Nejim Besma, Arhuidese Isibor, Rizwan Muhammmad, Khalil Lana, Locham Satinderjit, Zarkowsky Devin, Goodney Philip, Malas Mahmoud B
Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
Department of Surgery, University of South Florida, Tampa, Fla.
J Vasc Surg. 2017 Apr;65(4):1080-1088. doi: 10.1016/j.jvs.2016.10.112. Epub 2017 Feb 17.
Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome.
Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients' demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease.
Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001).
Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients' risk factors that might contribute to postoperative ARF.
在肾下腹主动脉瘤（AAA）的血管腔内修复术（EVAR）期间同时进行肾动脉血管成形术和支架置入术（RAAS），旨在维持肾灌注。本研究的目的是确定EVAR期间RAAS的当前实践及其对围手术期肾脏结局的影响。
从美国外科医师学会国家外科质量改进计划（ACS NSQIP，2011 - 2014年）数据库中识别出肾下腹主动脉瘤患者。将EVAR期间同时进行RAAS的患者的基线特征与仅接受EVAR的患者进行比较。采用双变量和多变量逻辑回归分析，控制患者的人口统计学、合并症和手术因素，以评估30天急性肾衰竭（ARF）的预测因素。进行敏感性分析以评估RAAS在既往有肾脏疾病患者中的作用。
总体而言，在研究期间，6183例患者接受了肾下腹主动脉瘤的EVAR治疗。其中，281例患者在EVAR期间进行了RAAS（4.5%）。患者的中位年龄为74岁；队列中81.7%为男性，但与仅接受EVAR的患者相比，接受EVAR + RAAS的女性患者比例更高（26.3%对17.9%；P <.001）。两组在合并症、接受透析或功能状态方面无差异，但EVAR + RAAS组肾小球滤过率<60 mL/min/1.73 m²的患者比例更高（45.2%对3;7.2%；P =.011）。RAAS与ARF发生的显著更高几率相关（调整后的优势比[aOR]，4.27；95%置信区间[CI]，2.06 - 8.84；P <.001）。30天ARF的其他高度预测因素包括肾小球滤过率<60（aOR，2.92；95% CI，1.47 - 5.78；P =.002）、急诊状态（aOR，2.97；95% CI，1.21 - 7.27；P =.017）以及破裂的AAA作为EVAR的指征（aOR，4.74；95% CI，1.80 - 12.50；P =.002）。既往有肾脏疾病且接受EVAR + RAAS的患者30天ARF的几率高出12倍（aOR，12.37；95% CI，4.66 - 32.89；P <.001）。
发现同时进行RAAS是肾下腹主动脉瘤EVAR术后不良肾脏结局的一个重要决定因素。即使在控制了可能导致术后ARF的患者风险因素后，这种影响仍然存在。
