Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK.
Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK.
Eur J Vasc Endovasc Surg. 2018 Oct;56(4):486-496. doi: 10.1016/j.ejvs.2018.01.021. Epub 2018 Mar 3.
OBJECTIVE/BACKGROUND: The effect of suprarenal (SR) as opposed to infrarenal (IR) fixation on renal outcomes post-endovascular aneurysm repair (EVAR) remains controversial. This meta-analysis aims to update current understanding of this issue.
A prior meta-analysis was updated through a Preferred Reporting Items for Systematic reviews and Meta-Analyses search for additional studies published in the last 3 years reporting on renal dysfunction or related outcomes post-EVAR. Random effects meta-analysis was undertaken using SPSS.
A total of 25 non-randomised studies comparing SR with IR fixation were included, totalling 54,832 patients. In total, 16,634 underwent SR and 38,198 IR. Baseline characteristics, including age, baseline estimated glomerular filtration rate, diabetes, cardiac disease, and smoking, were similar between the groups. There was a small but significant difference in outcomes for renal dysfunction at the study end point (SR 5.98% vs. IR 4.83%; odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.40 [p < .001]); however, at 30 days and 12 months there was no significant difference, and this did not hold up to sensitivity analysis. Incidence of renal infarcts (SR 6.6% vs. IR 2.3%; OR 2.78, 95% CI 1.46-5.29 [p = .002]), renal stenosis (SR 2.4% vs. IR 0.8%; OR 2.89, 95% CI 1.00-8.38 [p = .05]), and renal artery occlusion (SR 2.4% vs. IR 1.2%; OR 2.21, 95% CI 1.15-4.25 [p = 0.02]) favoured IR fixation; however, there was no difference in haemodialysis rates.
This meta-analysis has identified small but significantly worse renal outcomes in patients having SR fixation devices compared with IR; however, there was no difference in dialysis rates and a small effect on renal dysfunction, which did not stand up to rigorous sensitivity analysis. This should be taken into consideration during graft selection, and further studies must assess renal outcomes in the longer term, and in those with pre-existing renal dysfunction.
目的/背景：关于肾周（SR）相对于肾下（IR）固定对血管内动脉瘤修复（EVAR）后肾脏结局的影响，目前仍存在争议。本荟萃分析旨在更新对此问题的现有认识。
通过系统评价和荟萃分析的首选报告项目进行了一项先前的荟萃分析更新，以查找过去 3 年中报告有关 EVAR 后肾功能障碍或相关结局的额外研究。使用 SPSS 进行随机效应荟萃分析。
共纳入 25 项比较 SR 与 IR 固定的非随机研究，共纳入 54832 例患者。其中，16634 例行 SR 治疗，38198 例行 IR 治疗。两组的基线特征，包括年龄、基线估计肾小球滤过率、糖尿病、心脏病和吸烟情况，均相似。在研究终点时，肾功能障碍的结果存在微小但显著的差异（SR 为 5.98%，IR 为 4.83%；优势比 [OR] 1.29，95%置信区间 [CI] 1.18-1.40 [p < 0.001]）；然而，在 30 天和 12 个月时，无显著差异，且该结果在敏感性分析中仍然成立。肾梗死（SR 为 6.6%，IR 为 2.3%；OR 2.78，95%CI 1.46-5.29 [p = 0.002]）、肾动脉狭窄（SR 为 2.4%，IR 为 0.8%；OR 2.89，95%CI 1.00-8.38 [p = 0.05]）和肾动脉闭塞（SR 为 2.4%，IR 为 1.2%；OR 2.21，95%CI 1.15-4.25 [p = 0.02]）的发生率均有利于 IR 固定；然而，透析率无差异。
本荟萃分析发现，与 IR 固定装置相比，行 SR 固定装置的患者的肾功能结果略差，但差异显著；然而，透析率无差异，肾功能障碍的影响较小，且在严格的敏感性分析中不成立。在移植物选择时应考虑到这一点，并且必须进一步研究评估在更长时间内和在存在预先存在的肾功能障碍的患者中的肾脏结局。
