Postoperative renal function preservation with nonischemic femoral arterial cannulation for thoracoabdominal aortic repair.
BACKGROUND
Renal failure after thoracoabdominal aortic repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006, we reported the finding that direct cannulation led to leg ischemia in some patients and was associated with increased renal failure. After this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. In this article, we present the effects of this change on postoperative renal function.


METHODS
Between February 1991 and July 2008, we repaired 1464 thoracoabdominal aortic aneurysms. Distal aortic perfusion was used in 1088, and these were studied. Median patient age was 68 years, and 378 (35%) were women. In September 2006, we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 patients (15%). We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on the highest postoperative creatinine level, postoperative renal failure, and death. Analysis was by multiple linear or logistic regression with interaction.


RESULTS
The preoperative GFR was the strongest predictor of postoperative renal dysfunction and death. No significant main effects of sidearm cannulation were noted. For peak creatinine level and postoperative renal failure, however, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications of 15% to 20% when GFR was <60 mL/min/1.73 m(2). For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, although not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes.


CONCLUSIONS
Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with a low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed.
Miller
Charles C
CC
Department of Biomedical Sciences, Texas Tech University Health Sciences Center at El Paso Paul L Foster School of Medicine, El Paso, Tex 79905, USA. charles.miller@ttuhsc.edu
Grimm
Joshua C
JC
Estrera
Anthony L
AL
Azizzadeh
Ali
A
Coogan
Sheila M
SM
Walkes
Jon-Cecil M
JC
Safi
Hazim J
HJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D015415:Biomarkers / Q000097:blood; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D002406:Catheterization, Peripheral / Q000009:adverse effects; D003404:Creatinine / Q000097:blood; D019992:Databases as Topic; D005260:Female; D005263:Femoral Artery; D005919:Glomerular Filtration Rate; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D007866:Leg; D016014:Linear Models; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D012039:Regional Blood Flow; D051437:Renal Insufficiency / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D015415:Biomarkers; D003404:Creatinine