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Revised Duplex Criteria And Outcomes For Renal Stents And Stentgrafts Following Endovascular Repair Of Juxtarenal And Thoracoabdominal Aneurysms

Walid Mohabbat, Roy K. Greenberg, Tara Mastracci, Heather Gornick, Pablo Morales, Marcello Cury, Katherine Pfaff, Adrian Hernandez.
Cleveland Clinic Foundation, Cleveland, Ohio

OBJECTIVES: To further delineate analysis criteria and variables affecting outcome following endovascular repair of aortic aneurysms requiring the use of renal stents and stentgrafts.

METHODS: A prospective database of patients treated with fenestrated and branched endografts (2001-2006) where all patients had CT and duplex follow-up was reviewed to select all patients with evidence of renal issues (duplex ultrasound, serum renal markers, and CT images). Patients with any evidence of renal artery pathology on duplex (questionable renal flow, PSV<50 or >200 cm/s, renal aortic ratio >3.5), increased serum creatinine >30%, or CT (multiplanar reconstructions or delayed nephrograms) were selected for further analysis. Correlations of ultrasound, CT, angiographic and clinical outcomes were conducted. Revised duplex criteria were calculated using ROC analyses. Freedom from stenosis or occlusion was determined by Kaplan-Meier analysis with differences assessed by log rank tests.

RESULTS: 518 renal arteries were treated with renal stents or stentgrafts (287 patients). Mean follow-up was 25 months. ROC analysis determined optimal criteria for in-stent stenosis to be a peak systolic velocity (PSV)>280 cm/s or RAR>4.5. Occlusions were best identified by a mid renal artery PSV<57 cm/s in conjunction with an RAR<1.2. [Table1]. Patients treated with uncovered renal stents were more likely to develop in stent stenoses than those treated with covered renal stents (HR 0.4, 95% CI 0.2-0.9, p=0.04). [Figure 1]. However, only 20% of the patients with stenoses underwent secondary interventions, while most patients with occlusions underwent reintervention. Late occlusions were more commonly noted in the right renal artery, which was noted to have greater immediate post-stent posterior angulation.

CONCLUSIONS: Revised ultrasound criteria have been developed to improve the sensitivity and specificity of non-invasive interrogation of renal stents and stentgrafts following EVAR. Renal stentgrafts, in contrast to uncovered stents, are associated with a lower incidence of in stent stenosis, in patients treated for aneurysms involving or abutting the renal arteries. Anatomic differences between the right and left renal arteries may explain differences in outcome and have implication on stent/stentgraft design.
AUTHOR DISCLOSURES: W. Mohabbat, None; R.K. Greenberg, Cook Inc, Terarecon, W.L.Gore, Vascutek; Cook Inc; Cook Inc - Royalties for IP; T. Mastracci, None; V. Kashyap, None; H. Gornick, None; P. Morales, None; M. Cury, None; K. Pfaff, None; A. Hernandez, None.