Greenberg Roy K, Chuter Timothy A M, Lawrence-Brown Michael, Haulon Stephan, Nolte Lori
Division of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
J Vasc Surg. 2004 Jun;39(6):1219-28. doi: 10.1016/j.jvs.2004.02.033.
This study was undertaken to assess the effect on renal function of open surgery and endovascular abdominal aortic aneurysm (AAA) repair with suprarenal fixation with the Zenith device.
Data for 279 patients with similar preoperative comorbid conditions were prospectively analyzed after AAA repair. One hundred ninety-nine patients underwent endografting with the Zenith AAA Endovascular Graft, which incorporates suprarenal fixation (Zenith standard risk group, ZSR), and 80 patients underwent open surgery (standard surgical risk group, SSR). Endovascular repair was also performed in 100 patients considered poor candidates for open repair (Zenith high risk group, ZHR). Serum creatinine concentration (SCr) and anatomic defects were assessed before the procedure, before discharge, and at 1, 6, 12, and 24 months in all patients who underwent endovascular repair, and before the procedure and at 1 and 12 months in patients who underwent open surgical repair (only SCr was measured before discharge). Renal function was also analyzed, with a creatinine clearance calculation (Cockcraft-Gault). Renal insufficiency was defined as an increase in SCr greater than 30% from a preoperative baseline value, any SCr concentration in excess of 2.0 mg/dL, or any need for dialysis. Cumulative renal infarction and arterial occlusion rates were calculated with computed tomographic, ultrasonographic, and angiographic data, and reported as cumulative values.
Despite the initially superior renal function in the ZSR group at the pre-discharge evaluation (P =.01), there were no differences at 12 months with respect to rise in SCr greater than 30% (ZSR, 16%, vs SSR, 12%; P =.67), SCr rise greater than 2.0 mg/dL (ZSR, 2.5%, vs SSR, 3.4%; P =.66), incidence of renal artery occlusion (ZSR, 1%, vs SSR, 1.4%; P >.99), or infarction (ZSR, 1.5%, vs SSR, 1.4%; P >.99). Only one patient in each group required hemodialysis. Of note, both groups of patients demonstrated a reduction in creatinine clearance over 12 months, which then stabilized or improved by 24 months for ZSR patients.
Renal dysfunction occurs in a subset of patients regardless of type of repair (open or endovascular with suprarenal fixation). The cause of renal dysfunction after open or endovascular repair with a suprarenal stent is probably multifactorial. The observed dysfunction occurs in a small number of patients, and the effect in the endovascular group (no data for the surgical group at 24 months) appears to be transient. The initial dysfunction, apparent in both groups over 12 months of follow-up, stabilizes or improves at 12 to 24 months.
本研究旨在评估采用Zenith装置进行肾上固定的开放手术和血管腔内腹主动脉瘤（AAA）修复对肾功能的影响。
对279例术前合并症相似的患者在AAA修复术后进行前瞻性分析。199例患者接受了采用Zenith AAA血管腔内移植物的腔内修复术，该移植物采用肾上固定（Zenith标准风险组，ZSR），80例患者接受了开放手术（标准手术风险组，SSR）。另外100例被认为不适合开放修复的患者也接受了血管腔内修复（Zenith高风险组，ZHR）。对所有接受血管腔内修复的患者，在术前、出院前、术后1、6、12和24个月评估血清肌酐浓度（SCr）和解剖缺陷；对接受开放手术修复的患者，在术前、术后1和12个月进行评估（出院前仅测量SCr）。还通过计算肌酐清除率（Cockcroft-Gault公式）分析肾功能。肾功能不全定义为SCr较术前基线值升高超过30%、任何SCr浓度超过2.0mg/dL或任何需要透析的情况。利用计算机断层扫描、超声和血管造影数据计算累积肾梗死和动脉闭塞率，并报告为累积值。
尽管在出院前评估时ZSR组的肾功能最初更优（P = 0.01），但在12个月时，SCr升高超过30%（ZSR组为16%，SSR组为12%；P = 0.67）、SCr升高超过2.0mg/dL（ZSR组为2.5%，SSR组为3.4%；P = 0.66）、肾动脉闭塞发生率（ZSR组为1%，SSR组为1.4%；P > 0.99）或梗死发生率（ZSR组为1.5%，SSR组为1.4%；P > 0.99）方面均无差异。每组仅1例患者需要血液透析。值得注意的是，两组患者在12个月内肌酐清除率均降低，而对于ZSR组患者，在24个月时肌酐清除率趋于稳定或有所改善。
无论采用何种修复方式（开放手术或采用肾上固定装置的血管腔内修复），部分患者都会出现肾功能障碍。采用肾上固定支架进行开放或血管腔内修复后发生肾功能障碍的原因可能是多因素的。观察到的功能障碍仅发生在少数患者中，血管腔内修复组的影响（手术组24个月时无数据）似乎是短暂的。在随访的12个月中两组均出现的初始功能障碍，在12至24个月时趋于稳定或有所改善。
