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Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation

Banno, Hiroshi Ikeda, Shuta Kawai, Yohei Fujii, Takayuki Akita, Naohiro Takahashi, Noriko Sugimoto, Masayuki Kodama, Akio Komori, Kimihiro 名古屋大学

2020.02

概要

Background: Several reports have indicated that suprarenal (SR) fixation may impair renal function after endovascular abdominal aortic aneurysm repair (EVAR). However, most were short-term or at most, 1-year observational studies; therefore, the midterm effects on renal function remain unclear. This study aimed to identify predictors of midterm renal dysfunction after EVAR and compare renal outcomes in patients after EVAR with SR and infrarenal (IR) fixation. Methods: A total of 467 patients who underwent EVAR of nonruptured IR abdominal aortic aneurysm between 2007 and 2014 were reviewed in a prospectively collected database. Patients on hemodialysis at baseline were excluded. Among the remaining patients, those with 3-year laboratory testing were included in this study. Patients who developed acute kidney injury were excluded from the late renal function estimation. Predictors of 3-year renal function decline were estimated using logistic regression analysis. In addition, patients undergoing EVAR with IR (IR group) and SR fixation devices (SR group) were propensity matched by age, sex, baseline renal function, baseline aneurysm diameter, comorbidities, smoking habits, and regular use of medicines that may act on kidney function. Changes in renal function after surgery were compared between the IR group and the SR group. Results: During the study period, 237 patients (102 IRs and 135 SRs) were followed up with laboratory testing 3 years after surgery. Logistic regression analysis revealed that the use of a SR fixation device was independently predictive of a more than 20% decrease in the estimated glomerular filtration rate at 3 years after EVAR (odds ratio, 2.06; 95% confidence interval, 1.18-3.58; P = .011). Eleven patients who developed acute kidney injury (1 IR and 10 SRs) were excluded from the subsequent analysis. After propensity score matching, 87 pairs were selected (mean age, 77.2 ± 6.3 years; 151 males [86.8%]). The mean follow-up duration was 5.5 ± 1.8 years. In the SR group, estimated glomerular filtration rate at 3 years after surgery decreased significantly more than that in the IR group (mean of 17.8% vs 11.6%, respectively; P = .034). Conclusions: This study suggests that, compared with EVAR with IR endograft fixation, EVAR with SR endograft fixation is associated with worse outcomes for midterm renal function.

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参考文献

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Table 1. Patient demographics and characteristics.

n = 237

Follow-up duration, years, median (IQR)

Age, years, mean (SD)

5.1 (4.0, 6.4)

77.0 (6.3)

Male, n (%)

207 (87.3%)

HT, n (%)

182 (76.8%)

DL, n (%)

100 (42.2%)

DM, n (%)

22 (9.3%)

CAD, n (%)

74 (31.2%)

CVD, n (%)

37 (15.6%)

COPD, n (%)

124 (52.3%)

Baseline serum Cr, mg/dl, mean (SD)

1.00 (0.37)

Baseline eGFR, ml/min/1.73 m2, mean (SD)

60.0 (18.1)

ARB or ACEI, n (%)

118 (49.8%)

Diuretic, n (%)

28 (11.8%)

Antiplatelet, n (%)

98 (41.4%)

Statin, n (%)

97 (40.9%)

ß-blocker, n (%)

48 (20.3%)

CCB, n (%)

Current smoker, n (%)

Aneurysm diameter, mm, mean (SD)

134 (56.5%)

35 (14.8%)

52.7 (9.6)

Intraoperative contrast medium, ml, mean (SD)

Suprarenal fixation, n (%)

Acute kidney injury, n (%)

97.8 (46.1)

135 (57.0%)

11 (4.6%)

HT: hypertension, DL: dyslipidemia, DM: diabetes mellitus, CAD: coronary artery

disease, CVD: cerebrovascular disease, COPD: chronic obstructive pulmonary disease,

Cr: creatinine, eGFR: estimated glomerular filtration rate, ARB: angiotensin receptor

blocker, ACEI: angiotensin-converting enzyme inhibitor, CCB: calcium channel blocker

Table 2. Univariate and multivariate analyses of potential risk factors associated with

midterm renal function decline.

Univariate analysis

Multivariate analysis

Variable

95% CI

Female

1.08

0.50-2.33

0.853

Age

1.02

0.98-1.07

0.299

1.00

0.98-1.03

0.837

SR Fixation

2.00

1.17-3.41

0.011

CKD ≥ IIIa

0.93

0.55-1.56

0.781

CKD ≥ IIIb

1.00

0.52-1.89

0.987

0.68

0.37-1.25

0.210

1.17

0.70-1.98

0.553

1.44

0.60-3.48

0.413

CAD

1.18

0.68-2.06

0.553

CVD

0.72

0.35-1.49

0.374

COPD

1.01

0.61-1.70

0.957

ARB/ACEI

0.69

0.41-1.16

0.164

Diuretic

0.75

0.33-1.70

0.490

Antiplatelet

1.01

0.60-1.70

0.986

Statin

1.04

0.61-1.75

0.897

ß-blocker

0.72

0.37-1.38

0.319

Aneurysm

Diameter

95% CI

1.95

1.12-3.37

0.017

CCB

1.00

0.60-1.69

0.995

Smoker

1.05

0.51-2.18

0.888

AKI

4.00

1.03-15.48

0.045

2.50

0.60-10.44

0.208

SR: suprarenal, CKD: chronic kidney disease, HT: hypertension, DL: dyslipidemia, DM:

diabetes mellitus, CAD: coronary artery disease, CVD: cerebrovascular disease, COPD:

chronic obstructive pulmonary disease, ARB: angiotensin receptor blocker, ACEI:

angiotensin-converting enzyme inhibitor, CCB: calcium channel blocker, AKI: acute

kidney injury

CKD ≥ IIIa indicates eGFR < 60 ml/min/1.73 m2.

CKD ≥ IIIb indicates eGFR < 45 ml/min/1.73 m2.

Bold values indicate statistical significance (p < 0.05).

Table 3. Patient demographics and characteristics comparing infrarenal and suprarenal

fixation in the unmatched and matched cohorts.

Unmatched cohort

IR group

Matched cohort

SR group

IR group

SR group

(n = 87)

(n = 102)

(n = 135)

5.6 (3.8, 6.8)

5.0 (4.0, 6.0)

.14

6.0 (4.1, 7.0)

5.1 (4.0, 6.4)

.14

77.8 (6.2)

76.3 (6.3)

.064

77.4 (6.3)

77.0 (6.4)

.72

Male, n (%)

84 (82.4%)

123 (91.1%)

.045

74 (85.1%)

77 (88.5%)

.50

HT, n (%)

80 (78.4%)

102 (75.6%)

.60

67 (77.0%)

66 (75.9%)

.86

DL, n (%)

43 (42.2%)

57 (42.2%)

.99

36 (41.4%)

38 (43.7%)

.76

DM, n (%)

10 (9.8%)

12 (8.9%)

.81

8 (9.2%)

7 (8.0%)

.79

CAD, n (%)

31 (30.4%)

43 (31.9%)

.81

24 (27.6%)

27 (31.0%)

.62

CVD, n (%)

19 (18.6%)

18 (13.3%)

.27

15 (17.2%)

16 (18.4%)

.84

COPD, n (%)

52 (51.0%)

72 (53.3%)

.72

44 (50.6%)

51 (58.6%)

.29

1.00 (0.45)

1.00 (0.30)

.93

0.95 (0.29)

0.97 (0.30)

.66

60.7 (19.9)

59.5 (16.7)

.63

61.9 (18.2)

61.2 (17.3)

.78

CKD ≥ IIIa, n (%)

51 (50.0%)

76 (56.3%)

.34

43 (49.4%)

1.00

CKD ≥ IIIb, n (%)

20 (19.6%)

28 (20.7%)

.83

14 (16.1%)

16 (18.4%)

.69

ARB or ACEI, n (%)

52 (51.0%)

66 (48.9%)

.75

45 (51.7%)

43 (49.4%)

.76

Diuretic, n (%)

12 (11.8%)

16 (11.9%)

.98

11 (12.6%)

12 (13.8%)

.82

Antiplatelet, n (%)

44 (43.1%)

54 (40.0%)

.63

34 (39.1%)

35 (40.2%)

.88

Follow-up duration, years,

median (IQR)

Age, years, mean (SD)

Baseline serum Cr,

mg/dl, mean (SD)

Baseline eGFR,

ml/min/1.73 m2, mean (SD)

Statin, n (%)

41 (40.2%)

56 (41.5%)

.84

35 (39.8%)

33 (37.5%)

.76

ß-blocker, n (%)

22 (21.6%)

26 (19.3%)

.66

17 (19.5%)

18 (20.7%)

.85

CCB, n (%)

62 (60.8%)

72 (53.3%)

.25

52 (59.8%)

47 (54.0%)

.44

Current smoker, n (%)

13 (12.7%)

22 (16.3%)

.45

13 (14.9%)

11 (12.6%)

.66

51.3 (10.7)

53.7 (8.5)

.051

51.9 (9.5)

52.5 (7.5)

.61

90.6 (43.2)

103.2 (47.6)

.043

93.7 (39.2)

100.2 (49.7)

.36

0.96 (0.46)

0.95 (0.29)

.81

0.90 (0.30)

0.93 (0.30)

.45

64.1 (21.2)

62.9 (18.4)

.65

65.7 (19.8)

63.7 (18.8)

.50

1 (1.0%)

10 (7.5%)

.026

4.8 (2.0)

4.6 (1.9)

.45

5.0 (1.8)

4.9 (1.7)

.90

Aneurysm diameter,

mm, mean (SD)

Contrast medium,

ml, mean (SD)

Postoperative serum Cr,

mg/dl, mean (SD)

Postoperative eGFR,

ml/min/1.73 m2, mean (SD)

Acute kidney injury, n (%)

Number of times of CE-CT,

mean (SD)

IR: infrarenal, SR: suprarenal, HT: hypertension, DL: dyslipidemia, DM: diabetes

mellitus, CAD: coronary artery disease, CVD: cerebrovascular disease, COPD: chronic

obstructive pulmonary disease, Cr: creatinine, eGFR: estimated glomerular filtration rate,

ARB: angiotensin receptor blocker, ACEI: angiotensin-converting enzyme inhibitor,

CCB: calcium channel blocker, CE-CT: contrast enhanced computed tomogram

Bold values indicate statistical significance (p < 0.05).

...

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Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation

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Suprarenal fixation is associated with worse midterm renal function after endovascular abdominal aortic aneurysm repair compared with infrarenal fixation

概要

関連論文

ロボット支援腹腔鏡下腎部分切除術後仮性動脈瘤の自然消退に関する臨床的検討

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Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement on Changes in Cardiac Sympathetic Nervous Function: Assessment by 123I-Metaiodobenzylguanidine Myocardial Scintigraphy

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