Journal of Vascular Surgery
Volume 45, Issue 3 , Pages 451-460, March 2007

Carbon dioxide digital subtraction angiography–assisted endovascular aortic aneurysm repair in the azotemic patient

Presented at the Twenty-First Annual Meeting of the Western Vascular Society, La Jolla, Calif, Sept 16-19, 2006.

Department Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, Los Angeles, Calif.

Received 18 September 2005; accepted 3 November 2006. published online 26 January 2007.

Article Outline

Objective

This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO2-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA).

Methods

Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO2-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine ≥1.5 mg/dL, and CO2-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using χ2 analysis, Student t test, and the Fisher exact test.

Results

A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups.

Conclusions

CO2-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.

 

Endovascular aortic aneurysm repair (EVAR) has emerged as the treatment of choice for many patients with an abdominal aortic aneurysm (AAA). Recent prospective studies have documented that short-term morbidity and mortality are improved with EVAR compared with open repair.1, 2 One potential limitation to the use of EVAR in the medically compromised patient, for whom EVAR is of particular advantage, is the existence of renal dysfunction (serum creatinine, >1.5 mg/dL). The need for significant volumes of nephrotoxic iodinated contrast for preoperative assessment and endograft placement may aggravate pre-existing renal dysfunction and accelerate the appearance of end-stage renal disease in selected patients. In addition, there is evidence to suggest that the nephrotoxic effects of iodinated contrast on the renal parenchyma are not transient but rather permanent and cumulative.3

An alternative contrast approach for EVAR is the use of carbon dioxide (CO2) and CO2 digital subtraction angiography (CO2-DSA), which was first described for diagnostic purposes by Hawkins.4 Although the use and value of CO2-DSA in the diagnostic setting is well established,5 its safety and efficacy in guiding endovascular interventions and EVAR in particular has not been carefully studied or conclusively established.

We have extensive experience with CO2-DSA.6, 7, 8, 9 Since 2003, our group has used it as the preferential imaging technique for EVAR candidates who have pre-existing renal dysfunction. This report analyzes the safety and efficacy of CO2-DSA for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast (ICA).

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Patients and methods 

This is a retrospective cohort study of 100 consecutive patients treated by EVAR at the University of Southern California University Hospital between 2003 and 2005. The chart of each patient was retrospectively reviewed and data recorded in an investigational database. The research protocol was reviewed and approved by the Institutional Review Board.

Among the preoperative variables recorded were demographics and risk factors (diabetes mellitus, hypertension, coronary artery disease, and tobacco use), body mass index, and serum creatinine concentration. Estimated glomerular filtration rate (eGFR) was calculated using the Cockroft and Gault formula: GFR = [(140 – age) × weight in kg]/[72 × serum Cr in mg/dL] × f(P), where f(P) = 1 for males and 0.85 for females. EVAR intraoperative variables of graft type, fluoroscopy time, total radiation exposure (dose-area product), operative time, iodinated contrast volume, use of CO2, use of gadolinium and volume, presence of endoleak, and type and number of graft extenders were recorded.

Postoperative variables included serum creatinine concentration and eGFR on postoperative day 1 and at discharge, intensive care unit stay, hospital length of stay, postoperative morbidity, and mortality. Results of postoperative endograft imaging by computed tomography (CT), ultrasonography, or both, and the need for endograft revision at 1 and 6 months were recorded.

For purposes of analysis, preoperative renal function was used to categorize patients into one of two groups. Group I patients had normal renal function as evidenced by a serum creatinine <1.5 mg/dL and the EVAR was performed exclusively with iodinated contrast (ISOVUE 300, Bracco Diagnostics, Princeton, NJ). Group II patients had chronic renal insufficiency as defined by a serum creatinine ≥1.5 mg/dL and the primary intravascular contrast agent was CO2. When suboptimal imaging with CO2-DSA occurred, CO2-DSA was supplemented with gadolinium or iodinated contrast.

The primary end points of successful graft placement, renal function, and the need for graft revision were compared between the two groups. Other secondary end points for comparison included endoleak type and frequency and perioperative morbidity and mortality.

The technique of CO2-DSA involves the following (Fig 1)6, 7: A sterile bag (Angioflush 3 fluid collection bag, Angiodynamics, Queensbury, NY) with attached tubing (Connecting tube, Boston Scientific, Natick, Mass) with a stopcock is inflated with CO2. The bag is purged and inflated with CO2 three times to eliminate the possibility of room air contamination. The attached stopcock is closed, the inflated bag disconnected, and then connected to tubing (Angioflush fluid management system tubing, Angiodynamics) with one-way valves and a sidearm. The end of the catheter contains a three-way stopcock and is connected to the intra-arterial injection catheter. The sidearm of the tubing is connected to a 60 mL Luer lock syringe. With the three-way stopcock open to air and closed to the injection catheter, the syringe is filled and purged at least three times to rid the syringe and tubing of room air. After the final filling, the stopcock is closed to air and open to the injection catheter, creating a closed CO2 system.

Hand injection of 50 mL using digital subtraction imaging is used for angiography. Because CO2 is rapidly soluble in blood and disappears quickly, high frame rates of 3 to 6 frames per second are necessary. Stacking technology is used to combine frames and produce a single image for viewing, if necessary. Multiple injections in various imaging planes, rotation of the patient, or both, are sometimes necessary to demonstrate the relevant anatomy and to remove the vessel from overlying bowel gas or bone.

Indications for EVAR included patients with infrarenal AAA >5.0 cm with favorable endovascular anatomy. Imaging evaluation included spiral CT angiography (CTA) with axial and coronal reconstructions to evaluate anatomy. For group II patients, preoperative planning and postoperative endograft surveillance were done with a combination of imaging techniques that included noncontrast CT, aortic duplex imaging, and magnetic resonance imaging (MRI).

In all patients, hydration was initiated preoperatively, and group II patients received either pretreatment with N-acetylcysteine, intravenous bicarbonate, or a combination of the two. EVAR was performed with Ancure (Guidant, Indianapolis, Ind), Excluder (W.L. Gore & Assoc, Flagstaff, Ariz), AneuRx (Medtronic, Sunrise, Fla), or Zenith (Cook, Bloomington, Ind) endografts. All cases were performed under general anesthesia in a dedicated operating suite with fixed angiographic equipment (Phillips Allua 2001, Bothell, Wa).

The EVAR procedure consisted of bilateral groin access and initial angiography for localization of the renal and hypogastric arteries and definitive sizing of graft length. The main body of the graft was deployed in the infrarenal position after one or two angiograms with magnified views were performed of the perirenal aorta. After deployment, placement of the contralateral limb, and the ipsilateral limb in cases of the Zenith graft, was completed by using angiograms for localization of the hypogastric arteries. A final angiogram was used to evaluate for endoleaks and final graft position. Additional angiographic runs were used if an endoleak was detected that required additional intervention or placement of additional graft extensions. All type I and III endoleaks were addressed. Detected type II endoleaks were observed.

Statistical comparison of preoperative, intraoperative, and postoperative variables for groups I and II was performed using χ2 analysis for random ordinal variables, the Fisher exact test for nonrandom variables, and the Student two-tailed t test for comparison of continuous variables. A value of P < .05 was considered significant.

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Results 

Between 2003 and 2005, 100 patients (84 in group I and 16 in group II) underwent EVAR. The average patient age was 76 years, and 67% were men. The groups had similar preoperative demographics and risk factors, although a trend was noted towards an increased incidence of coronary artery disease in group II (30% group I vs 60% group II, P = .06; Table I). Patients in group II had a mean preoperative serum creatinine of 1.8 mg/dL and eGFR of 36 mL/(min·1.73 m2) and group I patients had a mean creatinine of 1.0 mg/dL and eGFR of 81 mL/(min·1.73 m2). Table II tabulates the breakdown of eGFR in the two groups by the National Kidney Foundation classification for chronic kidney disease. No patient in either group was on dialysis.

Table I. Preoperative variables
Characteristic⁎Group I n = 84 (%)Group II n = 16 (%)P
Male (n)69(82)15(94)NS
Age (years)76(54-93)77(59-89)NS
CAD25(30)10(60)NS
Hypertension50(60)11(70)NS
Tobacco use67(80)13(80)NS
COPD8(10)3(20)NS
Diabetes mellitus10(12%)3(20%)NS
Aneurysm size (cm)5.8(4.5-7.5)6.4(4.7-11)NS
Serum creatinine1.0(0.5-1.6)†1.8(1.5-3.2)<.05
Estimated GFR81(22-167)36(15-63)<.05

CAD, Coronary artery disease; COPD, chronic obstructive pulmonary disease; GFR, glomerular filtration rate.

⁎Categoric data are presented with percentages; continuous variables are presented as means (range).

†One patient had an admission creatinine of 1.6 mg/dL, all prior <1.5 so the procedure was done with iodinated contrast only and included in group I.

Table II. Chronic kidney disease stage for patients in groups I and II
GFRCKD stage⁎Group I n = 84(%)Group II n = 16(%)
90129(35)1(6)
60-89227(32)1(6)
30-59325(30)10(63)
15-2943(4)4(25)
<15500

GFR, glomerular filtration rate; CKD, chronic kidney disease.

⁎Stages CKD as defined by the National Kidney Foundation (www.kidney.org).

Endografts placed included 8 Ancure, 2 AneuRx, 81 Excluder, and 9 Zenith. The amount of iodinated contrast necessary for endograft placement differed significantly at 148 mL in group I vs 27 mL in group II (P ≤ .005). Thirteen (80%) patients in group II received either supplemental gadolinium (40 mL in a single patient) or iodinated contrast (mean volume, 23 mL in 12 patients). Operative time was shorter in group I (140 minutes vs 180 minutes, P = .05) as was fluoroscopy time (24 minutes vs 46 minutes, P = .01). Total radiation exposure was lower in group I at 529 Gy/cm2 vs group II at 925 Gy/cm2 (P = .04). There was no difference in the other intraoperative variables examined (Table III).

Table III. Intraoperative variables
Characteristic⁎Group I (n = 84)Group II (n = 16)P
Iodinated contrast dose (mL)148±2027±5<.005
Fluoroscopy time (min)24±1.546±7.01
Total radiation (Gy/cm2)529±44925±138.04
Endoleak detected43 (51%)10 (63%)NS
Operative time (hours)2.3±0.23.0±0.3.05
Graft extenders0.4±0.050.5±0.13NS
Hypogastric embolization0.18±0.040.38±0.11NS

⁎Continuous variables are expressed as mean ± standard error of the mean.

A total of 66 intraoperative endoleaks were detected in 56 patients: Ia in 28, Ib in 6, II in 31, and III in 1. All but two type I endoleaks were successfully managed intraoperatively by either redo balloon angioplasty at the attachment site or placement of additional components. There was no significant difference between groups in the total or types of endoleaks detected (Table IV). When used in group II, the use of supplemental iodinated or gadolinium contrast angiograms did not demonstrate endoleaks not previously seen with CO2-DSA.

Table IV. Intraoperative endoleaks by specific type
TypeGroup I⁎Group II†OR (95% CI)P
Type Ia24(29%)4(25%)1.2(0.4-4.1)NS
Type Ib4(5%)2(13%)0.4(0.1-2.1)NS
Type II26(31%)6(24%)0.7(0.2-2.3)NS
Type III1(1.2%)0(0%)N/ANS

OR, Odds ratio; CI, confidence interval; N/A, not applicable.

⁎Group 1: 53 endoleaks detected in 43 patients.

†Group 2: 12 endoleaks detected in 10 patients.

Overall mean postoperative serum creatinine and eGFR were unchanged from preoperative levels in both groups both on postoperative day 1 and at discharge. One patient in group 2 had a significant increase (>20%) in serum creatinine. This patient received 40 mLs of gadolinium, but no iodinated contrast. The serum creatinine level increased from a preoperative value of 2.2 to 3.0 mg/dL on the first postoperative day, but returned to the preoperative baseline by discharge. Serum creatinine values recorded in this patient 3 months before EVAR were from 2.2 to 3.5 mg/dL. No patient in either group required dialysis postoperatively or during follow-up.

Group I and group II were not significantly different in mean hospital length of stay (2.0 vs 3.9 days), mean length of intensive care unit stay (0.64 vs 0.86 days), and postoperative morbidity (6% vs 12%). Specific postoperative complications in group I were one patient each with unplanned hypogastric artery coverage, myocardial infarction, urinary retention, femoral arterial-venous fistula, and retroperitoneal bleed requiring transfusion; and in group 2, one patient each with iliac artery dissection, paraplegia, and femoral pseudoaneurysm. No deaths occurred in either group (Table V).

Table V. Postoperative variables
CharacteristicGroup IGroup IIP
LOS2±0.23.9±1NS
ICU LOS0.9±0.1.64±0.3NS
Post-op creatinine (mg/dL)0.9±0.031.8±0.14<.0002
Creatinine change (mg/dL)⁎–0.06±0.020.01±0.07NS
Morbidity6%12%NS
Mortality00NS

LOS, Length of stay; ICU, intensive care unit stay length.

⁎Creatinine change is difference between admission and discharge serum creatinine level.

At 1 month postoperatively, the incidence of endoleaks detected by imaging was 13% in group I vs 18% in group II (P = NS). Five type II endoleaks (four in group I and one in group II) not seen intraoperatively were detected at 1 month. Endoleak incidence was unchanged on 6-month endograft imaging studies (group I, 10% vs group II, 18%; P = NS). Diagnostic angiograms for possible type I endoleaks that were determined to be type II endoleaks were performed in two group I patients. No remedial procedures were required in either cohort at 6 months.

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Discussion 

Pre-existing chronic kidney disease occurs in approximately 7% to 25% of patients undergoing EVAR.10, 11 The reported incidence of acute renal failure after EVAR varies owing to differences in reporting standards but is between 2% and 16%, and recent studies confirm an associated mortality of 30% to 50% 3, 12, 13 Although pre-existing renal insufficiency carries the highest risk of post-EVAR renal failure, patients with normal preoperative serum creatinine values are not immune, and in a standard-risk group showed a 2.5% incidence of renal dysfunction when defined as a serum creatinine increase of 30%. Notably, when followed out to 1 year, the incidence of renal dysfunction increased to 16% in this same cohort.3

Part of the explanation for this observation in standard-risk patients, particularly those in the geriatric age group who have diminished muscle mass because of aging, is that the serum creatinine level can be a very inaccurate indicator of overall renal function. Our observation that a mean serum creatinine of <2 mg/dL was associated with a critically reduced mean eGFR of 36 mL/(min·1.73 m2) supports this explanation and argues that any reported clinical assessment of renal function should, at the very least, be indexed by body mass.

From open surgical data, it has been reported that patients with pre-existing renal dysfunction have a disproportionately high risk of perioperative morbidity (30% vs 13%) and acute renal failure.14 Whether EVAR might lessen the morbidity and incidence of renal decompensation in this particular patient population is unknown. Greenberg et al3 analyzed 279 patients undergoing open and EVAR with suprarenal fixation and saw an early renal benefit in renal function in the endovascular group. When the open group who required suprarenal cross-clamping was eliminated, however, the incidence of acute renal failure was equivalent.

Acute renal decompensation after endovascular or open repair has a number of causes.15, 16 Common reasons attributed to open surgery are renal or suprarenal cross-clamping, blood loss, hypotension, ischemia–reperfusion injury, and manipulation of thrombus, with renal parenchyma microembolization leading to activation of vasoactive components, endothelial damage, and cytokine release. Although many of these same factors can occur with EVAR, endovascular aortic procedures add the additional renal insult of iodinated contrast. With both intraoperative placement and postoperative surveillance by CT of aortic endografts contrast, the cumulative dose of nephrotoxic contrast becomes significant over time. Greenberg et al3 have stated that this repetitive use of iodinated contrast and the nephrotoxic insult incurred may be responsible for the observed deterioration in renal function after endograft replacement.

Previous studies have documented the risks of renal failure after diagnostic ICA. Moore reported an 11% rate of acute renal failure in 400 patients who underwent aortography. In the group with pre-existing renal dysfunction, acute renal decompensation developed in 42%, and 8% required dialysis.17 In a series of 164 patients undergoing EVAR, Walker et al13 documented a mortality of 47% in the 15 patients with preoperative renal impairment and 2.7% in those with normal renal function. More recent reports suggest that acute renal decompensation after diagnostic angiography is currently less common owing to a more judicious use of iodinated contrast as well as a combination of strategies aimed at reducing the risk of post contrast nephropathy.

These proposed strategies include the use N-acetylcysteine (Mucomyst, Roberts Pharmaceuticals, Eatontown, NJ), dilution of iodinated contrast, intravenous bicarbonate infusions, mannitol, fenoldopam, robust preprocedure and postprocedure hydration, and in selected circumstance, the use of gadolinium. We have found all these modalities empirically useful in selected patients but each with intrinsic limitations. For example, the contrast agent gadolinium appears to be a simple and reasonable alternative to iodinated contrast. In practice, however, the recommended dosage of 0.3 to 0.4 mmol/kg calculates to only 30 mL, and when doubled to its maximum, allows for only 60 mL. Although adequate for MRI, this dose is inadequate as a stand-alone agent for EVAR. In addition, those who have tried dilute gadolinium have been disappointed with its attenuating ability.18 Other limitations include hyperosmolarity and cost, and recent reports suggest that gadolinium may be nephrotoxic as well.19, 20, 21 This may have been the cause of the transient rise in serum creatinine in one patient who underwent CO2-DSA supplemented only with gadolinium.

Several groups have reported CO2-DSA to be safe and useful.5, 6, 7, 8, 9 Its mechanism is the transient displacement of arterial blood, providing a contrast image. Because of its buoyancy, visualization of dependent vasculature may be limited. Operators have circumvented this shortcoming by changing the patient position to place the area of interest in a nondependent position. In an experience with >800 cases of CO2-DSA, we have found these maneuvers to be rarely necessary. In most cases, simple repositioning of the injection catheter and reinjection of CO2 in different projection planes yields adequate views. Others have described the importance of using a specialized injector to achieve optimal angiography and avoid inadvertent introduction of air. We use a simple hand-injection method and closed system that includes a 60 mL syringe, three-way stopcock, and a bag of CO2.

Although some question the safety of CO2-DSA, we have found it to be a safe and valuable technique. In a recent review of 605 CO2-DSA procedures performed at our institution for a variety of endovascular interventions, adverse events occurred in 5.1% (31/605) and included abdominal pain in 8, puncture site hematoma in 11, transient hypotension in 4, nausea in 3, and 1 patient each with renal failure, chest pain, localized aortic dissection, hives, and paresthesia. Two patients had persistent abdominal pain after aortography associated with hyperamylasemia and clinical evidence of pancreatitis. One died, for a mortality rate of 0.17%; however, the role of CO2-DSA in that death is uncertain because microvascular cholesterol emboli were found at autopsy (Hood DB, Hua HT, Weaver FA. Carbon dioxide digital subtraction angiography: is it safe? Personal communication.)

The application of CO2-DSA for EVAR has previously been suggested by Gahlen et al,22 who reported its use in three patients. Our report adds 16 patients and compares them with a concurrent group undergoing EVAR. The use of CO2-DSA permitted a significant reduction in iodinated contrast use and minimized post-EVAR deterioration in renal function in patients with pre-existing azotemia. In three patients, EVAR was performed exclusively with CO2. Successful endograft placement was possible in all 16 patients in group II, and the incidence of intraoperative endoleaks in groups I and II was similar. Of interest is our observation that CO2, because of its lower viscosity, is actually more sensitive in documenting intraoperative endoleaks than iodinated contrast. A prospective trial at our institution to further investigate this clinical observation is in progress.

Subsequent 6-month clinical follow-up and graft surveillance documents equivalency for endoleak incidence and the need for endograft revision. One caveat to this observation is that postoperative imaging for group II did not include the use of iodinated contrast CT, but relied on duplex, noncontrast CT, and MRI. As a consequence, some endoleaks, particularly small low-flow type II endoleaks, could have been missed in group II.

An observation not previously noted concerning CO2-DSA for EVAR is the significant increase in radiation exposure documented in group II patients. There are a number of possible explanations for this finding.

First, adequate CO2-DSA imaging does require an increase in frame rate from the customary two frames per second for iodinated contrast to six frames per second. This more than doubles the radiation exposure for each CO2-DSA run compared with iodinated contrast. In addition, we also documented that total fluoroscopy time was approximately doubled in group II cases. This could have been due to increased technical complexity in the CO2-DSA–directed EVAR cases. The finding of numeric but not statistically significant increases in the average number of graft extenders and the requirement for hypogastric artery embolization in group II cases lends support to this possibility. That total operative time was also significantly increased in group II lends additional support.

An alternative explanation however, includes either difficulty with CO2 delivery or, more likely, poor image resolution with CO2-DSA necessitating the use of iodinated contrast and a “repeat run” of the same area of interest. This was certainly the case in 13 patients in group II in which some iodinated contrast or gadolinium was necessary.

The significance of this finding must be considered in the context of lifetime diagnostic and therapeutic radiation exposure. The difference of approximately 400 Gy/cm2 in average dose-area product between group I and II is roughly equivalent to 6,000 mrem. A standard abdominal CT angiogram exposes the patient to 144 Gy/cm2 (2000 mrem).23, 24 Consequently, the incremental increase in radiation exposure in group II is roughly equivalent to three additional CT scans over the life of the patient.

The effects of increased exposure to the operating team should also be commented on. The average radiology technician in our institution receives about 20 to 30 mrem a month (with detectors worn on the outside of lead shielding), with a maximum allowable exposure of 5000 mrem a year. As a point of reference, the average American is exposed to 360 mrem a year, mostly from terrestrial causes. It is estimated that the chance of cancer increases 10% after a total exposure of 250,000 mrem. The contribution of CO2-DSA in this context appears to be negligible, particularly if appropriate shielding and wearing of lead aprons is followed.

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Conclusion 

This experience documents CO2-DSA–directed EVAR to be a safe and effective strategy for reduction of contrast nephrotoxicity in the azotemic patient. The reduction in iodinated contrast use is accompanied by post-EVAR stability in renal function that is superior to the 2% to 16% incidence of renal deterioration that is reported in the literature. This salutary short-term outcome is accompanied by a late endoleak incidence and endograft revision rate that is equivalent to patients undergoing EVAR with iodinated contrast. These positive outcomes are tempered by the finding that CO2-DSA for EVAR does prolong fluoroscopy times and increases radiation exposure to both patient and operating room personnel (Fig 2, Fig 3).

  • View full-size image.
  • Fig 3. 

    Type II endoleak intraoperatively documented by (A) iodinated contrast and (B) carbon dioxide digital subtraction angiography. Arrows point to feeding lumbar arteries.

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Author contributions 


Conception and design: AC, KM, DBH, VLR, FAW

Analysis and interpretation: AC, KM, KP, DBH, VLR, RKB, FAW

Data collection: IT, AC, KM, KP, RKB

Writing the article: AC, IT, KM, DBH, FAW

Critical revision of the article: AC, FAW

Final approval of the article: AC, FAW

Statistical analysis: RKB

Obtained funding: Not applicable

Overall responsibility: FAW

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References 

  1. Prinssen M, Verhoeeven ELG, Buth J, Cuypers PWM, van Sambeek MRHM, Balm R, et al A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. New Engl J Med. 2004;351:1607–1618
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  3. Greenberg RK, Chuter TAM, Lawrence-Brown M, Haulon S, Nolte L Zenith Investigators. Analysis of renal function after aneurysm repair with a device using suprarenal fixation (Zenith AAA endovascular graft) in contrast to open surgical repair. J Vasc Surg. 2004;39:1219–1228
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 Competition of interest: none.

 CME article

PII: S0741-5214(06)02061-1

doi:10.1016/j.jvs.2006.11.017

Journal of Vascular Surgery
Volume 45, Issue 3 , Pages 451-460, March 2007

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