Endovascular AAA repair in patients with renal insufficiency: strategies for reducing adverse renal events

Vascular imaging, usually employing nephrotoxic contrast agents is relied u pon for all aspects of endovascular AAA repair causing some to consider ren al insufficiency a relative contraindication. We sought to determine if end ovascular AAA evaluation and repair could be successfully accomplished by m inimally or non-nephrotoxic modalities. Records and results for 98 consecutive patients undergoing endovascular AAA repair were reviewed. Patients requiring dialysis preoperatively were excl uded (N = 3). The average volume of iodinated contrast agent employed for intraoperative imaging was 152 cc (35-420 cc). Twenty patients (20%) had baseline renal in sufficiency (serum creatinine greater than or equal to1.3 mg/dl). A rise in serum creatinine above baseline was observed in 23 (24%) patients followin g repair; for 15 (16%) this was permanent. Creatinine rise occurred in pati ents with both normal (15) and abnormal (8) baseline values (P = 0.09). Ris e in creatinine was independent of contrast volume employed and of the use of infrarenal vs suprarenal device fixation (P >0.05). Two (2%) patients re quired permanent dialysis, one of which had a normal baseline creatinine an d unclear etiology for renal failure, the other had a baseline creatinine o f 2 and required device placement over an accessory renal artery. Strategie s to minimize the use of nephrotoxic contrast for patients with renal insuf ficiency included the use of MRA, rather than contrast-CT for pre and posto perative imaging (7, 35%) and use of Gadolinium rather than iodinated contr ast for performance of intraoperative arteriography (5. 25%). Endovascular grafts were successfully designed and implanted based upon MRA as the sole preoperative imaging modality in every case in which it was attempted (7). Mortality was not significantly different between those with and without ab normal baseline renal function (P>0.05). Adverse events (access failures, a rterial injuries, blood loss, endoleaks) were not significantly correlated with baseline renal insufficiency, rise in creatinine from baseline, use of MRA or intraoperative Gadolinium angiography (P >0.05). Pre- and postoperative evaluation and performance of endovascular AAA repai r can be accomplished in patients with renal insufficiency without increasi ng the rate of mortality or adverse events employing a strategy which minim izes the use of nephrotoxic contrast agents, relying upon Gadolinium arteri ography and MRA. Endovascular grafts can be successfully planned and follow ed employing MRA as the sole imaging modality. (C) 2001 The International S ociety for Cardiovascular Surgery. Published by Elsevier Science Ltd. All r ights reserved.