Clinical effect of accessory renal artery coverage after endovascular repair of aneurysms in abdominal and thoracoabdominal aorta.

BACKGROUND: The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms. METHODS: An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality. RESULTS: Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I2 = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I2 = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I2 = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I2 = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I2 = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I2 = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I2 = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I2 = 0%). CONCLUSIONS: ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.

Complete Antegrade Transapical Deployment of a Branched Aortic Arch Endograft: A Porcine Feasibility Study.

PURPOSE: To describe and prove the concept of a technique for complete transapical deployment of a single-branch aortic arch endograft in a porcine model. METHODS: Eight domestic pigs underwent antegrade transapical delivery of a single-branch arch endograft, including a mating stent-graft to the innominate artery. Technical feasibility, operating time, radiation parameters, and hemodynamic changes were studied according to a standardized protocol during baseline (T0), after establishing the transapical access and through-and-through wire (T1), and after stent-graft deployment (T2). Myocardial and cerebral blood flow status was assessed using fluorescent microspheres (FM) and transit-time flow measurement (TTFM) monitoring. RESULTS: Transapical access, introduction and deployment of the endograft, side branch catheterization, and deployment of the mating stent-graft were feasible in 6 of 8 animals. One animal died due to irreversible heart rhythm disorders and one due to accidental graft rotation during deployment, resulting in unintended coverage of the innominate artery. The mean operating and fluoroscopy times were 223±11 minutes and 27.2±6.3 minutes, respectively. During introduction and deployment of the stent-graft, transient aortic valve insufficiency occurred in all animals. Hemodynamic stability recovered within 10 minutes after retrieval of the delivery system in all animals. The innominate artery was patent, with unchanged TTFM measurements throughout the procedure. FM evaluation revealed stable cerebral blood flow. CONCLUSION: An antegrade transapical access to the aortic arch for implantation of a single-branch endograft is feasible in a porcine model with reversible impact on hemodynamic measures during deployment. Transapical access allows deployment of a complex endograft through a single large-bore access site in a porcine model.