Wooster Mathew, Back Martin, Patel Shivangi, Tanious Adam, Armstrong Paul, Shames Murray
Division of Vascular and Endovascular Surgery, USF Health Morsani College of Medicine, Tampa, Fla.
Division of Vascular and Endovascular Surgery, USF Health Morsani College of Medicine, Tampa, Fla.
J Vasc Surg. 2017 Oct;66(4):1149-1156. doi: 10.1016/j.jvs.2017.04.051. Epub 2017 Jun 22.
The objective of this study was to review the outcomes of renal artery revascularizations during open aortic aneurysm repair.
Open abdominal aneurysm repairs performed from 2010 to 2015 at a single institution were reviewed, including type IV thoracoabdominal, suprarenal, and juxtarenal aneurysms. Direct renal reconstruction techniques included eversion endarterectomy, bypass, and vessel reimplantation based on the patient's anatomy. Renal loss was defined by artery occlusion.
The study included 125 patients; of these, 57 patients (46%) had 76 renal reconstructions (38 single, 19 bilateral) performed. Interventions included endarterectomy (n = 21), transaortic stenting (n = 2), reimplantation with (n = 25) or without (n = 17) endarterectomy, bypass (n = 4), and ligation (n = 7). Mean aneurysm size was 6.4 cm, with 23% (n = 29) urgent/emergent operations and 20% (n = 25) having had a prior open or endovascular repair. Overall complication rate was 50%, with significant increase among the group requiring renal intervention, primarily accounted for by a 33% early or late dialysis requirement compared with 16% in patients with no renal revascularization (P = .01). Overall 30-day mortality was 9%, with no difference between groups. Urgent/emergent operation (P < .001) was associated with increased 30-day mortality (24% vs 4% elective procedures), but prior open or endovascular repair (P = .4) was not. Mean follow-up was 26 months, with directed imaging out to a mean of 18 months. Renal intervention (P = .01) and urgent/emergent status (P = .04) were predictive of dialysis requirement; however, among those undergoing intervention, renal loss was not associated with an increase in dialysis requirement (P = .2). Of the directed intervention techniques, renal reimplantation with or without endarterectomy was associated with increased risk of dialysis requirement (P = .005) and renal loss (P = .04) relative to endarterectomy alone. Mean creatinine concentration on late follow-up was 1.4 mg/dL (from 1.3 mg/dL preoperatively) and was not statistically significantly different between those undergoing renal intervention (1.5 mg/dL) and those who did not (1.4 mg/dL).
Renal artery reconstruction at the time of open repair of paravisceral aneurysms is associated with an increased complication rate, primarily driven by occlusion of reimplanted vessels and increased dialysis requirement. As reported by others, nonelective presentation is the greatest determinant of early death or adverse outcomes.
本研究的目的是回顾开放性主动脉瘤修复术中肾动脉血运重建的结果。
回顾了2010年至2015年在单一机构进行的开放性腹主动脉瘤修复术，包括IV型胸腹主动脉瘤、肾上腹主动脉瘤和肾旁腹主动脉瘤。直接肾重建技术包括根据患者解剖结构进行的外翻内膜切除术、旁路手术和血管再植术。肾丢失定义为动脉闭塞。
该研究纳入了125例患者；其中，57例患者（46%）进行了76次肾重建（38例单侧，19例双侧）。干预措施包括内膜切除术（n = 21）、经主动脉支架置入术（n = 2）、有（n = 25）或无（n = 17）内膜切除术的再植术、旁路手术（n = 4）和结扎术（n = 7）。平均动脉瘤大小为6.4 cm，23%（n = 29）为急诊/紧急手术，20%（n = 25）曾接受过开放性或血管腔内修复术。总体并发症发生率为50%，需要肾干预的组中显著增加，主要原因是33%的患者早期或晚期需要透析，而未进行肾血运重建的患者为16%（P = 0.01）。总体30天死亡率为9%，各组之间无差异。急诊/紧急手术（P < 0.001）与30天死亡率增加相关（24%对比择期手术的4%），但既往开放性或血管腔内修复术（P = 0.4）并非如此。平均随访时间为26个月，定向成像平均至18个月。肾干预（P = 0.01）和急诊/紧急状态（P = 0.04）可预测透析需求；然而，在接受干预的患者中，肾丢失与透析需求增加无关（P = 0.2）。在定向干预技术中，有或无内膜切除术的肾再植术相对于单纯内膜切除术，与透析需求增加风险（P = 0.005）和肾丢失风险（P = 0.04）相关。晚期随访时的平均肌酐浓度为1.4 mg/dL（术前为1.3 mg/dL），接受肾干预的患者（1.5 mg/dL）与未接受肾干预的患者（1.4 mg/dL）之间在统计学上无显著差异。
开放性修复内脏旁动脉瘤时进行肾动脉重建与并发症发生率增加相关，主要由再植血管闭塞和透析需求增加所致。如其他人所报道，非择期手术是早期死亡或不良结局的最大决定因素。
