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Abstract

Purpose

To report a prospective nonrandomized study comparing the effects of suprarenal (SR) vs. infrarenal (IR) stent-graft fixation on renal function in patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA).

Methods

Patients with AAA undergoing elective EVAR between June 2008 and June 2010 were eligible for the comparative study of fixation method on renal function. Patients with impaired renal function [estimated creatinine clearance (eCrCl) <30 mL/min] or a history of renal impairment were not eligible. Renal function was assessed by measuring serum creatinine (SCr) and total proteins and microalbumin in the urine preoperatively, on postoperative day 1, and at 1, 6, and 12 months. The eCrCl was calculated using the Cockcroft-Gault formula. A standard preoperative hydration protocol was followed in all patients, and stent-graft choice was at the operator's discretion. Of 116 patients undergoing elective EVAR in the study period, 16 were ineligible, leaving 100 patients (95 men; median age 74 years) enrolled in the study (49 SR and 51 IR).

Results

There was no statistically significant difference between the groups in the prevalence of any risk factor, the baseline SCr and eCrCl values, contrast usage, or procedure duration. At the postoperative measurement, there was no significant deterioration of renal function in either group, although total urinary proteins increased significantly in both groups (IR p=0.01, SR p<0.001). At the 12-month follow-up, patients in the IR group had no significant alteration in any marker vs. baseline, while patients in the SR group had significant alterations in SCr (p=0.001), eCrCl (p<0.001), and microalbumin (p=0.04) in urine. The number of patients with a >20% decrease in eCrCl was not significantly different between the groups. No patient had an adverse renal event.

Conclusion

Deterioration in renal function was observed 12 months after EVAR in patients receiving a stent-graft with suprarenal fixation, even though this did not seem to increase the likelihood of postoperative renal impairment. Furthermore, suprarenal fixation may be responsible for progressively significant proteinuria. Further studies are needed to determine the long-term impact of suprarenal fixation on renal function and investigate the potential risk of progressive renal disease in relation to type of fixation.

Keywords

abdominal aortic aneurysm endovascular aneurysm repair stent-graft suprarenal fixation infrarenal fixation renal function renal impairment serum creatinine estimated creatinine clearance proteinuria microalbumin

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References

Chaikof

Brewster

Dalman

. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(4 Suppl):S2–49.

United Kingdom EVAR Trial Investigators, Greenhalgh

Brown

. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1863–1871.

Lawrence

Charnsangavej

Wright

. Percutaneous endovascular graft: experimental evaluation. Radiology. 1987;163:357–360.

Parmer

Carpenter

. Endovascular aneurysm repair with suprarenal vs infrarenal fixation: a study of renal effects. J Vasc Surg. 2006;43:19–25.

Walsh

Boyle

Lynch

. Suprarenal endograft fixation and medium-term renal function: systematic review and meta-analysis. J Vasc Surg. 2008;47:1364–1370.e1.

Grego

Frigatti

Antonello

. Suprarenal fixation of endograft in abdominal aortic aneurysm treatment: focus on renal function. Ann Surg. 2004;240:169–178.

Sun

O'Donnell

Winder

. Effect of suprarenal fixation of aortic stent-grafts on the renal artery ostia: assessment of morphological changes by virtual intravascular endoscopy. J Endovasc Ther. 2007;14:650–660.

Choke

Munneke

Morgan

. Visceral and renal artery complications of suprarenal fixation during endovascular aneurysm repair. Cardiovasc Intervent Radiol. 2007;30:619–627.

O'Donnell

Sun

Winder

. Suprarenal fixation of endovascular aortic stent grafts: assessment of medium-term to long-term renal function by analysis of juxtarenal stent morphology. J Vasc Surg. 2007;45:694–700.

10.

Davey

Rose

Parkinson

. The midterm effect of bare metal suprarenal fixation on renal function following endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2006;32:516–522.

11.

Sun

Zheng

. Effect of suprarenal stent struts on the renal artery with ostial calcification observed on CT virtual intravascular endoscopy. Eur J Vasc Endovasc Surg. 2004;28:534–542.

12.

Pisimisis

Bechara

Barshes

. Risk factors and impact of proximal fixation on acute and chronic renal dysfunction after endovascular aortic aneurysm repair using glomerular filtration rate criteria. Ann Vasc Surg. 2013;27:16–22.

13.

Saratzis

Sarafidis

Melas

. Suprarenal graft fixation in endovascular abdominal aortic aneurysm repair is associated with a decrease in renal function. J Vasc Surg. 2012;56:594–600.

14.

Moll

Powell

Fraedrich

. Management of abdominal aortic aneurysms clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2011;41 Suppl 1:S1–S58.

15.

National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–266.

16.

Böckler

Krauss

Mannsmann

. Incidence of renal infarctions after endovascular AAA repair: relationship to infrarenal versus suprarenal fixation. J Endovasc Ther. 2003;10:1054–1060.

17.

Alric

Hinchliffe

Picot

. Long-term renal function following endovascular aneurysm repair with infrarenal and suprarenal aortic stent-grafts. J Endovasc Ther. 2003;10:397–405.

18.

Alsac

Zarins

Heikkinen

. The impact of aortic endografts on renal function. J Vasc Surg. 2005;41:926–930.

19.

Surowiec

Davies

Fegley

. Relationship of proximal fixation to postoperative renal dysfunction in patients with normal serum creatinine concentration. J Vasc Surg. 2004;39:804–810.

20.

Tiao

Semmens

Masarei

. The effect of age on serum creatinine levels in an aging population: relevance to vascular surgery. Cardiovasc Surg. 2002;10:445–451.

21.

Noorani

Walsh

Boyle

. Long-term effects of EVAR. Suprarenal versus infrarenal fixation. J Cardiovasc Surg (Torino). 2011;52:199–203.

22.

Bove

Long

Shanley

. Transrenal fixation of endovascular stent-grafts for infrarenal aortic aneurysm repair: mid-term results. J Vasc Surg. 2003;37:938–942.

23.

Subedi

Lee

Landis

. Suprarenal fixation barbs can induce renal artery occlusion in endovascular aortic aneurysm repair. Ann Vasc Surg. 2010;24:113, e7–e10.

24.

Levey

Bosch

Lewis

. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130:461–470.

25.

Levey

Stevens

Schmid

, et al; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–612.

26.

Gorriz

Martinez-Castelao

. Proteinuria: detection and role in native renal disease progression. Transplant Rev (Orlando). 2012;26:3–13.

27.

Brantsma

Bakker

de Zeeuw

; PREVEND Study Group. Extended prognostic value of urinary albumin excretion for cardiovascular events. J Am Soc Nephrol. 2008;19:1785–1791.

28.

Inker

Okparavero

. Cystatin C as a marker of glomerular filtration rate: prospects and limitations. Curr Opin Nephrol Hypertens. 2011;20:631–639.

Analysis of Effects of Fixation Type on Renal Function After Endovascular Aneurysm Repair