Planning, Execution, and Follow-up for Endovascular Aortic Aneurysm Repair Using a Highly Restrictive Iodinated Contrast Protocol in Patients with Severe Renal Disease

The cumulative amount of iodinated contrast medium necessary for endovascular repair (EVAR) planning, operative procedure, and subsequent follow-up is a threat for the onset of end-stage renal disease in patients with preoperative impaired kidney function. The purpose of this study was to describe a mini-invasive approach aimed to minimize the exposure of these patients to iodinated contrast medium and the subsequent risk of renal function worsening.

From 2012 to 2015, all patients with abdominal aortic aneurysm (AAA) at high surgical risk and fit for standard EVAR (simple aortic-iliac anatomy: proximal and distal neck length ≥15 mm, no severe angulation), underwent EVAR through the following "near-zero contrast" approach, if their glomerular filtration rate (GFR) was <30 mL/min: preoperative planning was performed by noncontrast-enhanced computed tomography and duplex ultrasound (DU); the origin of renal/hypogastric arteries and aortic bifurcation was evaluated and matched with vertebral bone landmarks and the endograft deployed accordingly, using <20 cc of isotonic iodinate contrast medium and contrast-enhancement DU (CEUS). Follow-up was by DU/CEUS at 1, 6, and 12 months. Primary end points were technical success (TS: renal/hypogastric artery patency, absence of type I/III endoleaks, iliac stenosis/kinking, intraoperative mortality, and conversion), 30-day mortality, and new onset of permanent dialysis with renal function evaluation at 1, 6, and 12 months. Secondary end points were type II endoleaks, reinterventions, AAA, and renal-related mortality during the follow-up.

Eighteen patients (median age: 74 years, interquartile range [IQR]: 6, male: 78%, American Society of Anaesthesiologists [ASA] IV: 100%) were enrolled. The median AAA diameter and preoperative GFR were 66 mm (IQR: 13) and 22 mL/min (IQR: 4), respectively. Infrarenal (n = 10) and suprarenal fixation (n = 8) endografts were implanted, with a mean dose of iodinate contrast medium injection of 18 mL (IQR) and 100% TS rate. Two type II endoleaks were detected at the completion CEUS. The median postoperative GFR was 22 mL/min (IQR: 5). No patients had GFR worsening ≥30% at 1 day and 30 days. The 30-day mortality was 11% (2 deaths for heart failure). At a median follow-up of 16 months (IQR: 8), no patients needed hemodialytic treatment and no endoleaks were detected. One patient died at 6 months for cancer and one at 13 months for myocardial infarction. No reinterventions or AAA and renal-related mortality occurred during the follow-up.

A "near-zero contrast" approach is feasible in EVAR for patients with simple aorto-iliac anatomy. Patients with very poor renal function may still undergo to successful procedures, avoiding renal function impairment.