The outcome of thoracic endovascular aortic repair (TEVAR) in patients with renal insufficiency
Presented at the Twenty-First Annual Meeting of the Eastern Vascular Society, Baltimore, Md, Sep 30-Oct 4, 2007.
Received 22 April 2008; accepted 23 July 2008. published online 25 November 2008.
Objective
We sought to determine the effects of renal insufficiency on thoracic endovascular aortic repair (TEVAR) outcome and to identify predictors for adverse events.
Methods
Eighty-four patients with renal insufficiency (creatinine ≥1.5 mg/dL) were analyzed from a prospective TEVAR database from April 1, 1999, to January 1, 2008. Patients were subdivided into groups by creatinine level (mg/dL): group 1 (1.5-2.0), group 2 (2.0-3.0), group 3 (>3.0), and group 4 (preoperative dialysis-dependent). Demographics, aneurysm/aortic lesion characteristics, perioperative morbidity, mortality, and follow-up data were compared with 246 control patients (<1.5 mg/dL).
Results
Comorbidities were similar between the renal insufficiency and control groups, except for age (74 ± 8 vs 69 ± 6 years, P < .0002), male gender (73% vs 58%, P < .02), and presence of peripheral vascular disease (56% vs 38%, P < .005). Mean follow-up was 9 months. The renal insufficiency and control groups had similar aortic pathologies, including fusiform (51% vs 57%) and saccular aneurysms (27% vs 37%). Overall mean serum creatinine and creatinine clearance did not worsen during follow-up. Perioperatively, 18 patients (21%) patients required dialysis. Nine patients (11%) presented a newly acquired need for dialysis. Degree of preoperative renal impairment correlated with increasing dialysis requirement: group 1, 5% (3 of 55); group 2, 25% (3 of 12); group 3, 38% (3 of 8); and group 4, 100% (9 of 9). Three patients did not recover baseline renal function. Contrast type (isosmolar vs hyposmolar) and amount (96 ± 8 mL vs 100 ± 8 mL, P = .33) was similar between the dialysis and no-dialysis groups. Renal insufficiency patients had a statistically significant higher rate of major adverse events (25% vs 6.9%, P < .00003), 30-day mortality (11% vs 4.4%, P < .05), and myocardial infarction (6.0% vs 1.0%, P < .013) than controls. One or more major adverse events occurred in 25%, including stroke (6.0%), myocardial infarction (6.0%), and spinal cord ischemia (4.8%). Predictors for adverse events included emergency repair (odds ratio, 3.1; 95% confidence interval, 1.1-8.4; P = 0.037) and baseline creatinine >2.0 (odds ratio, 5.9; 95% confidence interval, 2.1-16.8; P = .001). Age, gender, adjunctive access, type of aortic pathology, and number of device components did not adversely affect outcome.
Conclusion
Patients with preoperative renal insufficiency maintain renal function after TEVAR. However, this patient population may be susceptible to increased adverse events, with emergency repair and baseline creatinine >2.0 mg/dL serving as strong predictors.
Hospital of the University of Pennsylvania, Philadelphia, Pa
Correspondence: Dr Grace J. Wang, Hospital of the University of Pennsylvania, Surgery, 3400 Spruce St, 4 Maloney, Philadelphia, PA 19104
ABSTRACT