LAUSR

PURPOSE To evaluate the impact of intentional coverage of accessory renal arteries (ARA) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysm. METHODS We analyzed the clinical data of 296 patients enrolled in a prospective non-randomized study to evaluate outcomes of FB-EVAR between 2013-2018. Patients with solitary kidneys, intraoperative loss of main renal arteries or pre-existing Stage V chronic kidney disease were excluded. Two groups were analyzed, patients with intentional ARA coverage and controls who had complete preservation. End-points included 30-day mortality, major adverse events (MAEs), acute kidney injury (AKI) defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease), renal function deterioration (RFD) defined by >30% decline in baseline estimated glomerular filtration rate and presence of renal infarcts. RESULTS There were 254 patients (184 male, mean age 75±8 years old) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of which 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs. preservation (2.7 ± 0.9 vs. 3.4 ± 0.2mm; p<.001). There was no difference in demographics, cardiovascular risk factors and aneurysm extent. All ARAs intended to be incorporate were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs. 25%; p<.001). There were two (1%) deaths within 30-days, both among controls. Patients with ARA coverage had more MAEs (32% vs. 19%; p=.04) due higher incidence of AKI (21% vs. 9%; p=.02). None of the 16 patients who had ARA preservation developed AKI. At 3-years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55 ± 9 vs. 76 ± 5%; log-rank=.02). By multivariate analysis, predictors of AKI were ARA coverage (OR, 2.8; 95% CI, 1.2 - 6.2; p=.01) and estimated blood loss > 1L (OR, 3.8; 95% CI, 1.2 - 12.3; p=.03). Post-operative AKI (HR, 4.4; 95% CI, 2.4 - 8.1; p<.001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; p=.002), aneurysm diameter (HR, 1.04; 95% CI, 1.02 - 1.06; p<.001) and ARA coverage (HR, 2.0; 95% CI, 2.4 - 8.1; p=.02) were predictors of RFD. CONCLUSION Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included post-operative AKI, renal reinterventions for stenosis and ARA coverage. Incorporation of ARAs during FB-EVAR, when technically feasible, helps decrease risk of AKI and RFD.