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Unal EU, Iscan HZ, Erol ME, Naim Boran T, Mola S, Cetinkaya F, Hasanzade S, Gazioglu Ö, Levent M. Carbon Dioxide Guided Endovascular Aortic Aneurysm Repair in Impaired Renal Function: Propensity Score Matched Study. Eur J Vasc Endovasc Surg 2023; 66:521-529. [PMID: 37399989 DOI: 10.1016/j.ejvs.2023.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE Carbon dioxide (CO2) is the preferred contrast agent in patients with impaired renal function and or contrast allergy and, particularly, in patients who require large volumes of contrast for complex endovascular procedures. In this study, the aim was to clarify the possible protective effects of CO2 guided endovascular aneurysm repair (EVAR) for patients with impaired renal function by propensity score matching. METHODS A retrospective analysis of the database was performed for 324 patients having EVAR between January 2019 and January 2022. A total of 34 patients treated with CO2 guided EVAR were evaluated. This cohort was matched for age, sex, pre-operative serum creatinine levels and glomerular filtration rate (GFR) levels and specific comorbidities to obtain homogeneous groups that included only patients with impaired renal function (eGFR < 60 mL/min/1.73m2). The primary endpoint was to compare the decrease in eGFR from baseline and development of contrast induced nephropathy (CIN) using propensity score matching. Secondary endpoints were the need for renal replacement therapy, other peri-procedural morbidity and mortality. RESULTS Thirty-one patients (9.6%) of the total population developed CIN. There was no difference in the rate of CIN development between the standard EVAR group and the CO2 guided EVAR group in the unmatched population (10% vs. 3%, p = .15). After matching, the decrease in eGFR values after the procedure was more pronounced for the standard EVAR group (from 44 to 40 mL/min/1.73m2, interaction p = .034). Meanwhile, CIN development was more frequent for the standard EVAR group (24% vs. 3%, p = .027). In matched patients, early death did not differ between the groups (5.9% vs. 0, p = .15) CONCLUSION: Patients with impaired renal function are at higher risk of CIN after an endovascular procedure. CO2 guided EVAR is a safe, effective, and feasible treatment option, especially for patients with impaired renal function. CO2 guided EVAR may be a protective measure for contrast induced nephropathy.
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Affiliation(s)
- Ertekin Utku Unal
- Department of Cardiovascular Surgery, Ufuk University, Ankara, Turkey.
| | - Hakkı Zafer Iscan
- Department of Cardiovascular Surgery, Bilkent City Hospital, Ankara, Turkey
| | - Mehmet Emir Erol
- Department of Cardiovascular Surgery, Etlik City Hospital, Ankara, Turkey
| | - Tumer Naim Boran
- Department of Cardiovascular Surgery, Bilkent City Hospital, Ankara, Turkey
| | - Serkan Mola
- Department of Cardiovascular Surgery, Bilkent City Hospital, Ankara, Turkey
| | - Ferit Cetinkaya
- Department of Cardiovascular Surgery, Bilkent City Hospital, Ankara, Turkey
| | - Sabir Hasanzade
- Department of Cardiovascular Surgery, Bilkent City Hospital, Ankara, Turkey
| | | | - Mavioglu Levent
- Department of Cardiovascular Surgery, Bilkent City Hospital, Ankara, Turkey
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Tantawy TG, Seriki D, Rogers S, Katsogridakis E, Ghosh J. Endovascular Aneurysm Repair Assisted by CO 2 Digital Subtraction Angiography and Intraoperative Contrast-Enhanced Ultrasonography: Single-Center Experience. Ann Vasc Surg 2020; 70:459-466. [PMID: 32599109 DOI: 10.1016/j.avsg.2020.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Allergy to iodinated contrast (IC) agent and advanced chronic kidney disease are major limitations to endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). We describe our experience combining CO2-assisted EVAR with intraoperative contrast-enhanced ultrasound (CEUS) in an attempt to avoid contrast-induced allergy or nephropathy. METHODS Observational cohort study using prospectively acquired data on patients undergoing CO2-assisted EVAR in single institution. EVAR planning was performed using computed tomographic angiography or magnetic resonance aortography in patients contraindicated for IC. Patients were considered if their estimated glomerular filtration rate was <40 mL/min and anatomically suitable for conventional infrarenal EVAR. Outcomes of interest included technical success rate and reintervention rates, total radiation dose, length of hospital stay, and graft kinking or migration. RESULTS Fifteen patients (10 male) were treated across a 5-year period. Technical success was achieved in all cases. Completely IC-free EVAR was performed in 9 cases, whereas the remaining 6 required IC administration for adjunct procedures. CO2 completion angiography detected all type I endoleaks (2 Ia and 1 Ib) but was less sensitive to type II. Intraoperative CEUS confirmed all type I and 2 cases of type II endoleaks. Median hospital stay was 4 days. No significant deterioration in renal function was seen postoperatively. CONCLUSIONS In patients with abdominal aortic aneurysms and with contraindication for IC, a combined approach of using CO2 digital subtraction angiography and CEUS can be used safely and efficiently to minimize or obviate the need for IC agents with satisfactory mid-term results.
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Affiliation(s)
- Tamer Ghatwary Tantawy
- Department of Vascular and Endovascular Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Dare Seriki
- Department of Interventional Radiology, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Steven Rogers
- Independent Vascular Services Ltd, The Vascular Studies Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Academic Surgery Unit, Division of Cardiovascular Sciences, The University of Manchester, Manchester Academic Health Science Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Emmanuel Katsogridakis
- Department of Vascular and Endovascular Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jonathan Ghosh
- Department of Vascular and Endovascular Surgery, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Krasinski Z, Krasińska B, Olszewska M, Pawlaczyk K. Acute Renal Failure/Acute Kidney Injury (AKI) Associated with Endovascular Procedures. Diagnostics (Basel) 2020; 10:diagnostics10050274. [PMID: 32370193 PMCID: PMC7277506 DOI: 10.3390/diagnostics10050274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/14/2023] Open
Abstract
AKI is one of the most common yet underdiagnosed postoperative complications that can occur after any type of surgery. Contrast-induced nephropathy (CIN) is still poorly defined and due to a wide range of confounding individual variables, its risk is difficult to determine. CIN mainly affects patients with underlying chronic kidney disease, diabetes, sepsis, heart failure, acute coronary syndrome and cardiogenic shock. Further research is necessary to better understand pathophysiology of contrast-induced AKI and consequent implementation of effective prevention and therapeutic strategies. Although many therapies have been tested to avoid CIN, the only potent preventative strategy involves aggressive fluid administration and reduction of contrast volume. Regardless of surgical technique—open or endovascular—perioperative AKI is associated with significant morbidity, mortality and cost. Endovascular procedures always require administration of a contrast media, which may cause acute tubular necrosis or renal vascular embolization leading to renal ischemia and as a consequence, contribute to increased number of post-operative AKIs.
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Affiliation(s)
- Zbigniew Krasinski
- Department of Vascular, Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Beata Krasińska
- Department of Hypertension, Angiology and Internal Disease, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Marta Olszewska
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
| | - Krzysztof Pawlaczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
- Correspondence:
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The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound. CONTRAST MEDIA & MOLECULAR IMAGING 2018; 2018:7647165. [PMID: 29780288 PMCID: PMC5892285 DOI: 10.1155/2018/7647165] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/28/2018] [Accepted: 02/05/2018] [Indexed: 11/17/2022]
Abstract
Introduction Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS. Methods A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohen's concordance Index (K). Results Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohen's K: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohen's K: 0.65) for ELII detection. Conclusion CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.
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Park B, Mavanur A, Drezner AD, Gallagher J, Menzoian JO. Clinical Impact of Chronic Renal Insufficiency on Endovascular Aneurysm Repair. Vasc Endovascular Surg 2016; 40:437-45. [PMID: 17202089 DOI: 10.1177/1538574406294071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular aneurysm repair of abdominal aortic aneurysms has become a viable alternative to open repair. A significant proportion of this patient population has chronic renal insufficiency. The surgical outcomes associated with endovascular repair in 342 patients, with and without chronic renal insufficiency, are reported. Perioperative mortality, length of admission, length of intensive care unit admission, and rates of acute renal failure, congestive heart failure, myocardial infarction, conversion to open surgery, progression to hemodialysis, and incidence of endoleaks were retrospectively reviewed and analyzed. Endovascular repair demonstrated higher rates of acute renal failure, longer length of stay, and longer intensive care unit admissions in patients with chronic renal insufficiency. Patients with severe renal dysfunction demonstrated markedly elevated mortality and morbidity. These results indicate that chronic renal insufficiency is not an absolute contraindication to endovascular repair in patients with moderate renal dysfunction, but patients with severe renal dysfunction perform poorly after aortic reconstruction.
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Affiliation(s)
- Brian Park
- Division of Vascular Surgery, Hartford Hospital, Hartford, Connecticut 06102-5037, USA
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Abstract
Although endovascular surgery for aortic aneurysms can be traced to the 19th century, open surgery has dominated during the past 50 years. Indeed, open repair of aneurysms has been one of the most successful developments in vascular surgery. Despite improvements in mortality rates, open repair remains a major operation often undertaken in patients with significant comorbidities. Starting from basic research dating back several decades, the 1990s were noted for very active clinical development of endovascular abdominal aortic repair in an attempt to provide an alternative to open repair, especially for high-risk patients. Early successes with decreased intensive care unit and hospital stays were tempered by technical issues and the “endoleak,” the term given to an incomplete exclusion of the aneurysm from the circulation. This potential for rupture, despite treatment, was cause for concern. The need for long-term surveillance and secondary procedures, if not conversion to open repair, further compounded these issues. Despite these concerns, progress continued, and by the end of 2002, the Food and Drug Administration had approved three devices for marketing. Although surgeons are faced with increasingly complex issues related to endovascular repair, anesthesiologists have found their management of this procedure to be simpler in many ways. The smaller incisions and improved hemodynamic stability have led to a variety of anesthetics being tried, including monitored anesthesia care. Anesthesiologists continue to explore a number of opportunities to improve patient outcome in these procedures. These include selection of the most optimal anesthetic, the most appropriate perioperative renal protection, and the best preparation for and management of a conversion to an open procedure. Whatever the final role for endovascular surgery in the management of abdominal aortic aneurysms, it is an intellectually stimulating and scientifically promising technique for surgeons, anesthesiologists, and the patients they serve.
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Affiliation(s)
- Kenneth F. Kuchta
- Department of Anesthesiology, University of California, Los Angeles Medical Center, Los Angeles, CA
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Martin-Gonzalez T, Pinçon C, Hertault A, Maurel B, Labbé D, Spear R, Sobocinski J, Haulon S. Renal outcomes analysis after endovascular and open aortic aneurysm repair. J Vasc Surg 2015. [DOI: 10.1016/j.jvs.2015.03.075] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Benson RA, Paraskevas KI, Patterson BO, Loftus IM. Symptomatic Renal Artery Stenosis and Infra-renal AAA. Eur J Vasc Endovasc Surg 2015; 49:606-9. [PMID: 25817562 DOI: 10.1016/j.ejvs.2015.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 01/28/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To identify evidence to guide the vascular surgeon as to the relevance of renal artery stenting in a patient with symptomatic renal artery stenosis undergoing elective endovascular aortic aneurysm repair (EVAR). METHODS A comprehensive literature search of MEDLINE was performed without time limits. The following terms were used in the first instance: renal artery stenting and renal artery stenosis, and any other analogous terms identified during the search. Selection criteria were set to randomised control trials. RESULTS Despite several large, randomised controlled trials investigating renal artery stenting against medical treatment alone in symptomatic renal artery stenosis, there has been no significant benefit identified in terms of improvement in renal function, control of blood pressure, or need for dialysis. The stented populations were also more likely to suffer from complications caused by the procedure such as bleeding, cholesterol embolisation and flash pulmonary oedema. CONCLUSION There is no evidence for the use of renal artery stenting over optimal medical management in the treatment of patients with symptomatic atherosclerotic renal artery stenosis, irrelevant of the degree of stenosis. In the setting of EVAR, prevention of deterioration of renal function should be with involvement of the renal physicians, adequate hydration, and use of minimal contrast agent. Repair should be undertaken in centres with access to 24-hour haemofiltration services.
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Affiliation(s)
- R A Benson
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK.
| | - K I Paraskevas
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - B O Patterson
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
| | - I M Loftus
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK
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The incidence of contrast medium-induced nephropathy following endovascular aortic aneurysm repair: assessment of risk factors. Jpn J Radiol 2015; 33:253-9. [DOI: 10.1007/s11604-015-0408-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
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Karthikesalingam A, Bahia SS, Patel SR, Azhar B, Jackson D, Cresswell L, Hinchliffe RJ, Holt PJ, Thompson MM. A systematic review and meta-analysis indicates underreporting of renal dysfunction following endovascular aneurysm repair. Kidney Int 2015; 87:442-51. [PMID: 25140912 PMCID: PMC5590709 DOI: 10.1038/ki.2014.272] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 06/08/2014] [Accepted: 06/13/2014] [Indexed: 01/20/2023]
Abstract
Deterioration in renal function has been described after endovascular repair of abdominal aortic aneurysms (EVRs). The etiology is multifactorial and represents an important therapeutic target. A need exists to quantitatively summarize incidence and severity of renal dysfunction after EVR to allow better-informed attempts to preserve renal function and improve life expectancy. Here a systematic search was performed using Medline and Embase for renal function after EVR applying PRISMA statements. Univariate and multivariate random-effects meta-analyses were performed to estimate pooled postoperative changes in serum creatinine and creatinine clearance at four time points after EVR. Clinically relevant deterioration in renal function was also estimated at 1 year or more after EVR. Pooled probability of clinically relevant deterioration in renal function at 1 year or more was 18% (95% confidence interval of 14-23%, I2 of 82.5%). Serum creatinine increased after EVR by 0.05 mg/dl at 30 days/1 month, 0.09 mg/dl at 1 month to 1 year, and 0.11 mg/dl at 1 year or more (all significant). Creatinine clearance decreased after EVR by 5.65 ml/min at 1 month-1 year and by 6.58 ml/min at 1 year or more (both significant). Thus, renal dysfunction after EVR is common and merits attention.
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Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
| | - Sandeep S. Bahia
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
| | - Shaneel R. Patel
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
| | - Bilal Azhar
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
| | - Dan Jackson
- MRC Biostatistics Unit, University of Cambridge, MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge CB2 0SR
| | - Lynne Cresswell
- MRC Biostatistics Unit, University of Cambridge, MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge CB2 0SR
| | - Robert J. Hinchliffe
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
| | - Peter J.E. Holt
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
| | - Matt M. Thompson
- Department of Outcomes Research, St George’s Vascular Institute, 4 Floor St James Wing, St George’s Hospital NHS Trust, Blackshaw Road, London SW17 0QT
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Garvin RP, Ryer EJ, Kendrick JB, Franklin DP. Endoleak visualized with carbon dioxide angiography during endovascular aneurysm repair using the Endurant stent-graft. J Endovasc Ther 2014; 21:172-6. [PMID: 24502499 DOI: 10.1583/12-4123mr.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To make interventionists aware of the potential for type IV endoleak on completion carbon dioxide (CO2) angiography during endovascular aneurysm repair (EVAR) using the Endurant stent-graft. CASE REPORT A 74-year-old man with chronic kidney disease underwent EVAR with an Endurant stent-graft using CO2 angiography to guide graft placement. Completion CO2 angiography demonstrated immediate accumulation of CO2 in the aneurysm sac suggestive of an endoleak, but confirmatory angiography with conventional iodinated contrast showed no evidence of an endoleak. We speculate that this is a type IV endoleak, and graft porosity may be responsible. CONCLUSION Interventionists should be alerted to the possibility of visualizing these endoleaks through Endurant stent-grafts under CO2 angiography. Further work should be done to elucidate the exact mechanism of the endoleak.
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Sueyoshi E, Nagayama H, Sakamoto I, Uetani M. Carbon dioxide digital subtraction angiography as an option for detection of endoleaks in endovascular abdominal aortic aneurysm repair procedure. J Vasc Surg 2014; 61:298-303. [PMID: 25151598 DOI: 10.1016/j.jvs.2014.07.088] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/26/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate carbon dioxide digital subtraction angiography (CO2-DSA) as an option for the detection of endoleaks (ELs) in the endovascular abdominal aortic aneurysm repair (EVAR) procedure. METHODS Forty patients with abdominal aortic aneurysm who were scheduled to undergo EVAR were enrolled in the study. There were 35 men and five women (mean age, 77.9 years). All patients had both iodinated contrast conventional DSA (C-DSA) and CO2-DSA immediately after EVAR. The sensitivity and specificity were calculated for the ability of CO2-DSA to detect ELs. We also correlated with computed tomography findings 6 months after EVAR. RESULTS C-DSA showed that 27 of the 40 patients (68%) had 28 ELs (type I, four; type II, 20; type III, three; type IV, one). CO2-DSA showed that 16 of the 40 patients (40%) had 17 ELs (type I, four; type II, 10; type III, three; type IV, none). For the prediction of direct ELs (type I and type III) with use of C-DSA as the criterion standard, CO2-DSA has a sensitivity of 1.0 and a specificity of 1.0. For the detection of persistent type II ELs (n = 11) with use of computed tomography findings 6 months from EVAR as the criterion standard, CO2-DSA has a sensitivity of 0.87 and a specificity of 0.97. C-DSA has a sensitivity of 0.82 and a specificity of 0.64. CONCLUSIONS CO2-DSA is reliable for the detection of direct ELs and persistent type II ELs in EVAR. CO2-DSA can be an option to detect ELs in the EVAR procedure.
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Affiliation(s)
- Eijun Sueyoshi
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan.
| | - Hiroki Nagayama
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Ichiro Sakamoto
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Masataka Uetani
- Department of Radiology, Nagasaki University School of Medicine, Nagasaki, Japan
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Pirgakis KM, Makris K, Dalainas I, Lazaris AM, Maltezos CK, Liapis CD. Urinary cystatin C as an early biomarker of acute kidney injury after open and endovascular abdominal aortic aneurysm repair. Ann Vasc Surg 2014; 28:1649-58. [PMID: 24858592 DOI: 10.1016/j.avsg.2014.04.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 04/21/2014] [Accepted: 04/30/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) is associated with increased mortality and hospital costs. Early detection of AKI is critical to prevent its progression. Recent findings demonstrate that elevated levels of urinary cystatin C (uCysC) may reflect tubular dysfunction. We prospectively evaluated whether uCysC can detect renal dysfunction earlier than serum creatinine (sCr). METHODS In a prospective study, 126 consecutive patients (mean age ± SD, 69.1 ± 8.66 years) with AAA (EVAR = 87, OR = 39) were enrolled. sCr and uCysC were measured preoperatively (baseline) and at 6, 24, and 48 hr postoperatively. A final measurement was made on day 5. AKI was defined according to Acute Kidney Injury Network criteria. RESULTS The incidence of AKI was significantly higher (χ(2) test, P < 0.05) in the OR group (n = 13, 33%) than in the EVAR group (n = 15, 17%). The baseline median (interquartile range) value of uCysC was significantly higher (t-test, P < 0.05) in patients of both groups (OR-EVAR) who developed AKI from those who did not (OR/AKI group: 0.06 [0.02-0.12] mg/L, EVAR/AKI group: 0.08 [0.05-0.11] mg/L versus no-AKI subjects: 0.04 [0.02-0.07] mg/L). Subsequent analysis showed that at 6 hr postoperatively, the patients who developed AKI increased their uCysC levels significantly from baseline (OR/AKI group: 0.58 [0.42-0.70] mg/L, EVAR/AKI group: 0.59 [0.30-1.07] mg/L). The median value of uCysC in AKI patients increased at 24 hr (OR/AKI group: 1.37 [0.78-3.40] mg/L, EVAR/AKI group: 2.11 [0.70-2.42] mg/L) and peaked at 48 hr (OR/AKI group: 6.16 [1.74-10.73] mg/L, EVAR/AKI group: 2.57 [1.21-7.40] mg/L), while no increase was observed among those who did not develop AKI at the same time points (0.06 [0.04-0.14] vs. 0.08 [0.04-0.19] mg/L). The diagnostic accuracy of uCysC at 6 hr post-surgery was excellent (area under the curve - receiver-operating characteristic [AUC-ROC] = 0.968), significantly higher than sCr (AUC-ROC = 0.844) and a cutoff value set at 0.30 mg/L can diagnose AKI with a sensitivity of 85.71% and a specificity of 98.97%. CONCLUSIONS uCysC is superior to sCr in the early diagnosis of AKI following open and endovascular AAA repair.
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Affiliation(s)
| | | | - Ilias Dalainas
- Department of Vascular Surgery, Attikon Hospital, University of Athens, Athens, Greece
| | - Andreas M Lazaris
- Vascular Unit, 3rd Surgical Department, Attikon Hospital, University of Athens, Athens, Greece
| | | | - Christos D Liapis
- Department of Vascular Surgery, Attikon Hospital, University of Athens, Athens, Greece
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Endovascular Abdominal Aortic Aneurysm Repair Using Transvenous Intravascular US Catheter Guidance in Patients with Chronic Renal Failure. J Vasc Interv Radiol 2014; 25:702-6. [DOI: 10.1016/j.jvir.2013.12.561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 12/21/2013] [Accepted: 12/21/2013] [Indexed: 11/24/2022] Open
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Abdelhamid MF, Davies RS, Vohra RK, Adam DJ, Bradbury AW. Assessment of Renal Function by Means of Cystatin C Following Standard and Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2013; 27:708-13. [DOI: 10.1016/j.avsg.2012.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 06/13/2012] [Accepted: 06/23/2012] [Indexed: 10/27/2022]
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Huang SG, Woo K, Moos JM, Han S, Lew WK, Chao A, Hamilton A, Ochoa C, Hood DB, Rowe VL, Weaver FA. A prospective study of carbon dioxide digital subtraction versus standard contrast arteriography in the detection of endoleaks in endovascular abdominal aortic aneurysm repairs. Ann Vasc Surg 2013; 27:38-44. [PMID: 23257072 DOI: 10.1016/j.avsg.2012.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 07/09/2012] [Accepted: 10/23/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of this study is to compare intraoperative endoleak detection by carbon dioxide digital subtraction angiography (CO(2)-DSA) during endovascular aortic aneurysm repair (EVAR) with standard iodinated contrast angiography (ICA). METHODS Between 2006 and 2010, 76 patients with abdominal aortic aneurysms undergoing EVAR were enrolled in a prospective study. After EVAR, both an ICA and CO(2)-DSA completion study were performed. Two blinded vascular surgeons who were not involved with the EVAR separately interpreted the ICA and CO(2)-DSA results for the presence or absence of an endoleak. Identified endoleaks were classified by types. A third, "tie-breaker" blinded observer was used to resolve differences in interpretations. The sensitivity, specificity, negative predictive value, and positive predictive value were calculated for the ability of CO(2)-DSA to detect endoleaks. Cohen's κ statistic was used to assess interobserver agreement between the 2 initial interpreting surgeons. RESULTS Of the 76 patients undergoing EVAR, 66 were men with average age of 76 years, a mean aneurysm size of 5.8 cm (range, 4-10 cm), and creatinine of 1 (standard deviation, 0.33). ICA identified 35 type I and 15 type II endoleaks, respectively, while CO(2)-DSA identified 40 type I and 10 type II endoleaks. Overall, CO(2)-DSA had a sensitivity of 0.84, specificity of 0.72, positive predictive value of 0.86, and negative predictive value of 0.69 of intraoperative endoleak detection, with respect to ICA as the criterion standard. The interobserver κ between surgeons for ICA was 0.56, for detection of any endoleak or type I endoleak with CO(2)-DSA was 0.58, and for detection of type II endoleak with CO(2)-DSA was 0.29. CONCLUSIONS Interobserver agreement for the detection of endoleaks is superior with ICA compared to CO(2)-DSA. However, the sensitivity for detecting any endoleak and both the sensitivity and specificity for detecting type I endoleaks using CO(2)-DSA are acceptable. For detecting type II endoleaks using CO(2)-DSA, the sensitivity and positive predictive value are poor. Compared to ICA, CO(2)-DSA provides adequate images for endoleak detection during EVAR and is an acceptable alternative to ICA in patients at risk for contrast-related nephrotoxicity.
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Affiliation(s)
- S Grace Huang
- Division of Vascular Surgery and Endovascular Therapy, CardioVascular Thoracic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Brooks CE, Middleton A, Dhillon R, Scott D, Denton M. Predictors of creatinine rise post-endovascular abdominal aortic aneurysm repair. ANZ J Surg 2012; 81:827-30. [PMID: 22295426 DOI: 10.1111/j.1445-2197.2011.05699.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endovascular abdominal aortic aneurysm repair involves manipulation of the aorta around the renal arteries. Fenestrated grafts involve the direct cannulation, stenting and injecting of contrast into the renal arteries. These procedures may be associated with an acute post-operative creatinine rise. METHODS We retrospectively examined data from all endovascular aortic repairs at our institution from 2005 to 2009, where contrast dosage had been recorded. Renal impairment was defined as a 25% increase in creatinine during the 5-day postoperative period. Univariable analysis was undertaken for a number of likely predictors, including: age, contrast dosage, preoperative creatinine, graft type (fenestrated or standard), diabetes mellitus, hypertension, hypercholesterolaemia, ischaemic heart disease, aspirin therapy, statins therapy, non-steroidal anti-inflammatory drug use, preoperative N-acetyl-cysteine and intravenous pre-hydration. Multivariable analysis was then applied to variables with a univariable P-value of < 0.05. RESULTS We identified 106 consecutive cases, with complete data for 102. Twenty per cent of patients developed renal impairment (22/102). Contrast dose (P = 0.043) and fenestrated grafts (P = 0.006) were identified as significant risk factors for post-operative creatinine increase (P = 0.043). Multivariable analysis demonstrated that fenestrated grafts were a risk factor independent of contrast dosage (P < 0.05). CONCLUSIONS Patients who received a fenestration graft (P < 0.01) and increased contrast dose (P < 0.05) were at a significant increased risk of a 25% post-operative creatinine rise. The risk of fenestration grafts persisted when multivariable regression was performed to control for contrast dosage (P < 0.05). Other variables investigated were not found to be significant in this study.
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High-dose erythropoietin has no effect on short- or long-term graft function following deceased donor kidney transplantation. Kidney Int 2012; 81:314-20. [PMID: 22012130 DOI: 10.1038/ki.2011.349] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Guntani A, Okadome J, Kawakubo E, Kyuragi R, Iwasa K, Fukunaga R, Kuma S, Matsumoto T, Okazaki J, Maehara Y. Clinical Results of Endovascular Abdominal Aortic Aneurysm Repair in Patients with Renal Insufficiency without Hemodialysis. Ann Vasc Dis 2012; 5:166-71. [PMID: 23555506 DOI: 10.3400/avd.oa.11.00094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 02/04/2012] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Chronic renal insufficiency may be a relative contraindication to endovascular aneurysm repair (EVAR) for the use of contrast enhanced mediums. It is thought that more contrast enhanced media are needed in patients who are not anatomically suitable for EVAR, because of procedural difficulties. We reviewed a 2 year EVAR experience at our institution to determine whether the procedure and use of contrast enhanced mediums has any deleterious effect on renal function in patients with pre-existing chronic renal insufficiency. MATERIALS AND METHODS EVAR was performed in 46 patients with pre-existing chronic renal insufficiency without hemodialysis. Patients were retrospectively assigned to two groups on the basis of their preoperative creatinine clearance levels. Furthermore, patients were assigned to two other groups on the basis of anatomical suitability for EVAR. The absolute change in the serum creatinine (Cr) level was reviewed in the each renal insufficiency group between the preoperative and post-operative time periods. RESULTS No increase in the serum Cr level was noted, and no patient required temporary or permanent hemodialysis, in any of the groups. CONCLUSIONS EVAR with contrast agents can be accomplished in patients with chronic renal insufficiency without hemodialysis; therefore,elevated Cr levels maynot be a contraindication in EVAR.
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Affiliation(s)
- Atsushi Guntani
- Department of Vascular Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
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Gómez Palonés F, Vaquero Puerta C, Gesto Castromil R, Serrano Hernando F, Maeso Lebrun J, Vila Coll R, Clará Velasco A, Escudero Román J, Riambau Alonso V. Tratamiento endovascular del aneurisma de aorta abdominal. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Grande W, Stavropoulos SW. Treatment of complications following endovascular repair of abdominal aortic aneurysms. Semin Intervent Radiol 2011; 23:156-64. [PMID: 21326759 DOI: 10.1055/s-2006-941446] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Endovascular aneurysm repair (EVAR) is an important treatment option for abdominal aortic aneurysms, with lower perioperative morbidity and mortality rates than open surgical aneurysm repair. However, EVAR is associated with several unique complications that are not encountered with surgical repair such as endoleaks, graft migration, and renal artery occlusion. Preservation of the morbidity and mortality advantages of EVAR relies on the successful treatment of these complications by minimally invasive, endovascular approaches. Some of the techniques used to treat EVAR complications include balloon dilation and stenting, deployment of additional stent-graft pieces, coil embolization, and thrombolysis. Although the employment of these endovascular salvage techniques is common, data regarding their intermediate- to long-term efficacy is sparse, and further studies are needed to determine their efficacy in preventing conversion to open aneurysm repair and aneurysm rupture.
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Affiliation(s)
- William Grande
- Department of Radiology, Division of Interventional Radiology, Hospital of University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Moulakakis K, Matoussevitch V, Borgonio A, Gawenda M, Brunkwall J. Evidence that Statins Protect Renal Function During Endovascular Repair of AAAs. Eur J Vasc Endovasc Surg 2010; 40:608-15. [DOI: 10.1016/j.ejvs.2010.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 05/04/2010] [Indexed: 10/19/2022]
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Abstract
Preoperative evaluation of patients with renal dysfunction often requires the collaborative efforts of the primary care physician, nephrologist, surgeon, and anesthesiologist. Renal dysfunction is typically a spectrum of disease with multisystem effects. Optimization of preexisting medical issues is the key, as is a thorough understanding of the potential perioperative risks for further renal injury. Surgical or anesthetic techniques may require alteration for the patient with significant renal dysfunction. Identification of those at risk for renal injury may allow for preventative therapies in the perioperative period. This article focuses on defining the population at risk, a framework for preoperative evaluation, and developments in the area of perioperative renal protection.
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Affiliation(s)
- Dean R Jones
- Department of Anesthesiology, Columbia University, PH 5-133, 622 West 168th Street, New York, NY 10032, USA
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Abstract
Preoperative evaluation of patients with renal dysfunction often requires the collaborative efforts of the primary care physician, nephrologist, surgeon, and anesthesiologist. Renal dysfunction is typically a spectrum of disease with multisystem effects. Optimization of preexisting medical issues is the key as is a thorough understanding of the potential perioperative risks for further renal injury. Surgical or anesthetic techniques may require alteration for the patient with significant renal dysfunction. Identification of those at risk for renal injury may allow for preventative therapies in the perioperative period. This article focuses on defining the population at risk, a framework for preoperative evaluation, and developments in the area of perioperative renal protection.
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Affiliation(s)
- Dean R Jones
- Department of Anesthesiology, Columbia University, PH 5-133, New York, NY 10032, USA
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25
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Chronic kidney disease and postoperative mortality: A systematic review and meta-analysis. Kidney Int 2008; 73:1069-81. [DOI: 10.1038/ki.2008.29] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Impact on Renal Function after Endovascular Aneurysm Repair with Uncovered Supra-renal Fixation Assessed by Serum Cystatin C. Eur J Vasc Endovasc Surg 2008; 35:439-45. [DOI: 10.1016/j.ejvs.2007.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 10/09/2007] [Indexed: 11/18/2022]
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Walsh SR, Boyle JR, Lynch AG, Sadat U, Carpenter JP, Tang TY, Gaunt ME. Suprarenal endograft fixation and medium-term renal function: systematic review and meta-analysis. J Vasc Surg 2008; 47:1364-1370. [PMID: 18280095 DOI: 10.1016/j.jvs.2007.11.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Revised: 11/05/2007] [Accepted: 11/11/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Suprarenal fixation is widely used in endovascular aneurysm repair. Numerous small, underpowered studies have concluded that it does not increase the risk of renal impairment compared with infrarenal fixation. A recent meta-analysis demonstrated that renal infarction is more common with suprarenal fixation, but the effect on renal function remains unclear. METHODS Electronic abstract databases, article reference lists, and conference proceedings were searched for series reporting renal function data after suprarenal fixation. There was considerable study heterogeneity with respect to key factors such as pre-existing renal dysfunction and length of follow-up. Authors were contacted to obtain individual patient data for a pooled reanalysis using standardized criteria. RESULTS Of 46 potentially relevant citations, only 11 were eligible for inclusion in the meta-analysis. Complete data sets were available for four studies (1065 patients), with a median follow-up of 33 months. Kaplan-Meier curves were constructed for postoperative renal impairment in the suprarenal fixation and infrarenal fixation groups and compared by the log-rank test. Median time free of renal impairment was 38.5 months in the infrarenal fixation group compared with 32.4 months in the suprarenal fixation group (P = .0038). However, to account for significant methodologic differences, further analysis was required using a Weibull regression model fitted in open Bayesian inference using Gibbs sampling (BUGS). The pooled hazard ratio for deterioration of renal function after suprarenal fixation was 0.6 (95% confidence interval, 0.3-10). CONCLUSION Currently available data are insufficient to determine the precise effect of suprarenal fixation on medium-term renal function. Conventional Kaplan-Meier analysis of the pooled data set suggested that suprarenal fixation increased the risk of renal dysfunction; however, the effect disappeared when sophisticated statistical modelling was performed to account for study heterogeneity. A randomised controlled trial of suprarenal fixation may resolve this issue.
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Affiliation(s)
- Stewart R Walsh
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom.
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Walsh SR, Tang TY, Boyle JR. Renal Consequences of Endovascular Abdominal Aortic Aneurysm Repair. J Endovasc Ther 2008; 15:73-82. [PMID: 18254679 DOI: 10.1583/07-2299.1] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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29
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Tratamiento de las arterias hipogástricas en la cirugía endovascular del aneurisma de aorta abdominal. ANGIOLOGIA 2008. [DOI: 10.1016/s0003-3170(08)01001-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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30
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O’Donnell ME, Sun Z, Winder RJ, Ellis PK, Lau LL, Blair PH. Suprarenal fixation of endovascular aortic stent grafts: Assessment of medium-term to long-term renal function by analysis of juxtarenal stent morphology. J Vasc Surg 2007; 45:694-700. [DOI: 10.1016/j.jvs.2006.12.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2006] [Accepted: 12/08/2006] [Indexed: 11/17/2022]
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Waasdorp E, van't Hullenaar C, van Herwaarden J, Kelder H, van de Pavoordt E, Overtoom T, Moll F, de Vries JP. Renal Function After Endovascular Aortic Aneurysm Repair:A Single-center Experience with Transrenal Versus Infrarenal Fixation. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[130:rfaeaa]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Franks SC, Sutton AJ, Bown MJ, Sayers RD. Systematic Review and Meta-analysis of 12 Years of Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2007; 33:154-71. [PMID: 17166748 DOI: 10.1016/j.ejvs.2006.10.017] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 10/03/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endovascular repair (ER) of abdominal aortic aneurysm (AAA) is a new technique, and reported rates of endoleak, conversion to open repair, rupture and mortality vary widely. The aim of this study was to estimate these rates from the published data, and examine how this has changed as more patients have undergone ER. METHODS A systematic review and meta-analysis of publications identified through searches of the electronic databases EMBASE and Medline. All publications quoting endoleak, conversion to open repair, rupture and mortality rates for a series of patients undergoing ER were included. RESULTS 163 studies pertaining to 28,862 patients undergoing ER were identified as relevant for the review and meta-analysis. The pooled estimate for operative mortality was 3.3% (95% confidence interval 2.9 to 3.6%). The pooled estimate for type 1 endoleaks was 10.5% (95% confidence interval 9.0 to 12.1%), with an annual rate of 8.4% (95% confidence interval 5.7% to 12.2%). The pooled estimate of type 2,3 and 4 endoleaks was 13.7% (95% confidence interval 12.3 to 15.3%), with an annual rate of 10.2% (95% confidence interval 7.4% to 14.1%). The pooled estimate for primary conversion to open repair was 3.8% (95% confidence interval 3.2 to 4.4%), and for secondary conversion to open repair 3.4% (95% confidence interval 2.8 to 4.2%). The pooled estimate for post-operative rupture was 1.3% (95% confidence interval 1.1 to 1.7%), with an annual rupture rate of 0.6% (95% confidence interval 0.5% to 0.8%). Multivariate meta-regression analysis showed that rates of operative mortality, post-operative rupture and total number of endoleaks all fell significantly (p<0.05) over time. CONCLUSIONS This study demonstrates a low mortality and a gradual reduction in vascular morbidity and mortality associated with endovascular repair since it was first introduced.
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Affiliation(s)
- S C Franks
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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Chao A, Major K, Kumar SR, Patel K, Trujillo I, Hood DB, Rowe VL, Weaver FA. Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient. J Vasc Surg 2007; 45:451-8; discussion 458-60. [PMID: 17254739 DOI: 10.1016/j.jvs.2006.11.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2005] [Accepted: 11/03/2006] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO(2)-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA). METHODS Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO(2)-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine >or=1.5 mg/dL, and CO(2)-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using chi(2) analysis, Student t test, and the Fisher exact test. RESULTS A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups. CONCLUSIONS CO(2)-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.
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Affiliation(s)
- Alex Chao
- Department Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Influence of Suprarenal Stentgraft Fixation on Renal Function in Patients After Abdominal Aortic Aneurysm Endovascular Exclusion. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0002-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sun Z, Mwipatayi BP, Semmens JB, Lawrence-Brown MMD. Short to Midterm Outcomes of Fenestrated Endovascular Grafts in the Treatment of Abdominal Aortic Aneurysms:A Systematic Review. J Endovasc Ther 2006; 13:747-53. [PMID: 17154710 DOI: 10.1583/06-1919.1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To perform a systematic review of the short to midterm outcomes of fenestrated endovascular grafts in patients with abdominal aortic aneurysms (AAA). METHODS A search of PubMed and Medline databases for English-language literature was performed to find studies published between 1999 and 2006. Studies investigating the short to midterm results of fenestrated endovascular grafts for AAA were analyzed for clinical outcomes and postprocedural complications. RESULTS Nineteen studies involving fenestrated endovascular grafting were retrieved, and 6 of them met criteria for inclusion in the analysis. The remaining studies were excluded because they dealt with technical or case reports or cumulative addition of previous cases. Pooled estimates (95% confidence interval) of postprocedural complications were 1.1% (0.4%-2.7%) for 30-day mortality; 8.3% (2.9%-13.6%) for late mortality; 97% (92%-100%) and 90% (85%-95%) for perfusion of fenestrated vessels at perioperative and late follow-up, respectively; 13.3% (4.1%-22.5%) for postprocedural renal dysfunction; and 11.2% (3.2%-22.5%) and 9.4% (2.6%-16.3%) for early and late endoleak, respectively. There was correlation between preoperative renal insufficiency and postprocedural renal dysfunction, although this was not a statistically significant difference (p=0.2). CONCLUSION Our systematic review showed that fenestrated endovascular grafting provides an alternative technique to treat patients with complex aneurysm necks, achieving lower mortality than open repair under comparable conditions. Preoperative renal impairment is a strong indicator of postoperative renal dysfunction. Long-term stability and patency of the fenestrated vessels deserves to be validated.
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Affiliation(s)
- Zhonghua Sun
- Department of Imaging and Applied Physics, Curtin University of Technology, Bentley, Western Australia
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Davey P, Rose JD, Parkinson T, Wyatt MG. The Mid-term Effect of Bare Metal Suprarenal Fixation on Renal Function Following Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2006; 32:516-22. [PMID: 16781875 DOI: 10.1016/j.ejvs.2006.04.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Accepted: 04/27/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to assess the mid term effect of proximal bare metal fixation design on renal function in patients undergoing endovascular repair (EVR) of abdominal aortic aneurysm (AAA). METHODS Consecutive EVR patients for AAA from December 1995-2001 were included and grouped to either infrarenal (Group 1) or uncovered suprarenal (Group 2) fixation. Peri-operative renal function and at 6, 12 and 24 months was determined by serum creatinine (sCr mmol l(-1)) and Cockroft-Gault creatinine clearance (CrC ml min(-1)). Changes in renal function were compared using non-parametric analysis. RESULTS Of the 179 EVR procedures during this six-year period, paired renal data was available for 135 patients at a minimal follow-up of 6 months (Gp1, n = 63; Gp2, n = 72). Median pre-EVR sCr and CrC were 113, 57 in Group 1 and 108, 58 in Group 2, p = NS. There was no significant deterioration in renal function within or between either group at 2 years post-EVR: median sCr, CrC values were 118, 56 (Group 1) and 111, 56 (Group 2), all p = NS. CONCLUSION This study suggests mid-term renal function remains unaffected following EVR of AAA, irrespective of proximal fixation type. Designs to improve stent durability and EVR applicability do not appear to compromise renal function.
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Affiliation(s)
- P Davey
- Northern Vascular Centre, Freeman Hospital, Newcastle upon Tyne, UK
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Rashid ST, Salman M, Agarwal S, Hamilton G. Occult renal impairment is common in patients with peripheral vascular disease and normal serum creatinine. Eur J Vasc Endovasc Surg 2006; 32:294-9. [PMID: 16716614 DOI: 10.1016/j.ejvs.2005.06.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2005] [Accepted: 06/27/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The incidence of peripheral vascular disease (PVD) and angiography/angioplasty is rising annually. The UK Small Aneurysm Trial and other trials have shown renal function is a predictor of increased mortality and failed infrainguinal bypass despite patent vessels. Renal function is classically assessed by serum creatinine (SCr). However, SCr can be normal despite significant renal impairment. A more sensitive test is creatinine clearance (CrCl) as determined by 24-hour urine collection in combination with SCr. We studied the incidence of renal impairment, as defined by CrCl, in PVD patients with normal SCr. METHODOLOGY All patients with PVD sufficient to necessitate angiography and normal SCr (< or =120 micromol/l - men; < or =97 micromol/l - women) had their CrCl assessed prior to angiography: using both 24-hour urine collection and the Cockcroft-Gault formula. Various blood tests, a detailed history and examination were performed. A control group of arthritic patients, age and sex-matched with similar SCr, also had their CrCl determined. RESULTS 65 of 76 patients (86%) with normal SCr had a subnormal CrCl (<100 ml/min) and 49 (65%) had a CrCl below 60 ml/min. In the control group of arthritic patients, the proportion having impaired CrCl was significantly less - 67% below 100 mls/min (p=0.0471) and only 15% below 60 mls/min (p<0.0001). The median and interquartile range CrCl of 52 [38-81] mls/min for PVD patients was significantly worse than for control patients (80 [68-119] mls/min -p<0.0001). The Cockcroft-Gault formula for calculating CrCl did not correlate well with the urinary CrCl for the control group but did for PVD patients (p<0.0001). Factors associated with a significantly reduced CrCl were age of at least 75 years, SCr of at least 85 micromol/l and a history of coronary heart disease (all p<0.05). This had a sensitivity of 88% and specificity of 82% for identifying subnormal CrCl. Statin use was associated with a significantly improved CrCl (p=0.040). CONCLUSION Most PVD patients with normal serum creatinine have occult, significantly impaired renal function as defined by creatinine clearance. Vascular surgeons should include creatinine clearance in pre-operative assessment of renal function especially in patients over 75 years old, with a history of coronary heart disease or a serum creatinine over 85 micromol/l. The method of determining creatinine clearance could be the Cockcroft-Gault calculation or ideally 24-hour urinary creatinine clearance measurement. This would allow appropriate early referral to a nephrologist for further investigation and management. It is worth noting that statin use seems to be associated with a protective effect on renal function.
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Affiliation(s)
- S T Rashid
- University Department of Vascular Surgery, Royal Free Hospital, London, UK.
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Parmer SS, Carpenter JP. Endovascular aneurysm repair with suprarenal vs infrarenal fixation: A study of renal effects. J Vasc Surg 2006; 43:19-25. [PMID: 16414382 DOI: 10.1016/j.jvs.2005.09.025] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 09/13/2005] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Although suprarenal fixation may be of benefit during endovascular aneurysm repair (EVAR), its safety with regards to renal effects remains uncertain. To date, there has been no controlled study of the topic, with most reports relying upon single-center experiences that use heterogeneous patient populations and devices from different manufacturers. The purpose of this analysis was to evaluate the effect of suprarenal fixation on renal function by comparing homogeneous patient populations receiving EVAR grafts from a single manufacturer that are identical in design and delivery method, except for utilizing either suprarenal (SR) or infrarenal (IR) fixation. METHODS During two pivotal US Food and Drug Administration trials, 283 patients underwent EVAR with the Powerlink bifurcated graft. The trials' inclusion and exclusion criteria and grafts were identical except for fixation scheme. Clinical, laboratory, and computed tomographic (CT) data were retrospectively reviewed. A comparison of preoperative, perioperative (1 to 7 days), and postoperative (>7 days) alterations in serum creatinine (SCr), creatinine clearance (CrCl), and blood pressure was performed. Renal adverse events were determined by CT scan and clinical chart review and included renal infarction, renal artery stenosis (either progressive or requiring renal stent placement), and renal artery occlusion. RESULTS Both SR and IR groups demonstrated a significant increase in SCr and a decrease in CrCl over time. No significant difference in SCr or CrCl existed between groups during any time period. There were no differences in postoperative renal impairment (IR, 10.2%; SR, 7.6%, P = .634), the need for hemodialysis (IR, 0.7%; SR, 0%, P = 1.00), or systolic and diastolic blood pressure during subsequent follow-up between treatment groups. There was no significant difference in the number of renal adverse events detected by CT between the IR (10, 6.8%) and SR (3, 3.8%) groups (P = .550). CONCLUSION Suprarenal fixation does not lead to a significant increase in acute renal events, renal impairment, or alteration in blood pressure compared with infrarenal fixation. Patients undergoing aneurysm repair with devices that use either suprarenal or infrarenal fixation develop progressive renal dysfunction over time. Further studies are needed to determine the long-term effects of suprarenal fixation on renal function and progression of renal artery stenosis.
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Affiliation(s)
- Shane S Parmer
- Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Alsac JM, Zarins CK, Heikkinen MA, Karwowski J, Arko FR, Desgranges P, Roudot-Thoraval F, Becquemin JP. The impact of aortic endografts on renal function. J Vasc Surg 2005; 41:926-30. [PMID: 15944586 DOI: 10.1016/j.jvs.2005.02.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the impact on late postoperative renal function of suprarenal and infrarenal fixation of endografts used to treat infrarenal abdominal aortic aneurysm (AAA). METHODS Retrospective analysis of 277 patients treated from 2000 to 2003 with three different endografts at two clinical centers. Five patients on dialysis for preoperative chronic renal failure were excluded. Group IF of 135 patients treated with an infrarenal device (Medtronic AneuRx) was compared with group SF of 137 patients treated with a suprarenal device (106 Cook Zenith and 31 Medtronic Talent). Renal function was evaluated by calculating preoperative and latest postoperative creatinine clearance (CrCl) using the Cockcroft formula. Patients who developed a >20% decrease in CrCl were considered to have significantly impaired renal function. RESULTS There were no significant differences in patient age, sex, aneurysm size, preoperative risk factors, dose of intra- and postoperative contrast, or baseline CrCl (IF: 69.3 mL/min, SF: 71.7 mL/min, P = .4). Follow-up time of 12.2 months was the same in both groups. CrCl decreased significantly during the follow-up period in both groups (IF: 69.3 mL/min to 61.7 mL/min, P < .01; SF: 71.7 mL/min to 64.9 mL/min, P < .03). Postoperative CrCl (IF: 61.7 mL/min, SF: 64.9 mL/min, P = .3), and the rate of CrCl decrease during the follow-up period (IF: -10.9%, SF: -9.5%, P = .2) was not different between the two groups. The number of patients with a >20% decrease in CrCl was not different between the two groups (IF: n = 35 [25.9%], SF: n = 41 [29.9%], P = .46). However, the magnitude of decrease in CrCl in patients with renal impairment was greater in patients treated with suprarenal fixation endografts (SF: -39%) compared with those treated with infrarenal endografts (IF: -31%, P = .005). This greater degree of renal impairment was not due to identifiable differences in preoperative risk factors, age, or baseline CrCl. No patients in these series required dialysis. CONCLUSIONS Regardless the type of endograft used, there is a 10% decrease in CrCl in the first year after endovascular aneurysm repair. Suprarenal fixation does not seem to increase the likelihood of postoperative renal impairment. Decline in renal function over time after endovascular aortic repair is probably due to multiple factors, and measures known to be effective in protecting kidneys should be considered for these patients. Long-term follow-up with measurement of CrCl, along with renal imaging and regular blood pressure measurements, should be performed to detect possible late renal dysfunction. Prospective studies comparing suprarenal versus infrarenal fixation are needed to confirm those results.
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Affiliation(s)
- Jean-Marc Alsac
- Department of Vascular Surgery, Stanford University Hospital, Calif, USA.
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Bown MJ, Norwood MGA, Sayers RD. The Management of Abdominal Aortic Aneurysms in Patients with Concurrent Renal Impairment. Eur J Vasc Endovasc Surg 2005; 30:1-11. [PMID: 15933976 DOI: 10.1016/j.ejvs.2005.02.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Patients with concurrent renal impairment and abdominal aortic aneurysms present a significant challenge in terms of pre-operative, intra-operative and post-operative management. This aim of this review was to determine the risks of surgery in this patient group and determine whether any clear management strategies exist to enhance their clinical management. METHODS Systematic review of published literature giving details of the outcome of open or endovascular abdominal aortic aneurysm repair in patients with pre-operative renal impairment. Papers concerning the management of post-operative acute renal failure in patients with normal pre-operative renal function has not been included. RESULTS There is little data regarding patients with end-stage renal failure and AAA although these patients appear to have a high peri-operative mortality rate. In contrast, those with renal impairment do not have a significantly higher mortality rate than those with normal renal function, rather they have a higher risk of complications associated with surgery and may require more intensive post-operative organ system support than normal patients. Many have a transient deterioration in renal function in the immediate peri-operative period that will resolve. In the case of patients with ruptured AAA, it is not clear whether pre-operative renal impairment affects mortality.
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Affiliation(s)
- M J Bown
- Department of Surgery, Leicester Royal Infirmary, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester LE2 7LX, UK.
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Krämer SC, Görich J, Bachmann R, Fuge D, Kuhnt B, Scharrer-Pamler R. Incidence of Renal Infarctions After Transrenal Stent Placement in an Animal Model. J Endovasc Ther 2005; 12:312-7. [PMID: 15943506 DOI: 10.1583/04-1486mr.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate the incidence and appearance of renal infarctions after transrenal stent placement in an animal model. METHODS An aortic stent was placed via a femoral approach in 20 female Merino sheep. Ten animals had intentional coverage of one renal ostium with the bare struts, 1 sheep had both renal artery ostia covered, and the other 9 sheep had no stent impingement on the renal orifices. Animals were sacrificed after 3 to 12 months (mean 6) for gross pathological and histological evaluation. Infarction locations and patterns were evaluated and correlated to stent placement. RESULTS Of the 40 renal arteries, coverage was proven at autopsy in 12 cases; the remaining 28 arteries were free of any stent overlay. Overall, 14 (35%) renal infarctions were detected; 7 were found in the 12 arteries with a transrenal stent (58.3% incidence in covered renal arteries). By comparison, the other 7 infarctions were found in the 28 unaffected arteries (25% incidence in noncovered renal arteries; p = 0.04). All infarctions appeared to be well-defined punctate lesions. CONCLUSIONS A transrenal stent position in the abdominal aorta is related to increased renal infarctions in an animal model.
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Affiliation(s)
- Stefan C Krämer
- Department of Clinical Radiology, University of Münster, Germany.
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Canaud B. [Postoperative acute renal failure: definition, diagnostic and prognostic criteria]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:125-33. [PMID: 15737498 DOI: 10.1016/j.annfar.2004.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Affiliation(s)
- B Canaud
- Service de néphrologie, hôpital Lapeyronie, CHU de Montpellier, 371, avenue du Doyen-G.-Giraud, 34925 Montpellier cedex 5, France.
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Vasquez J, Rahmani O, Lorenzo AC, Wolpert L, Podolski J, Gruenbaum S, Gallagher JJ, Allmendinger P, Hallisey MJ, Lowe R, Windels M, Drezner AD. Morbidity and mortality associated with renal insufficiency and endovascular repair of abdominal aortic aneurysms: a 5-year experience. Vasc Endovascular Surg 2004; 38:143-8. [PMID: 15064845 DOI: 10.1177/153857440403800206] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To evaluate the outcome of patients with renal insufficiency undergoing endovascular repair of abdominal aortic aneurysm (AAA), data were prospectively collected between 1998 and 2003 on patients undergoing elective repair of their AAA with a stent graft. The patients were divided into 2 groups: those with serum creatinine (Crs) concentrations <1.2 (Group A) and those with Crs > or =1.2 mg/dL not requiring hemodialysis (Group B). The outcomes of the procedure for these 2 groups were compared. Different variables that existed between the 2 groups and contributed to mortality included estimated blood loss (EBL), volume of contrast used in the operating room, incidence of diabetes (DM), tobacco use, and history of myocardial infarction (MI). In total, 213 patients underwent elective repair of their AAA with use of a stent graft: 61% who had a Crs <1.2 mg/dL (Group A) and 39% who had a Crs > or =1.2 mg/dL not requiring dialysis (Group B). Among 129 patients with normal renal function there was an 18.6% complication rate and 1.6% mortality rate. Of 83 patients with renal insufficiency not on hemodialysis 30.1% (Fisher's Exact Test = 0.076) had 1 or more complications and there was a 6% (Fisher's Exact Test = 0.166) mortality rate. One patient in Group A (0.8%) progressed to hemodialysis and 5 (6%) patients in Group B progressed to end-stage renal disease requiring hemodialysis (p=0.068). A statistically significant higher proportion of the patients in Group B had a history of MI (p<0.001). There was no difference in the amount of EBL between the 2 groups, but a significantly lower amount of contrast (p<0.05) was used in patients with renal insufficiency.
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Affiliation(s)
- Jay Vasquez
- Hartford Hospital/Connecticut Vascular Institute, Hartford, CT 06106, USA
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Grego F, Frigatti P, Antonello M, Lepidi S, Ragazzi R, Iurilli V, Zucchetta P, Deriu GP. Suprarenal fixation of endograft in abdominal aortic aneurysm treatment: focus on renal function. Ann Surg 2004; 240:169-78. [PMID: 15213633 PMCID: PMC1356389 DOI: 10.1097/01.sla.0000130721.78358.63] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this work was to evaluate any variation of renal function detected by renal scintigraphy after the suprarenal fixation of endografts for abdominal aortic aneurysm (AAA) repair. SUMMARY BACKGROUND DATA In the few articles that have considered this problem, renal function was evaluated only by biochemical tests, which are inadequate in demonstrating small changes in renal function and in appreciating the worsening of a single kidney's function. METHODS Between April 1999 and May 2002, 47 patients with an inappropriate infrarenal proximal neck had a suprarenal fixation for AAA. To assess renal function, a technetium-99m diethylene triamine penta-acetic acid (TC-DTPA) perfusion scintigraphy was performed preoperatively on the third postoperative day and at 6, 12 months, and then yearly thereafter. Worsening of renal function was defined as a decrease of glomerular filtration rate (GFR) > or =20% (detected with Gates method). Serum creatinine level was tested preoperatively and at the first and third postoperative day. RESULTS Endograft deployment was technically successful in 44 patients (93.6%); clinical perioperative success was obtained in 46 patients (97.8%). In 12 patients (25.5%), a permanent reduction of the GFR was observed using postoperative TC-DTPA perfusion scintigraphy. By 99m TC-DTPA perfusion scintigraphy, a permanent reduction of GFR was observed postoperatively in 12 patients. A slight GFR reduction (<20%) was present in 7 (14.9%) patients, due to the planned occlusion of accessory renal arteries. A more significant GFR reduction (>20%) was present unexpectedly in 5 (10.6%) patients, in 3 of these a single kidney was involved, in 5 both with an increase of the serum creatinine level >20%. CONCLUSIONS Suprarenal fixation of endografts in AAA treatment is a safe procedure with good early and midterm procedural results and a risk of GFR impairment (>20%) of 10.6%.
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Affiliation(s)
- Franco Grego
- Division of Vascular Surgery, Endovascular Surgery Section, Department of Medical and Surgical Sciences, University of Padova, Medical School, Padova, Italy
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Mehta M, Veith FJ, Lipsitz EC, Ohki T, Russwurm G, Cayne NS, Suggs WD, Feustel PJ. Is elevated creatinine level a contraindication to endovascular aneurysm repair? J Vasc Surg 2004; 39:118-23. [PMID: 14718828 DOI: 10.1016/s0741-5214(03)01041-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE It is widely believed that chronic renal insufficiency (CRI) greatly increases the risk associated with endovascular abdominal aortic aneurysm repair (EVAR) and is a relative contraindication to the procedure and to the use of intra-arterial contrast agents (IACA). We reviewed a 5-year EVAR experience to determine whether the procedure and use of IACA have an important deleterious effect on renal function in patients with and without pre-existing CRI. METHODS Endovascular aneurysm repair (EVAR) was performed in 200 patients with a variety of endografts, with intra-arterial contrast agents. The patients were retrospectively assigned to three groups on the basis of preoperative serum creatinine concentration (Cr): group 1 (n = 108), Cr less than 1.5 mg/dL (normal range); group 2 (n = 65), Cr 1.5 to 2.0 mg/dL; group 3 (n = 27), Cr 2.1 to 3.5 mg/dL. No patients had undergone hemodialysis. In groups 2 and 3, patients received hydration perioperatively, and received mannitol intraoperatively; no nephrotoxic drugs were administered during the procedure, other than nonionic contrast agent (Omnipaque 350). RESULTS The incidence of postoperative complications between the three study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in three patients (2.7%), two of whom (1.9%) required temporary hemodialysis and one (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in two patients (3.1%); both patients (3.1%) required temporary hemodialysis, and one patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in two patients (7.4%); one patient (3.7%) required temporary hemodialysis, and one patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (P <.05), and larger contrast volume was associated with an increase in serum Cr (P <.05) during the postoperative period. CONCLUSIONS EVAR with intra-arterial contrast agents can be accomplished in patients with chronic renal insufficiency who do not require dialysis, with limited and acceptable morbidity and mortality, similar to that observed with open aneurysm repair. Contrary to other reports in which perioperative precautions were not used, our study shows that with EVAR the risk for worsening renal failure, dialysis, and death is only slightly, and not significantly, greater in patients with preoperative chronic renal insufficiency compared with patients with normal renal function. Perioperative hypotension and increased contrast volume are significant risk factors for postoperative increase in serum Cr and death. With appropriate precautions such as averting perioperative hypotension and limiting the volume of nonionic contrast agents, elevated Cr need not be a contraindication to EVAR with intra-arterial contrast agents.
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Affiliation(s)
- Manish Mehta
- Division of Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA.
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Böckler D, Krauss M, Mansmann U, Halawa M, Lange R, Probst T, Raithel D. Incidence of Renal Infarctions After Endovascular AAA Repair:Relationship to Infrarenal Versus Suprarenal Fixation. J Endovasc Ther 2003. [DOI: 10.1583/1545-1550(2003)010<1054:ioriae>2.0.co;2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cayne NS, Rhee SJ, Veith FJ, Lipsitz EC, Ohki T, Gargiulo NJ, Mehta M, Suggs WD, Wain RA, Rosenblit A, Timaran C. Does transrenal fixation of aortic endografts impair renal function? J Vasc Surg 2003; 38:639-44. [PMID: 14560206 DOI: 10.1016/s0741-5214(03)00932-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Transrenal fixation (TFX) of aortic endografts is thought to increase the risk for renal infarction and impaired renal function. We studied the late effects of TFX on renal function and perfusion. METHODS Of 189 patients with commercial aortic endografts, which we inserted between 1995 and 2002, we reviewed data for 130 patients (112 men, 18 women) with available creatinine (Cr) concentration and contrast enhanced computed tomography (CT) scans preoperatively and 1 to 97 months after the procedure. Of the 130 patients, 69 patients had TFX and 61 patients had infrarenal fixation (IFX). Both groups were physiologically comparable. Average age was 76 +/- 8 years for patients with TFX and 75 +/- 8 years for patients with IFX. Presence of renal infarct or renal artery occlusion was determined by nephrograms on serial contrast-enhanced CT scans. RESULTS Mean follow-up was 17 +/- 16 months (range, 1-54 months) for TFX and 21 +/- 21 months (range, 1-97 months) for IFX. Mean serum Cr concentration increased significantly during long-term follow-up in both groups (TFX, 1.3 +/- 0.5 mg/dL to 1.5 +/- 0.8 mg/dL, P <.01; IFX, 1.3 +/- 0.7 mg/dL to 1.4 +/- 0.8 mg/dL, P <.03). Creatinine clearance (CrCl) similarly decreased over long-term follow-up in both groups (TFX, 53.3 +/- 17.7 mL/min/1.73 m(2) to 47.9 +/- 16.2 mL/min/1.73 m(2), P <.01; IFX, 58.1 +/- 22.7 mL/min/1.73 m(2) to 53.1 +/- 23.4 mL/min/1.73 m(2), P <.02). There were no significant differences in the increase in Cr concentration (P =.19) or decrease in CrCl (P =.68) between TFX and IFX groups. Small renal infarcts were noted in four patients (5.8%) in the TFX group and one patient (1.6%) in the IFX group. No increase in Cr concentration or decrease in CrCl was noted in any patient with a renal infarct. Postoperative renal dysfunction developed in 7 of 69 patients (10.1%) in the TFX group and 7 of 61 patients (11.5%) in the IFX group. There were no statistically significant differences between groups with respect to number of patients with new renal infarcts (P =.37) or postoperative renal dysfunction (P =.81). CONCLUSION There is a slight increase in serum Cr concentration and decrease in CrCl after aortic endografting. However, there was no significant difference in these changes between patients with TFX and IFX. Although TFX may produce a higher incidence of small renal infarcts, these do not impair renal function. Thus our midterm results suggest that TFX can be performed safely, with no greater change in renal function than observed after IFX.
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Affiliation(s)
- Neal S Cayne
- Department of Vascular Surgery, New York University, Montefiore Medical Center, New York, NY, USA
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Alric P, Hinchliffe RJ, Picot MC, Braithwaite BD, MacSweeney STR, Wenham PW, Hopkinson BR. Long-term Renal Function Following Endovascular Aneurysm Repair With Infrarenal and Suprarenal Aortic Stent-Grafts. J Endovasc Ther 2003. [DOI: 10.1583/1545-1550(2003)010<0397:lrffea>2.0.co;2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Reid JA, Mole DJ, Johnston LC, Lee B. Delayed paraplegia after endovascular repair of abdominal aortic aneurysm. J Vasc Surg 2003; 37:1322-3. [PMID: 12764283 DOI: 10.1016/s0741-5214(02)75447-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Paraplegia is rare after open repair of infrarenal abdominal aortic aneurysm, and only two cases have been reported after endovascular repair, both due to atheroembolism. Incidence of renal failure after endovascular repair of abdominal aortic aneurysm (EVAR) in patients with normal preoperative renal function is about 8.7%, but is much higher in those with preexisting renal impairment, possibly because of administration of nephrotoxic contrast media during EVAR. We report a case in which contrast medium-induced acute renal failure is believed to have led to delayed paraplegia after EVAR.
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Affiliation(s)
- Julie A Reid
- Vascular and Endovascular Unit, Belfast City Hospital, Belfast, Ireland.
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Izzedine H, Koskas F, Cluzel P, Mallet A, Maksud P, Deray G. Renal function after aortic stent-grafting including coverage of renal arterial ostia. Am J Kidney Dis 2002; 39:730-6. [PMID: 11920338 DOI: 10.1053/ajkd.2002.31992] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Considerable experience has been gained with endoluminal stent-graft techniques for the treatment of infrarenal aortic aneurysms. The inclusion of uncovered suprarenal stents eases the treatment of cases with a short, angulated, or bottlenecked proximal neck. However, few data have been published on the effect of a stent-graft crossing renal artery ostia on long-term renal function. We therefore retrospectively analyzed the influence of intra-aortic stent-grafts, including suprarenal fixation on long-term renal function. Thirty-nine patients who received a Gianturco Z stent across renal artery ostia as part of a made-to-measure stent-graft treating an infrarenal aortic aneurysm were evaluated at 6 (all patients) and 30 months (15 patients) after surgery. Renal function evaluation included serum creatinine level, creatinine clearance using the Cockcroft-Gault formula, and renal tomography. Initial technical success was achieved in all patients. There were no minor or major complications. Mean serum creatinine levels were 1.16 +/- 0.25, 1.12 +/- 0.28, and 1.24 +/- 0.25 mg/dL before and 6 and 30 months after endoluminal stent-graft performance, respectively (P = not significant [NS]). Mean creatinine clearances were 60.3 +/- 19.7, 63 +/- 23, and 60.6 +/- 17.5 mL/min before and 6 and 30 months after endoluminal stent-graft performance, respectively (P = NS). Only two patients (5%) had a decrease in glomerular filtration rate greater than 20% at 6 months. Both patients had renal insufficiency before endovascular grafting. Renal function was stable in all patients at 30 months' follow-up. We suggest that renal function is unaffected by coverage of renal arterial ostia with Gianturco Z stents.
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Affiliation(s)
- Hassane Izzedine
- Department of Nephrology, Pitié Salpétrière Hospital, Paris, France.
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