Tanious Adam, Boitano Laura T, Wang Linda J, Shames Murray L, Lee Jason T, Eagleton Matthew J, Clouse W Darrin, Conrad Mark F
Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA.
Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA.
Ann Vasc Surg. 2020 Jan;62:63-69. doi: 10.1016/j.avsg.2019.05.005. Epub 2019 Jun 13.
Coverage of one or both renal arteries may be required to facilitate endovascular aneurysm repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures.
Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival.
Overall, there were 2,278 patients presenting with ruptured aneurysms. Most patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR] = 5.7, ±4; P = 0.030), permanent dialysis/30-day death (OR = 9.5, ±7; P = 0.016), and permanent dialysis (OR = 47.5, ±47; P < 0.001). Two patients with bilateral renal coverage did not suffer permanent dialysis/death. Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR = 2.8, ±1.6; P = 0.044) driven mainly by its effect on the outcome of permanent dialysis (OR = 12.3, ±6; P < 0.001). Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR] = 3.4, P = 0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR = 3.5, P = 0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models.
Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.
对于破裂性腹主动脉瘤（rAAA）且不适合开放手术的患者，可能需要覆盖一侧或双侧肾动脉以促进血管内动脉瘤修复（EVAR）。我们试图了解这些急诊手术中肾动脉覆盖的后果。
利用2013年至2018年的VQI数据集，我们选择了接受rAAA的EVAR治疗的患者。根据患者是否有未覆盖、单侧或双侧肾动脉覆盖来区分。如果患者先前接受过透析或进行过保留肾灌注的干预，则将其排除。主要终点包括住院死亡率、永久性透析/30天死亡复合终点和1年生存率。
总体而言，有2278例患者出现破裂性动脉瘤。大多数患者没有肾动脉覆盖（n = 2230；98%），其次是单侧肾动脉覆盖（n = 30；1.2%），最后是双侧肾动脉覆盖（n = 18；0.8%）。在多变量回归分析中，双侧肾动脉覆盖与住院死亡率增加的几率相关（比值比[OR]=5.7，±4；P = 0.030）、永久性透析/30天死亡（OR = 9.5，±7；P = 0.016）以及永久性透析（OR = 47.5，±47；P < 0.001）。两名双侧肾动脉覆盖的患者未发生永久性透析/死亡。单侧肾动脉覆盖显著增加了永久性透析/30天死亡的几率（OR = 2.8，±1.6；P = 0.044），主要是因其对永久性透析结局的影响（OR = 12.3，±6；P < 0.001）。未调整的Kaplan-Meier 1年生存率估计在双侧肾动脉覆盖时显著更低（风险比[HR]=3.4，P = 0.0002）。在调整分析中，双侧覆盖仍然是一个显著的预测因素（HR = 3.5，P = 0.002）；然而，在未调整或调整模型中，单侧肾动脉覆盖对生存率没有显著影响。
rAAA患者的双侧肾动脉覆盖显著增加住院死亡率并降低长期生存率。虽然单侧肾动脉覆盖主要因其对永久性透析的影响而增加永久性透析/30天死亡的风险，但它对住院死亡率或1年生存率没有显著影响，对于某些rAAA患者可能是一个可行的选择。
