Advertisement

Outcomes after Elective Abdominal Aortic Aneurysm Repair Have Improved Over Time in Patients on Dialysis

      Background

      Prior studies have demonstrated poor perioperative and long-term survival of patients with end-stage kidney disease (ESKD) on dialysis who undergo abdominal aortic aneurysm repair (AAAR). However, survival in dialysis patients overall has improved over time. We hypothesize that the contemporary rates of perioperative and long-term survival following AAAR in ESKD patients are also improving.

      Methods

      Data on AAAR procedures in dialysis patients were collected from the United States Renal Data System between 2008 and 2017. Endovascular (EVAR) and open AAA repair (OAR) were identified by Current Procedural Terminology codes. Patients with a functioning renal transplant, a ruptured aneurysm, and insurance other than Medicare were excluded. Demographics, comorbidities, procedural details, and long-term outcomes were collected. Standard statistical methods were used.

      Results

      We identified 3,374 patients who underwent EVAR (86%, 2,914/3,374) and OAR (14%, 460/3,374). The utilization of OAR decreased significantly from 2008 to 2017 (17.34% vs. 7.43%, P < 0.001). Kaplan–Meier survival analysis revealed no significant difference in 5-year survival between OAR and EVAR (24% vs. 17%, P = 0.1, Wilcoxon–Breslow test), but open repair was associated with increased long-term survival (Hazards ratio 0.994, confidence interval 0.990–0.999, P = 0.017) in an adjusted Cox regression model. The cohort was then divided based on the year of AAAR, group 1: 2008–2010 (1,269/3,374), group 2: 2011–2013 (1,071/3,374), and group 3: 2014–2017 (1,034/3,374). Compared to groups 1 and 2, Group 3 was less likely to have coronary artery device, peripheral vascular disease, recent pneumonia, be nonambulatory, live in a nursing facility, or undergo an OAR and more likely to be younger and dialyze through an arteriovenous fistula/arteriovenous graft at the time of AAA repair. Thirty-day postoperative mortality was significantly lower in group 3 compared to groups 1 and 2 (5.4% [56/1,034] vs. 10.3% [131/1,269]/7.3% [78/1,071], P < 0.031). One-year survival by Kaplan–Meier estimate was significantly higher in group 3 (77.7% [803/1,034]) versus groups 1 and 2 (56.7% [719/1,269], 66.9% [716/1,071], P < 0.001, log-rank test). Five-year survival was also significantly higher in group 3 (27.3%) compared to groups 1 and 2 (14.2% and 16.5%, P < 0.001, log-rank test). In a Cox regression model of long-term mortality adjusted for variables significant on a univariate testing, more recent procedure year was associated with increased survival (Hazards ratio 0.81, [0.77, 0.85], P < 0.001).

      Conclusions

      Postoperative and long-term survival following AAA repair have increased over time in ESKD patients on dialysis. This increased survival persists after accounting for differences in patient demographics and type of procedure over time. Elective AAA repair should be considered in carefully selected good-risk patients on dialysis.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Centers for Disease Control and Prevention
        • National Center for Health Statistics
        Underlying Cause of Death 1999–2018 on CDC WONDER Online Database website.
        • McPhee J.T.
        • Hill J.S.
        • Eslami M.H.
        The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004.
        J Vasc Surg. 2007; 45: 891-899
        • Chaikof E.L.
        • Dalman R.L.
        • Eskandari M.K.
        • et al.
        The society for vascular surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.
        J Vasc Surg. 2018; 67: 2-77.e2
        • Prinssen M.
        • Verhoeven E.L.G.
        • Buth J.
        • et al.
        A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.
        N Engl J Med. 2004; 351: 1607-1618
        • Dangas G.
        • O’Connor D.
        • Firwana B.
        • et al.
        Open versus endovascular stent graft repair of abdominal aortic aneurysms: a meta-analysis of randomized trials.
        JACC Cardiovasc Interv. 2012; 5: 1071-1080
        • Lederle F.A.
        • Freischlag J.A.
        • Kyriakides T.C.
        • et al.
        Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial.
        JAMA. 2009; 302: 1535-1542
        • Greenhalgh R.M.
        • Brown L.C.
        • Epstein D.
        • et al.
        Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial.
        Lancet. 2005; 365: 2179-2186
        • Collins A.J.
        • Foley R.N.
        • Chavers B.
        • et al.
        United States Renal Data System 2011 Annual Data Report: Atlas of chronic kidney disease & end-stage renal disease in the United States.
        Am J Kidney Dis. 2012; 59: e1-e420
        • Yuo T.H.
        • Sidaoui J.
        • Marone L.K.
        • et al.
        Limited survival in dialysis patients undergoing intact abdominal aortic aneurysm repair.
        J Vasc Surg. 2014; 60: 908-913.e1
        • Liang N.L.
        • Yuo T.H.
        • Al-Khoury G.E.
        • et al.
        High mortality rates after both open surgical and endovascular thoracic aortic interventions in patients with end-stage renal disease.
        J Vasc Surg. 2017; 66: 991-996
        • Saran R.
        • Robinson B.
        • Abbott K.C.
        • et al.
        US renal data system 2018 annual data report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2019; 73: A7-A8
        • Lok C.E.
        • Huber T.S.
        • Lee T.
        • et al.
        KDOQI clinical practice guideline for vascular access: 2019 update.
        Am J Kidney Dis. 2020; 75: S1-S164
        • Lee T.
        Fistula first initiative: historical impact on vascular access practice patterns and influence on future vascular access care.
        Cardiovasc Eng Technol. 2017; 8: 244-254
        • Liu J.
        • Huang Z.
        • Gilbertson D.T.
        • et al.
        An improved comorbidity index for outcome analyses among dialysis patients.
        Kidney Int. 2010; 77: 141-151
        • Hall D.E.
        • Arya S.
        • Schmid K.K.
        • et al.
        Association of a frailty screening initiative with postoperative survival at 30, 180, and 365 days.
        JAMA Surg. 2017; 152: 233-240
        • Komshian S.
        • Farber A.
        • Patel V.I.
        • et al.
        Patients with end-stage renal disease have poor outcomes after endovascular abdominal aortic aneurysm repair.
        J Vasc Surg. 2019; 69: 405-413
        • Elkouri S.
        • Gloviczki P.
        • McKusick M.A.
        • et al.
        Perioperative complications and early outcome after endovascular and open surgical repair of abdominal aortic aneurysms.
        J Vasc Surg. 2004; 39: 497-505
        • Huber T.S.
        • Wang J.G.
        • Derrow A.E.
        • et al.
        Experience in the United States with intact abdominal aortic aneurysm repair.
        J Vasc Surg. 2001; 33: 304-311
        • Schermerhorn M.L.
        • O’Malley A.J.
        • Jhaveri A.
        • et al.
        Endovascular vs. Open repair of abdominal aortic aneurysms in the Medicare population.
        N Engl J Med. 2008; 358: 464-474
        • Anderson P.L.
        • Arons R.R.
        • Moskowitz A.J.
        • et al.
        A statewide experience with endovascular abdominal aortic aneurysm repair: rapid diffusion with excellent early results.
        J Vasc Surg. 2004; 39: 10-18
        • Sweeting M.J.
        • Patel R.
        • Powell J.T.
        • et al.
        Endovascular repair of abdominal aortic aneurysm in patients physically ineligible for open repair.
        Ann Surg. 2017; 266: 713-719
        • Noronen K.
        • Laukontaus S.
        • Kantonen I.
        • et al.
        The natural course of abdominal aortic aneurysms that meet the treatment criteria but not the operative requirements.
        J Vasc Surg. 2013; 57: 326-331
        • Galal W.
        • Van Gestel Y.R.B.M.
        • Hoeks S.E.
        • et al.
        The obesity paradox in patients with peripheral arterial disease.
        Chest. 2008; 134: 925-930
        • Ludhwani D.
        • Wu J.
        Obesity paradox in peripheral arterial disease: results of a propensity match analysis from the national inpatient sample.
        Cureus. 2019; 11: e4704
        • Brazile T.
        • Mulukutla S.
        • Thoma F.
        • et al.
        Inverse association of mortality and body mass index in patients with left ventricular systolic dysfunction of both ischemic and non-ischemic etiologies.
        Clin Cardiol. 2021; 44: 495-500
        • Miller M.S.
        • Kang M.
        • Cornwall J.C.
        • et al.
        The impact of body mass index on perioperative and postoperative outcomes for endovascular abdominal aneurysm repair.
        Ann Vasc Surg. 2020; 62: 183-190.e1