Abstract

Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR.We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury. Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography scans, and CKD stage progression were assessed at latest follow up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics.From 2012-2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3 months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs 73.0 years, P=.04), had increased preoperative creatinine (1.6 vs 0.9 mg/dL, P<.01) and demonstrated increased renal artery ostial calcification (37.7% vs 21.5%, P=.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs 228 ml, P=.01), longer operative times (186 vs 162 min, P=.04), and longer length of stay (3 vs 2 days, P<.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs 95.1%, P<.01 and 55.4% vs 70.8%, P=.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1 year (94.4% vs 100%, P=.015) and 5 years (84.7% vs 100%, P<.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs CKD 3-5 14.3%, P=.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scans between groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P=.17). On multivariable modeling, age (HR 1.05, 95%CI 1.01-1.09, P=.02) and CKD stage 4-5 (HR 6.39, 95%CI 2.26-18.05, P<.01) were independently associated with mortality.Preoperative CKD status did not negatively impact the durability nor technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.

View details for DOI 10.1016/j.avsg.2023.07.102

View details for PubMedID 37586562