Miller Larry E, Razavi Mahmood K, Lal Brajesh K
Miller Scientific Consulting, Inc, Asheville, NC.
Department of Clinical Trials, Heart & Vascular Center, St. Joseph Hospital, Orange, Calif.
J Vasc Surg. 2015 May;61(5):1340-9.e1. doi: 10.1016/j.jvs.2015.01.037. Epub 2015 Feb 27.
The effect of stent graft fixation type on renal function after endovascular aneurysm repair (EVAR) remains controversial. This systematic review and meta-analysis was conducted to determine whether suprarenal (SR) or infrarenal (IR) fixation influences the risk of renal complications after EVAR.
We searched MEDLINE and EMBASE with no date or language restrictions for comparative studies evaluating EVAR with SR vs IR fixation on renal dysfunction, renal artery stenosis, renal artery occlusion, renal infarction, and new need for hemodialysis. For each outcome, we calculated the absolute risk difference (RD) with a random effects meta-analysis and performed assessments of heterogeneity and publication bias. Post hoc subgroup analyses explored the influence of individual moderator variables.
A total of 21 nonrandomized studies comparing SR vs IR fixation representing 4474 unique patients (SR, 1949; IR, 2525) were included. Baseline patient characteristics were similar between the SR and IR groups. Median patient follow-up was 12 months in each group. There were no statistically significant differences in the risk of any renal complication between SR and IR fixation groups. The absolute RD between the SR and IR fixation groups was <1%, with no evidence of heterogeneity or publication bias for renal dysfunction, renal artery stenosis, renal artery occlusion or new need for hemodialysis after EVAR. Renal infarction occurred in 6.4% of SR patients and in 2.5% of IR patients (P = .09), with evidence of heterogeneity (I(2) = 85%) and publication bias (Egger P = .08). Subgroup analyses revealed that older studies (median treatment period before 2000) reported greater risks of renal infarction with SR fixation (RD, 6.2%; P = .01). However, more contemporary studies (median treatment period after 2000) demonstrated no difference between SR and IR fixation on renal infarction risk (RD, 0.2%; P = .75).
There is no difference in the risk of postoperative renal complications when comparing stent grafts using SR vs IR fixation, particularly with newer-generation devices. Contemporary comparative studies with longer-term follow-up are warranted to further elucidate the influence of SR and IR fixation on renal complications.
血管内动脉瘤修复术（EVAR）后，支架移植物固定类型对肾功能的影响仍存在争议。本系统评价和荟萃分析旨在确定肾上（SR）固定或肾下（IR）固定是否会影响EVAR术后发生肾脏并发症的风险。
我们检索了MEDLINE和EMBASE，纳入了评估采用SR固定与IR固定进行EVAR对肾功能不全、肾动脉狭窄、肾动脉闭塞、肾梗死以及新出现的血液透析需求影响的比较研究，检索无日期或语言限制。对于每个结局，我们采用随机效应荟萃分析计算绝对风险差（RD），并进行异质性和发表偏倚评估。事后亚组分析探讨了各个调节变量的影响。
共纳入21项比较SR固定与IR固定的非随机研究，涉及4474例患者（SR组1949例，IR组2525例）。SR组和IR组患者的基线特征相似。每组患者的中位随访时间为12个月。SR固定组和IR固定组在任何肾脏并发症风险方面均无统计学显著差异。SR固定组和IR固定组之间的绝对RD<1%，对于EVAR术后的肾功能不全、肾动脉狭窄、肾动脉闭塞或新出现的血液透析需求，均无异质性或发表偏倚的证据。6.4%的SR组患者和2.5%的IR组患者发生肾梗死（P = 0.09），存在异质性证据（I² = 85%）和发表偏倚（Egger P = 0.08）。亚组分析显示，较早的研究（中位治疗时间在2000年之前）报告SR固定的肾梗死风险更高（RD，6.2%；P = 0.01）。然而，更近期的研究（中位治疗时间在2000年之后）表明，SR固定和IR固定在肾梗死风险方面无差异（RD，0.2%；P = 0.75）。
比较使用SR固定与IR固定的支架移植物时，术后肾脏并发症风险无差异，尤其是使用新一代装置时。需要开展有长期随访的当代比较研究，以进一步阐明SR固定和IR固定对肾脏并发症的影响。
