January 12, 2016
Study Evaluates Treatment of Isolated RAAs in Endovascular Era
January 12, 2016—Findings from a study on the management and outcomes of isolated renal artery aneurysms (RAAs) in the endovascular era were published by Dominique B. Buck, MD, et al in the Journal of Vascular Surgery (JVS; 2016;63:77–81). The background of the study is that isolated RAAs are rare, and controversy remains about indications for surgical repair; however, little is known about the impact of endovascular therapy on patient selection and outcomes.
The investigators concluded that more RAAs are being treated due to the advent of endovascular techniques, without a reduction in operative mortality or a reduction in open surgery, and therefore, indications for repair should be re-evaluated.
As summarized in JVS, the investigators identified all patients undergoing open or endovascular repair of isolated RAAs in the Nationwide Inpatient Sample from 1988 to 2011 for epidemiologic analysis. Elective cases were selected from the period of 2000 to 2011 to create comparable cohorts for outcome comparison.
All patients with a primary diagnosis of RAA undergoing open surgery (reconstruction or nephrectomy) or endovascular repair (coil or stent) were identified. Patients with concomitant aortic aneurysms or dissections were excluded. The investigators evaluated patient characteristics, management, and in-hospital outcomes for open and endovascular repair, and they examined changes in management and outcomes over time.
The investigators found that there were 6,234 RAA repairs between 1988 and 2011. Total repairs increased after the introduction of endovascular repair (8.4 in 1988 to 13.8 in 2011 per 10 million population in the United States; P = .03). Endovascular repair increased from 0 in 1988 to 6.4 in 2011 per 10 million population (P < .0001). However, there was no concomitant decrease in open surgery (5.5 in 1988 to 7.4 in 2011 per 10 million population; P = .28).
From 2000 to 2011, there were 1,627 open and 1,082 endovascular elective repairs. Patients undergoing endovascular repair were more likely to have a history of coronary artery disease (18% vs 11%; P < .001), previous myocardial infarction (5.2% vs 1.8%; P < .001), and renal failure (7.7% vs 3.3%; P < .001).
In-hospital mortality was 1.8% for endovascular repair, 0.9% for open reconstruction (P = .037), and 5.4% for nephrectomy (P < .001 compared with all revascularization). Complication rates were 12.4% for open repair vs 10.5% for endovascular repair (P = .134), including more cardiac (2.2% vs 0.6%; P = .001) and peripheral vascular complications (0.6% vs 0%; P = .014) with open repair. Open repair had a longer length of hospital stay (6 vs 4.6 days; P < .001).
After adjusting for other predictors of mortality, including age (odds ratio [OR], 1.05 per decade; 95% confidence interval [CI], 1–1.1; P = .001), heart failure (OR, 7; 95% CI, 3.1–16; P < .001), and dysrhythmia (OR, 5.9; 95% CI, 2–16.8; P = .005), endovascular repair was still not protective (OR, 1.6; 95% CI, 0.8–3.2; P = .145), reported the investigators in JVS.