The outcome of thoracic endovascular aortic repair (TEVAR) in patients with renal insufficiency.

OBJECTIVE: We sought to determine the effects of renal insufficiency on thoracic endovascular aortic repair (TEVAR) outcome and to identify predictors for adverse events.
METHODS: Eighty-four patients with renal insufficiency (creatinine >or=1.5 mg/dL) were analyzed from a prospective TEVAR database from April 1, 1999, to January 1, 2008. Patients were subdivided into groups by creatinine level (mg/dL): group 1 (1.5-2.0), group 2 (2.0-3.0), group 3 (>3.0), and group 4 (preoperative dialysis-dependent). Demographics, aneurysm/aortic lesion characteristics, perioperative morbidity, mortality, and follow-up data were compared with 246 control patients (<1.5 mg/dL).
RESULTS: Comorbidities were similar between the renal insufficiency and control groups, except for age (74 +/- 8 vs 69 +/- 6 years, P < .0002), male gender (73% vs 58%, P < .02), and presence of peripheral vascular disease (56% vs 38%, P < .005). Mean follow-up was 9 months. The renal insufficiency and control groups had similar aortic pathologies, including fusiform (51% vs 57%) and saccular aneurysms (27% vs 37%). Overall mean serum creatinine and creatinine clearance did not worsen during follow-up. Perioperatively, 18 patients (21%) patients required dialysis. Nine patients (11%) presented a newly acquired need for dialysis. Degree of preoperative renal impairment correlated with increasing dialysis requirement: group 1, 5% (3 of 55); group 2, 25% (3 of 12); group 3, 38% (3 of 8); and group 4, 100% (9 of 9). Three patients did not recover baseline renal function. Contrast type (isosmolar vs hyposmolar) and amount (96 +/- 8 mL vs 100 +/- 8 mL, P = .33) was similar between the dialysis and no-dialysis groups. Renal insufficiency patients had a statistically significant higher rate of major adverse events (25% vs 6.9%, P < .00003), 30-day mortality (11% vs 4.4%, P < .05), and myocardial infarction (6.0% vs 1.0%, P < .013) than controls. One or more major adverse events occurred in 25%, including stroke (6.0%), myocardial infarction (6.0%), and spinal cord ischemia (4.8%). Predictors for adverse events included emergency repair (odds ratio, 3.1; 95% confidence interval, 1.1-8.4; P = 0.037) and baseline creatinine >2.0 (odds ratio, 5.9; 95% confidence interval, 2.1-16.8; P = .001). Age, gender, adjunctive access, type of aortic pathology, and number of device components did not adversely affect outcome.
CONCLUSION: Patients with preoperative renal insufficiency maintain renal function after TEVAR. However, this patient population may be susceptible to increased adverse events, with emergency repair and baseline creatinine >2.0 mg/dL serving as strong predictors.