title: Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure.
abstract: OBJECTIVE
  Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome.
  
  
  METHODS
  Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients' demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease.
  
  
  RESULTS
  Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m2(45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001).
  
  
  CONCLUSIONS
  Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients' risk factors that might contribute to postoperative ARF.
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
authors.forename: Besma
authors.initials: B
authors.lastname: Nejim
authors.affiliation: Department of Surgery, University of South Florida, Tampa, Fla.
authors.forename: Isibor
authors.initials: I
authors.lastname: Arhuidese
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
authors.forename: Muhammmad
authors.initials: M
authors.lastname: Rizwan
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
authors.forename: Lana
authors.initials: L
authors.lastname: Khalil
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md.
authors.forename: Satinderjit
authors.initials: S
authors.lastname: Locham
authors.affiliation: Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors.forename: Devin
authors.initials: D
authors.lastname: Zarkowsky
authors.affiliation: Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip
authors.initials: P
authors.lastname: Goodney
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutes, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
mesh_terms: D058186:Acute Kidney Injury / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D012042:Registries; D012078:Renal Artery Obstruction / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States