Plotkin Anastasia, Weaver Fred A, Abou-Zamzam Ahmed, Malas Mahmoud B, Lee Jason T, Han Sukgu M, Ding Li, Magee Gregory A
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
Division of Vascular Surgery, Department of Surgery, Loma Linda University Health, Loma Linda, Calif.
J Vasc Surg. 2021 Oct;74(4):1193-1203.e3. doi: 10.1016/j.jvs.2021.02.033. Epub 2021 Mar 5.
Endovascular abdominal aortic repair can involve the incorporation of renal arteries. Revascularization after intentional or unintentional renal artery (RA) coverage is not always technically successful, and the loss of a single RA may result in the need for postoperative dialysis. Thus, we compared the outcomes after endovascular aneurysm repair (EVAR) stratified by RA involvement (RAI).
Patient data from the Vascular Quality Initiative from 2009 to 2018 registry were analyzed. The exclusion criteria were preoperative dialysis, missing RAI data, and repair above the superior mesenteric artery. The repair type cohorts were defined as (1) no RAI (NRAI), (2) RAI with revascularization (RAI-R), and (3) RAI with no revascularization (RAI-NR). A sensitivity analysis was performed by excluding ruptured presentations. The primary outcome was the need for postoperative dialysis. The secondary outcomes were 30-day mortality, dialysis at follow-up, postoperative renal function, and 2-year survival. Multivariate analysis was used to determine the independent predictors for postoperative dialysis. The 2-year survival analysis was performed using Kaplan-Meier log-rank test.
Of 54,020 patients in the EVAR and TEVAR (thoracic EVAR)/complex EVAR modules in the Vascular Quality Initiative, 25,724 met the criteria for inclusion (NRAI, n = 24,879; RAI-R, n = 733; RAI-NR, n = 112). The demographics and comorbidities were similar among the three groups. The RAI-NR group had more frequently had ruptured or symptomatic aneurysms. The postoperative dialysis requirement was higher in the RAI-NR group (NRAI, 0.7%; RAI-R, 2.2%; RAI-NR, 17%; P < .0001), as were the 30-day mortality and dialysis requirement at follow-up. On multivariate analysis, RAI-R (odds ratio [OR], 2.2; P = .03) and RAI-NR (OR, 5.9; P < .0001) were independent predictors of postoperative dialysis and remained so after excluding ruptured presentations (RAI-R: OR, 3; P = .003; RAI-NR: OR, 22.3; P < .0001). Other independent predictors of the need for postoperative dialysis were worse preoperative renal function, a symptomatic presentation, any preoperative or intraoperative blood transfusion, and larger blood loss (≥200 mL). Excluding those with rupture, the overall survival at 2 years on Kaplan-Meier analysis was lower for the RAI-NR group (NRAI, 92%; RAI-R, 89%; RAI-NR, 80%; P = .004).
RAI is highly predictive of the need for postoperative and permanent dialysis after EVAR. RAI-NR was associated with lower overall survival. These risks should be considered when planning and performing EVAR and should be weighed against the risks of open repair when considering the treatment options.
血管腔内腹主动脉修复术可能涉及肾动脉的处理。在有意或无意覆盖肾动脉（RA）后进行血运重建并非总能在技术上取得成功，而单一肾动脉丧失可能导致术后需要透析。因此，我们比较了根据肾动脉受累情况（RAI）分层的血管腔内动脉瘤修复术（EVAR）后的结局。
分析了2009年至2018年血管质量倡议登记处的患者数据。排除标准为术前透析、缺少RAI数据以及肠系膜上动脉上方的修复。修复类型队列定义为：（1）无RAI（NRAI），（2）有血运重建的RAI（RAI-R），以及（3）无血运重建的RAI（RAI-NR）。通过排除破裂病例进行敏感性分析。主要结局是术后需要透析。次要结局是30天死亡率、随访时的透析情况、术后肾功能以及2年生存率。采用多变量分析确定术后透析的独立预测因素。使用Kaplan-Meier对数秩检验进行2年生存率分析。
在血管质量倡议的EVAR和TEVAR（胸主动脉腔内修复术）/复杂EVAR模块中的54020例患者中，25724例符合纳入标准（NRAI，n = 24879；RAI-R，n = 733；RAI-NR，n = 112）。三组患者的人口统计学和合并症情况相似。RAI-NR组中破裂或有症状的动脉瘤更为常见。RAI-NR组术后透析需求更高（NRAI为0.7%；RAI-R为2.2%；RAI-NR为17%；P <.0001），30天死亡率和随访时的透析需求也更高。多变量分析显示，RAI-R（比值比[OR]，2.2；P =.03）和RAI-NR（OR，5.9；P <.0001）是术后透析的独立预测因素，在排除破裂病例后依然如此（RAI-R：OR，3；P =.003；RAI-NR：OR，22.3；P <.0001）。术后需要透析的其他独立预测因素包括术前肾功能较差、有症状表现、任何术前或术中输血以及失血量大（≥200 mL）。排除破裂病例后，Kaplan-Meier分析显示RAI-NR组2年总生存率较低（NRAI为92%；RAI-R为89%；RAI-NR为80%；P =.004）。
RAI对EVAR术后及永久性透析需求具有高度预测性。RAI-NR与较低的总生存率相关。在规划和实施EVAR时应考虑这些风险，并在考虑治疗方案时与开放修复的风险进行权衡。
