAs). However, patients with advanced chronic kidney disease (CKD) are a high-risk group, and it is unknown which patients with CKD benefit from EVAR vs continued surveillance. The purpose of this study was to identify which patients with advanced CKD may benefit from EVAR.

METHODS

The Vascular Quality Initiative Database was utilized to identify elective EVARs for AAAs. Patients were excluded if they underwent urgent or emergent repairs. CKD stages were categorized based on preoperative estimated glomular filtration rate (eGFR) and dialysis status. Predicted 1-year mortality of untreated AAAs was calculated by modifying a validated comorbidity score that predicts 1-year mortality (Gagne Index) without repair. The primary outcome was actual 1-year mortality, which was compared with the predicted 1-year mortality without repair.

RESULTS

A total of 34,926 patient met study criteria. There were differences in Gagne Indices among the varying classes of CKD. Patients with CKD 4 and CKD 5 had the highest 1-year mortality rates, followed by CKD 3b, which was significantly higher than those with CKD 1 and CKD 2. Patients with CKD 4 had no differences between actual 1-year mortality with EVAR and predicted 1-year survival without EVAR across all AAA sizes. Those with CKD 5 had worse actual 1-year survival with EVAR than predicted 1-year survival without EVAR for AAAs <5.5 cm. Patients with CKD 5 only experienced an actual mortality benefit with EVAR compared with predicted 1-year mortality without EVAR for AAAs ≥7.0 cm.

CONCLUSION

The current data suggest that patients with CKD 3b, 4, and 5 represent a high-risk group who may not benefit from elective EVAR utilizing traditional size criteria. Patients with CKD 4 and 5 with AAAs <5.5 cm do not benefit from elective EVAR. In patients with CKD 5, elective EVAR may need to be reserved for AAAs ≥7.0 cm unless there are other concerning anatomic characteristics.

One-year sac regression is associated with freedom from fatal adverse events after endovascular aneurysm repair

OBJECTIVE

Although the predictors of long-term prognosis after endovascular aneurysm repair (EVAR) have been investigated, several reports have suggested that early sac shrinkage (ESS) is associated with superior long-term prognosis. However, it was not clear whether ESS was associated with aneurysm-related mortality. The aim of this study was to define fatal adverse events and to examine their association with ESS.

METHODS

All consecutive patients who underwent EVAR for an abdominal aortic aneurysm at Nagoya University Hospital between June 2007 and August 2018 were identified. We defined ESS as an aneurysm diameter decrease of 10 mm or more at 1 year after EVAR, and we defined fatal adverse events as aneurysm-related death, aneurysm sac rupture, open conversion, secondary type Ia endoleak, or secondary type IIIa/b endoleak. Then, we evaluated the association between ESS and fatal adverse events and identified predictors of ESS.

RESULTS

During the study period, 553 patients were identified and included. Fatal adverse events occurred in 42 patients (7.6%), and the details of the fatal adverse events were as follows: 13 aneurysm-related deaths, 17 aneurysm sac ruptures, 14 open conversions, 13 type Ia endoleaks, and 6 type III endoleaks. ESS occurred in 146 patients (26.4%). Kaplan-Meier curves showed that the ESS group had a significantly lower incidence of fatal adverse events (P < .001). Multivariate analysis showed that there were significant differences in terms of 5 or more preoperatively patent lumbar arteries (odds ratio [OR], 0.67; P = .049; 95% confidence interval [CI], 0.45-1.00), chronic kidney disease (OR, 0.49; P < .01; 95% CI, 0.29-0.84), and Zenith endograft use (OR, 1.76; P < .01; 95% CI, 1.16-2.67). Furthermore, the percentage of cases that achieved an aneurysm diameter of less than 40 mm was significantly higher in the ESS group (76.0% vs 15.5%; P < .01). The use of Zenith endografts showed a significantly higher rate of aneurysm disappearance than the use of Endurant endografts (P < .01) and Excluder endografts (P < .01). In addition, it was found that ESS was more likely to occur with the use of Zenith endografts, even when propensity score matching was performed for the neck morphology.

CONCLUSIONS

ESS was associated with a lower rate of life-threatening adverse events after EVAR. The use of Zenith endografts was a predictor of ESS and was associated with increased rates of long-term sac shrinkage and aneurysm disappearance compared with the Endurant and Excluder endografts. Using the predictors of ESS identified in this study, we may be able to expand the indications for EVAR to patients with a longer life expectancy.