Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair.
OBJECTIVE
To characterize the inflammatory and coagulopathic response after endovascular thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the effect of the response on postoperative renal function.


METHODS
From July 2005 to June 2008, 42 patients underwent elective endovascular repair of a TAAA using custom designed multi-branched stent-grafts at a single academic institution. Four patients were excluded from the analysis. White blood cell count (WBC), platelet count, prothrombin time (PT), and creatinine were measured in all patients. In the last nine patients, interleukin-6 (IL-6), protein C, Factor V, d-dimers, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) levels were also measured. Change in lab values were expressed as a percentage of baseline values.


RESULTS
The 30-day mortality rate was 5% (2/38). All patients (n = 38) had a higher WBC (mean +/- SD: 139 +/- 80%, P < .0001), lower platelet count (56 +/- 15%, P < .0001), and higher PT (median: 17%, Interquartile range (IQR) 12%-22%, P < .0001) after stent-graft insertion. Twelve of 38 patients (32%) developed postoperative acute renal insufficiency (>50% rise in creatinine). Patients with renal insufficiency had significantly larger changes in WBC (178 +/- 100% vs 121 +/- 64%, P = .04) and platelet count (64 +/- 17% vs 52 +/- 12%, P = .02) compared with those without renal insufficiency. All patients (n = 9) had significant increases in NGAL (182 +/- 115%, P = .008) after stent-graft insertion. Six of nine patients (67%) had increased cystatin C (35 +/- 43%, P = .04) after stent-graft insertion, with a greater rise in those with postoperative renal insufficiency (87 +/- 32% vs 8 +/- 13%, P = .02). IL-6 levels were markedly increased in all patients (n = 9) after repair (9840 +/- 6160%, P = .008). Protein C (35 +/- 10%, P = .008) and Factor V levels (28 +/- 20%, P = .008) were uniformly decreased, while d-dimers were elevated after repair in all patients (310 +/- 213%, P = .008).


CONCLUSIONS
Leukocytosis and thrombocytopenia were uniform following endovascular TAAA repair, and the severity of the response correlated with post-operative renal dysfunction. Elevation of a sensitive marker of renal injury (NGAL) suggests that renal injury may occur in all patients after stent-graft insertion.
Chang
Catherine K
CK
Department of Surgery, Division of Vascular Surgery, University of California at San Francisco, San Francisco, Calif. 94143-0222 , USA.
Chuter
Timothy A M
TA
Niemann
Claus U
CU
Shlipak
Michael G
MG
Cohen
Mitchell J
MJ
Reilly
Linda M
LM
Hiramoto
Jade S
JS
D058186:Acute Kidney Injury / Q000097:blood / Q000209:etiology*; D000209:Acute-Phase Proteins; D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D001778:Blood Coagulation Disorders / Q000097:blood / Q000209:etiology*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D003404:Creatinine / Q000097:blood; D055316:Cystatin C / Q000097:blood; D005165:Factor V / Q000032:analysis; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006801:Humans; D015850:Interleukin-6 / Q000097:blood; D007958:Leukocyte Count; D007964:Leukocytosis / Q000209:etiology; D000071068:Lipocalin-2; D054834:Lipocalins / Q000097:blood; D008297:Male; D010976:Platelet Count; D011474:Prosthesis Design; D011486:Protein C / Q000032:analysis; D011517:Prothrombin Time; D011518:Proto-Oncogene Proteins / Q000097:blood; D015607:Stents; D018746:Systemic Inflammatory Response Syndrome / Q000097:blood / Q000209:etiology*; D013921:Thrombocytopenia / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome
D000209:Acute-Phase Proteins; D015415:Biomarkers; C525030:CST3 protein, human; D055316:Cystatin C; D005338:Fibrin Fibrinogen Degradation Products; C508600:IL6 protein, human; D015850:Interleukin-6; C489506:LCN2 protein, human; D000071068:Lipocalin-2; D054834:Lipocalins; D011486:Protein C; D011518:Proto-Oncogene Proteins; C036309:fibrin fragment D; D005165:Factor V; D003404:Creatinine