SS16 - Severity of Acute Kidney Injury is Associated with Survival After Fenestrated and Branched Endovascular Aneurysm Repair

Friday, June 16, 2023

10:20 AM – 10:31 AM ET

Submitting & Presenting Author(s)

Eric J. Finnesgard, MD, MS (he/him/his)

Resident Physician
University of Massachusetts Chan Medical School
Worcester, Massachusetts

Co-Author(s)

Adam W. Beck, MD

Director, Division of Vascular Surgery and Endovascular Therapy
University of Alabama at Birmingham
Birmingham, Alabama
Matthew J. Eagleton, MD (he/him/his)

Chief, Division of Vascular and Endovascular Surgery
Massachusetts General Hospital
Boston, Massachusetts
MF

Mark Farber
WG

Warren J. Gasper

University of California San Francisco
San Francisco, California
WL

Woongchae A. Lee, MD

Boca Raton Regional Hospital
Boca Raton, Florida
Gustavo S. Oderich, MD

Professor of Surgery and Chair of Vascular and Endovascular Surgery
University of Texas Health Science Center at Houston
Houston, Texas
Darren B. Schneider, MD

Professor of Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
Matthew P. Sweet

Associate Professor
University of Washington
Seattle, Washington
Carlos H. Timaran, MD, MS

Professor, Division of Vascular and Endovascular Surgery
University of Texas Southwestern Medical Center
Dallas, Texas
Jessica P. Simons, MD

Associate Professor of Surgery
University of Massachusetts Medical School
Worcester, Massachusetts

Senior Author(s)

Andres Schanzer, MD (he/him/his)

Professor of Surgery
University of Massachusetts Medical School
Worcester, Massachusetts

Objectives: Acute kidney injury (AKI) occurs frequently in complex aortic surgery and has been implicated in perioperative and long-term survival. This study sought to characterize the relationship between AKI severity and mortality after fenestrated and branched endovascular aneurysm repair (F/B-EVAR).

Methods: Consecutive patients enrolled by the US Aortic Research Consortium in 10, prospective, non-randomized, physician-sponsored investigational device exemption studies evaluating F/B-EVAR, between 2005 and 2023, were included in this study. Perioperative AKI during hospitalization was stratified by KDIGO (Kidney Disease Improving Global Outcomes) serum creatinine criteria. Determinants of AKI were evaluated with backwards stepwise multivariable ordinal logistic regression. Survival was analyzed with conditionally adjusted survival curves and backwards stepwise Cox proportional hazards modelling.

Results: In the study period, 2413 patients with a median [IQR] age of 74 years [69-79] underwent F/B-EVAR. The median follow-up duration was 2.2 years [0.7-3.7]. Median baseline eGFR and creatinine were 60 mL/min/1.73m2 [49-76] and 1.1 mg/dL [0.9-1.3], respectively. Ninety-six repairs (4%) were performed urgently/emergently with technical success in 2315 (96%). Stratification of AKI identified 316 patients (13%) with Stage 1 injury, 42 (2%) with Stage 2 injury, and 74 (3%) with Stage 3 injury. Renal replacement therapy was initiated during the index hospitalization in 36 patients (1.5% of cohort, 49% of Stage 3 injuries). Thirty-day major adverse events were associated with AKI severity (Figure 1). Multivariable predictors of AKI severity included baseline creatinine (proportional OR [95%CI]: 1.3 per 1 mg/dL [1.1-1.6]; p=0.01), preoperative hematocrit (0.94 per 1% [0.92-0.95]; p< 0.0001), renal artery technical failure (2.6 [1.4-4.7]; p=0.0002), and procedure time (1.05 per 10 minutes [1.04-1.06]; p< 0.0001). One-year unadjusted survivals (% [95%CI]) for AKI strata (Stage 1-3) were 80% [76-85], 71% [59-86], and 45% [35-59], respectively (Figure 2). Multivariable determinants of survival included AKI severity (HR [95%CI]; Stage 1: 1.5 [1.1-2.1], Stage 2: 2.9 [1.6-5.1], Stage 3: 4.3 [2.4-7.9]; p< 0.0001), age (1.05 per year [1.04-1.06]; p< 0.0001), procedure technical success (0.6 [0.4-0.9]; p=0.006), postoperative paralysis (2 [1.3-2.9]; p=0.0006), baseline CHF (1.7 [1.4-2.1]; p< 0.0001), and baseline COPD (1.5 [1.3-1.8]; p< 0.0001).

Conclusions: AKI, as stratified by KDIGO criteria, occurred in 18% of patients after F/B-EVAR. The severity of renal injury was associated with incrementally worse post-operative survival. The predictors of AKI severity identified in these analyses suggest future opportunity for risk mitigation in complex aortic repair.