Midterm outcome of renal function after branched thoracoabdominal aortic aneurysm repair.

OBJECTIVE: The aim of this study was to investigate the incidence and impact of acute and chronic kidney dysfunction after branched endovascular aortic aneurysm repair (BEVAR) perioperatively and during follow-up. METHODS: Patients with a thoracoabdominal aortic aneurysm were treated with BEVAR. Serum creatinine; estimated glomerular filtration rate at baseline, after 48 hours, at discharge, and after 1 and two years; perioperative results; and outcome during follow-up were evaluated. RESULTS: Treatment of thoracoabdominal aortic aneurysm using BEVAR was performed in 113 patients (mean age, 71 years; 79 male) with 434 side branches and two additional fenestrations (0.46%) for renovisceral perfusion. Sixty patients (53%) underwent staged procedures with temporary aneurysm sac perfusion and secondary side branch completion. Perioperative mortality was 9 of 113 (8%). Postoperative acute kidney injury (AKI) was observed in 41 of 113 patients (36%) with recovery of renal function after 2 years in most patients. However, chronic kidney disease (CKD) stage progression after 1 and 2 years was observed in 25 of 104 patients (24%) and 17 of 52 patients (32.7%), respectively. Seven patients (6.7%) required permanent dialysis during 2 years of follow-up. Risk factors for AKI were nonstaged procedures (P = .02) and multiorgan failure (P = .01). CKD progression was related to renal branch reinterventions (P = .047), all branch reinterventions (P = .03), and postoperative AKI (P = .001). During follow-up, survival was decreased in patients with AKI, especially in those with nonmalignant diseases (P = .01). CONCLUSIONS: Postoperative AKI after BEVAR was observed in about one-third of patients associated with increased CKD stages after 2 years. Preoperative CKD was not a risk factor for postoperative AKI or perioperative outcome. The prevention of AKI by staged procedures, early interventions for renal side branch complications, and regular surveillance is recommended to improve outcomes.

Evaluation of visible spinal arteries on computed tomography angiography before and after branched stent graft repair for thoracoabdominal aortic aneurysm.

OBJECTIVE: The aim of this study was to evaluate the impact of intercostal and lumbar segmental arteries (SAs) detectable on computed tomography angiography (CTA) on the risk of spinal cord ischemia (SCI) in patients undergoing single-step or two-staged branched endovascular aneurysm repair (BEVAR). METHODS: A retrospective analysis of patients treated with branched stent grafts for thoracoabdominal aortic aneurysm at a single institution from January 2009 to June 2015 was performed. Data including preoperative comorbidities, perioperative and aneurysm-related parameters, presence and type of endoleak, and rate of severe SCI at discharge or 30 days after the procedure were collected. Preoperative and postoperative contrast-enhanced CTA images were semiquantitatively analyzed by two independent investigators, and the number of visible SAs in the stented aorta before and after BEVAR was evaluated to find a possible correlation with severe SCI. RESULTS: Seventy-seven patients were treated for thoracoabdominal aortic aneurysm with BEVAR (47 men; mean age, 71.0 years), 40 (51.9%) of them with temporary aneurysm sac perfusion (TASP; open branch/TASP group) and 37 without (single-step group). The groups were comparable regarding parameters related to the patient, aneurysm type, and endovascular procedure. Severe SCI or paraplegia was observed in 10 patients (12.3%), and SCI was lower in the open branch/TASP group (2/40) compared with the single-step group (8/37; P = .032). The number of visible SAs in the intentionally overstented aortic segment was significantly reduced on postoperative CTA (10.0 vs 15.57 SAs; P < .001) in comparison to preoperative CTA imaging, with similar results in the open branch/TASP group (9.48 vs 15.83 SAs) and the single-step group (10.57 vs 15.30 SAs; P < .001 for both groups). Within the open branch/TASP group, more visible SAs were detected during the TASP interval in comparison to postoperative CTA after side branch completion (12.93 vs 9.48 SAs; P < .001). Receiver operating characteristic curve analysis in the single-step group revealed a cutoff point of 15 SAs on preoperative CTA with correlation to severe SCI (P = .006). In the high-risk subgroup of patients with 15 or more overstented SAs during BEVAR, staged open branch/TASP procedures again reduced the risk of SCI in comparison to the single-step patients (1/20 vs 8/22; P = .008). CONCLUSIONS: More spinal arteries are visible during the TASP interval, supporting the open branch and TASP concept with a reduction of severe SCI during BEVAR. An intentional coverage of more than 15 SAs is related to an increased risk of SCI, and the rate of paraplegia was reduced after staged BEVAR with open branch/TASP in these high-risk patients.

Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy.

OBJECTIVE: To evaluate and compare the outcome after endovascular abdominal aortic aneurysm repair (EVAR) with the newly released Endurant endograft system in patients with different aortoiliac anatomic characteristics. METHODS: We conducted a prospective observational study assigning patients with infrarenal abdominal aortic aneurysm (AAA) treated with the Endurant endoprosthesis from February 2009 to March 2010. Two groups were studied, according to the presence of a friendly (group I [GI] = 43) or hostile (group II [GII] = 34) infrarenal aortoiliac anatomy. Hostile profile was defined as any (or combination) of the following measurements: 5 mm ≤ proximal neck length (Lpr) ≤ 12 mm, 60° < proximal neck angle (A°pr) ≤ 90° and 60° < any iliac axis angle (A°iliac) ≤ 90°. Primary end points included technical and clinical success, freedom from early or late secondary interventions, any type of endoleak, and aneurysm-related death. All outcome measures were calculated using the Kaplan-Meier method and the log rank test was applied for comparisons between the groups. RESULTS: The mean comorbid severity scoring was higher in GII (P = .018). The mean follow-up period in GI and GII was 12.9 ± 3.9 months (± SD, range: 6.4-19.8) and 12.4 ± 4 months (range: 4.2-19.6), respectively. Two unplanned conversions to aortouniiliac configurations were required in GI. The technical success rate in GI and GII was 95.4% and 100%, respectively. The requirement for intentional occlusion of the internal iliac artery, the requirement for cross-limb technique, the necessity of troubleshooting techniques, the procedure and radiation times, the frequency of postimplantation syndrome, and mean hospital stay were significantly higher in GII (P = .028, P = .013, P = .005, P = .037, P < .001, P = .032, P = .021, respectively). Two patients of GI died in the early postoperative period (one aneurysm but not device-related death), whereas no deaths in GII were recorded, yielding an overall 30-day mortality rate of 2.3%. No type I/III endoleaks were recorded up to the end of the study. Freedom from any type of endoleak, early or late secondary interventions, and aneurysm-related death at 12 months were found in 93.2%, 87.1%, and 93.3% of GI patients; respective values for GII were 86% (P = .21), 93.4% (P = .066), and 93.4%. The clinical success rate was 82.1% and 100% at 12 months for GI and GII, respectively. CONCLUSIONS: Early (12 months) results suggest similar clinical performance of the Endurant stent graft system in endovascular treatment of AAAs with friendly and hostile anatomies, however, demonstrating more intra- and perioperative adversities for the last group. Larger prospective studies or even randomized trials comparing different new generation graft models are required to evaluate the comparable long-term results and possible expansion of EVAR indications for this specific endograft in adverse anatomies.