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Planning, Execution, and Follow-up for Endovascular Aortic Aneurysm Repair Using a Highly Restrictive Iodinated Contrast Protocol in Patients with Severe Renal Disease.

Abstract：

BACKGROUND:The cumulative amount of iodinated contrast medium necessary for endovascular repair (EVAR) planning, operative procedure, and subsequent follow-up is a threat for the onset of end-stage renal disease in patients with preoperative impaired kidney function. The purpose of this study was to describe a mini-invasive approach aimed to minimize the exposure of these patients to iodinated contrast medium and the subsequent risk of renal function worsening. METHODS:From 2012 to 2015, all patients with abdominal aortic aneurysm (AAA) at high surgical risk and fit for standard EVAR (simple aortic-iliac anatomy: proximal and distal neck length ≥15 mm, no severe angulation), underwent EVAR through the following "near-zero contrast" approach, if their glomerular filtration rate (GFR) was <30 mL/min: preoperative planning was performed by noncontrast-enhanced computed tomography and duplex ultrasound (DU); the origin of renal/hypogastric arteries and aortic bifurcation was evaluated and matched with vertebral bone landmarks and the endograft deployed accordingly, using <20 cc of isotonic iodinate contrast medium and contrast-enhancement DU (CEUS). Follow-up was by DU/CEUS at 1, 6, and 12 months. Primary end points were technical success (TS: renal/hypogastric artery patency, absence of type I/III endoleaks, iliac stenosis/kinking, intraoperative mortality, and conversion), 30-day mortality, and new onset of permanent dialysis with renal function evaluation at 1, 6, and 12 months. Secondary end points were type II endoleaks, reinterventions, AAA, and renal-related mortality during the follow-up. RESULTS:Eighteen patients (median age: 74 years, interquartile range [IQR]: 6, male: 78%, American Society of Anaesthesiologists [ASA] IV: 100%) were enrolled. The median AAA diameter and preoperative GFR were 66 mm (IQR: 13) and 22 mL/min (IQR: 4), respectively. Infrarenal (n = 10) and suprarenal fixation (n = 8) endografts were implanted, with a mean dose of iodinate contrast medium injection of 18 mL (IQR) and 100% TS rate. Two type II endoleaks were detected at the completion CEUS. The median postoperative GFR was 22 mL/min (IQR: 5). No patients had GFR worsening ≥30% at 1 day and 30 days. The 30-day mortality was 11% (2 deaths for heart failure). At a median follow-up of 16 months (IQR: 8), no patients needed hemodialytic treatment and no endoleaks were detected. One patient died at 6 months for cancer and one at 13 months for myocardial infarction. No reinterventions or AAA and renal-related mortality occurred during the follow-up. CONCLUSIONS:A "near-zero contrast" approach is feasible in EVAR for patients with simple aorto-iliac anatomy. Patients with very poor renal function may still undergo to successful procedures, avoiding renal function impairment.

journal_name

Ann Vasc Surg

journal_title

Annals of vascular surgery

authors

Gallitto E,Faggioli G,Gargiulo M,Freyrie A,Pini R,Mascoli C,Ancetti S,Vento V,Stella A

doi

10.1016/j.avsg.2017.06.050

subject

Has Abstract

pub_date

2018-02-01 00:00:00

pages

205-211

eissn

0890-5096

issn

1615-5947

pii

S0890-5096(16)30860-3

journal_volume

pub_type

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Planning, Execution, and Follow-up for Endovascular Aortic Aneurysm Repair Using a Highly Restrictive Iodinated Contrast Protocol in Patients with Severe Renal Disease.