Villa Federico, Mozzetta Gaddiel, Esposito Davide, Stefano Lucia Di, Pratesi Giovanni, Pulli Raffaele, Angiletta Domenico, Piffaretti Gabriele
Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy.
Vascular Surgery, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa School of Medicine, Genoa, Italy.
J Endovasc Ther. 2024 Feb 26:15266028241234277. doi: 10.1177/15266028241234277.
To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort.
This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year.
The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042).
AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality.
This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.
分析近期一项大型多中心队列研究中，择期标准血管腔内主动脉修复术（EVAR）后急性肾损伤（AKI）的发生率及预测因素。
这是一项多中心、回顾性、无资金支持的由医生发起的观察性队列研究。2018年1月至2021年3月期间，仅分析了接受择期标准EVAR治疗肾下非感染性腹主动脉瘤的患者。已接受血液透析（HD）的患者被排除。AKI定义为48小时内血清肌酐（sCr）升高≥0.3mg/dL，或sCr升高至≥基线的1.5倍（已知或推测在7天内发生），或尿量<0.5mL/kg/h持续6小时。主要关注的结局是30天时的AKI发生率和1年随访时无需HD。次要结局是无严重术后并发症，以及1年时无主动脉相关死亡率（ARM）。
最终队列分析了526例（29.8%）。男性489例（93%），女性37例（7%）：中位年龄为76岁（四分位间距[IQR]，71 - 81岁）。86例（16.3%）患者存在慢性肾脏病（CKD）。8例（1.5%）患者观察到早期死亡，均与主动脉无关。并发症发生率为17.1%（n = 89）。观察到17例（3.2%）发生AKI。4例（0.8%）需要肾脏替代治疗。HD在2例中为暂时性，1例为确定性。二元逻辑回归分析确定CKD（比值比[OR]：4.68，95%置信区间[CI]：2.10 - 10.45，p<0.001）和肾动脉狭窄的存在（OR：3.80，95%CI：1.35 - 10.66，p = 0.011）与术后AKI风险增加相关。1年时估计的无ARM率为94.9%。1年时估计的无需HD率为94%：术前有CKD的患者与术前无CKD的患者之间存在显著差异（对数秩检验，p = 0.042）。
择期标准EVAR术后仍会发生AKI，但发生率可接受地低。术前CKD是术后AKI的最重要预测因素，其与1年随访时是否需要HD无关，但死亡率倾向较高。
这一“真实世界”经验证实，按照标准造影剂方案进行的EVAR对急性肾损伤的发生仍然是安全的。因此，只有术前处于临界状态或已确诊慢性肾脏病的患者将从使用二氧化碳造影剂中获益最大。
