Comparison of short and long-term outcomes of endovascular and open repair for the treatment of juxta and pararenal abdominal aortic aneurysm

[P. Zlatanović]

68 str.

Medicina - Rekonstruktivna hirurgija / Medicine - Reconstructive surgery

Jedna od najčešće prisutnih formi kompleksnih aneurizmi abdominalne aorte (AAA) su juksta- i pararenalne AAA (JAAA/PAAA). Ne postoje tačni epidemiološki podaci, ali procenjuje se da je prevalenca JAAA/PAAA izmeĎu 15-20% svih AAA. Ishodi tretmana nakon hirurgije JAAA/PAAA su različiti u poreĎenju sa tretmanom infrarenalnih AAA. U poslednje dve decenije endovaskularni tretman AAA (EVAR – engl. endovascular aortic repair) je doţiveo značajnu evoluciju dizajna stent-graftova i u mnogim razvijenim zemljama je danas prva linija tretmana kompleksnih AAA. Studije koje porede EVAR i otvorenu hirurgiju (OSR- engl. open surgical repair) su retke, posebno po pitanju dugoročnih ishoda. Poslednji evropski (ESVS - engl. European Society for Vascular Surgery) i američki vodič (SVS – engl. Society for Vascular Surgery) ne daju jasne preporuke o tretmanu JAAA i PAAA, zbog dosadašnjih publikovanih studija koje daju oprečne rezultate. Stoga je primarni cilj ovog istraţivanja bio da se uporede kratkoročni i dugoročni rezultati EVARa i OSRa u tretmanu JAAA/PAAA u pet akademskih centara sa visokim volumenom tretmana kompleksnih AAA. Sekundarni cilj je identifikacija faktora rizika koji utiču na akutno oštećenje bubreţne funckije u obe grupe pacijenata, kao i poreĎenje kratkoročnih i dugoročnih ishoda kod pacijenata sa i bez akutnog oštećenja bubreţne funkcije u EVAR i OSR grupi pacijenata. MATERIJAL I METODE Istraţivanje je sprovedeno u formi retrospektivne kliničke opservacione studije sa prospektivnim karakterom konsekutivno tretiranih pacijenata u periodu izmeĎu januara 2010. i januara 2020. godine u pet evroskih centara sa visokim volumenom specijalizovanih za tretman kompleksnih AAA: Klinika za vaskularnu i endovaskularnu hirurgiju Univerzitetskog Kliničkog Centra Srbije/Beograd, Odeljenje vaskularne hirurgije San Raffaele bolnica Milan/Italija, Odeljenje za vaskularnu hirurgiju Univerziteta Sant'Orsola u Bolonji/Italija, Odeljenje za vaskularnu hirurgiju Univerzitetskog medicinskog centra u Amsterdamu/Holandija, Odeljenje vaskularne hirurgije Univerzitetske bolnice u Helsinkiju/Finska. Centar sa visokim volumenom je definisan ukoliko se tretira više od 50 elektivnih infrarenalnih AAA, odnosno više od 20 elektivnih kompleksnih AAA na godišnjem nivou. JAAA je definisana kao AAA gde je aneurizmatski vrat kraći od 1cm ili kada je proksimalna klema iznad barem jedne renalne arterije, dok je PAAA definisana kao AAA gde barem jedna renalna arterija ishodi iz aneurizmatske kese i zahteva njenu rekonstrukciju, ali ne obuhvata gornju mezenteričnu arteriju. Pacijenti sa suprarenalnom, torakoabdominalnom, mikotičnom, disekantnom, simptomatskom i rupturiranom AAA, kao i pacijenti sa bolestima vezivnog tkiva su isključeni iz studije. Prikupljani su demografski podaci i komorbiditeti, vaţne angiografske karakteristike JAAA/PAAA, intraoperativni podaci, postoperativne komplikacije (hospitalne i 30-dnevne). Kratkoročni ciljevi su bili: hospitalni i 30-dnevni mortalitet i postoperativni neţeljeni klinički dogaĎaji, naročito akutna povreda bubrea (engl. acute kidney injury – AKI) i ishemija kičmene moţdine (engl. spinal cord ischaemia – SCI). Prema RIFLE krijerijumima, AKI je definisana kao dvostruko povećanja vrednosti kreatinina ili smanjenje vrednosti glomerulane filtacije (engl. glomerular filtratio rate – GFR) za više od 50% unutar tri dana od aortne hirurgije. SCI je definisana kao novi neurološki deficit, koji se prezentuje paraparezom i paraplegijom prema Tarlovljevoj skali...

INTRODUCTION One of the most common forms of complex abdominal aortic aneurysms (AAA) are the juxta- and pararenal AAAs (JAAA/PAAA). There are no exact epidemiological data, but it is estimated that the prevalence of JAAA/PAAA is between 15-20% of all AAAs. Outcomes of JAAA/PAAA are different in comparison with infrarenal AAA. In the last two decades endovascular aortic repair (EVAR) underwent a significant improvement of stent-graft design and is nowdays the first line treatment in many developed countries of complex AAA. Studies that are comparing EVAR and open surgical treatment (OSR) are scarce, especially with regards to long-term data. The last European Society for Vascular Surgery (ESVS) and Society for Vascular Surgery (SVS) guidelines do not have clear recommendations about the treatment of JAAA/PAAA, because published data provide conflicting results. Therefore, the primary aim of this research was to compare short- and long-term results of EVAR and OSR for the treatment of JAAA/PAAA in five high-volume academical aortic centres for complex AAA. Secondary goal was the identification of risk factors associated with the development of acute kidney injury (AKI), as well as the comparison of short- and long-term outcomes in patients with and without AKI in EVAR and OSR group of patients. MATERIAL AND METHODS This was a retrospective clinical observation study with prospective character of all consecutively treated patient between January 2010 and January 2020, in five high-volume academic centres specialized for the treatment of complex AAA: Clinic for Vascular and Endovascular Surgery/University Clinical Centre of Serbia, Belgrade, Serbia; Vascular Surgery Unit/San Rafaelle Hospital, Milan, Italy; Department of Vascular Surgery, Sant'Orsola University Bologna, Italy; Department of Vascular Surgery, University Medical Centre Amsterdam, Netherlands; Department of Vascular Surgery, University Hospital Helsinki, Finland. High-volume aortic centre was defined as having more than 50 elective infrarenal AAA repairs and more than 20 elective complex AAA repairs per year. JAAA was defined as AAA where the aneurysm neck is shorter than 10mm or when the proximal clamp is above at least one renal artery, while the PAAA was defined where at least one renal artery derives from AAA and requires its reconstruction, and extends proximally until the superior mesenteric artery. Patients with suprarenal, thoracoabdominal, mycotic, postidissectious, symptomatic and ruptured AAA, as well as the patients with connective tissue disorders were excluded from this research. Demographics, baseline clinical characteristics, imprortant angiographic characteristics of JAAA/PAAA, intraoperative data, postoperative complications (hospital and 30-day) were collected. Short-term outcomes were: hospital and 30-day mortality, and postoperative adverse clinical outcomes, especially acute kidney injury (AKI) and spinal cord ischaemia (SCI). According to the RIFLE criteria, AKI was defined as a two-fold increase of serum creatinine or decrease of glomerual filtration rate (GFR) for more than 50% within three days of aneurysm repair. Spinal cord ischaemia (SCI) was defined as new onset neurologic deficit, presenting with parapersis or paraplegia according to the Tarlov scale...

juksta/pararenalna aneurizma abdominalne aorte (JAAA/PAAA); kratkoročni mortalitet; akutna povreda bubrega (engl. acute kidney injury – AKI); dugoročni mortalitet; dugoročna aortna reintervencija

juxta/pararenal abdominal aortic aneurysm (JAAA/PAAA); short-term mortality; acute kidney injury (AKI); long-term mortality; long-term aortic-related reintervention

616.13‑007.64-089(043.3)

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