Preoperative proteinuria is associated with higher mortality after fenestrated/branched aortic repair of complex anatomy aortic aneurysms.

Abstract

Previous literature demonstrated an association between preoperative proteinuria and mortality after endovascular repair of juxtarenal aortic aneurysms. The aim of this study is to evaluate the association of preoperative proteinuria on 1- and 5-year survival after fenestrated/branched endovascular repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs), pararenal aortic aneurysms, and juxtarenal aortic aneurysms treated with patient-specific company-manufactured devices (CMDs) or off-the-shelf devices. The impact on kidney function after F/BEVAR was also analyzed. A retrospective analysis was performed with prospectively collected data, including patients with complex anatomy aortic aneurysms who underwent F/BEVAR at a single institution from July 2012 to February 2024. All patients were treated with a company-manufactured device or off-the-shelf devices under a physician-sponsored investigational device exemption protocol. Patients were divided into two groups based on the preoperative urinalysis performed within 30 days before the index procedure: patients with trace or no proteinuria vs patients with proteinuria (1+, 30-100 mg/dL; 2+, 100-299 mg/dL; 3+, ≥300 mg/dL). Primary outcomes were 1-year and 5-year survival. Secondary outcomes were 30-day mortality, myocardial infarction, stroke/transient ischemic attack, acute kidney injury, and spinal cord ischemia. The follow-up protocol included imaging studies (chest, abdomen and pelvis computed tomography angiography, abdominal radiography, and renal-mesenteric duplex ultrasound examination) and laboratory analysis. Time-to-event analysis was performed with Kaplan-Meier plots compared through log-rank testing. Binary logistic regression model was designed to investigate predictors associated with 5-year survival after F/BEVAR. A total of 454 patients underwent the F/BEVAR procedure; patients were 71.5% male and 15.4% Black, with a mean age of 72 ± 5.2 years. Sixty-seven patients (14.7%) had preoperative proteinuria of ≥30 mg/dL. Patients with and without preoperative proteinuria were similar in terms of demographics, aneurysm extension, and comorbidities, except for chronic kidney disease and cerebrovascular disease, which were more prevalent in patients with proteinuria (P < .001 and P = .011, respectively). There was no significant differences observed in 30-day mortality, acute kidney injury, spinal cord ischemia, stroke/transient ischemic attack, or myocardial infarction rates. The survival analysis demonstrated a significantly lower 1-year (77.9 ± 5.4% vs 89.4 ± 1.6%; P = .004) and 5-year survival (33.8 ± 8.8% vs 65.2 ± 3.0%; P = .002) among the patients with proteinuria when compared with individuals presenting trace or no proteinuria. Patients with preoperative proteinuria had a risk of death almost two times higher (odds ratio, 1.95; 95% confidence interval, 1.27-2.99; P = .002) and a risk of developing kidney failure requiring dialysis at 5 years more than eight times higher (odds ratio, 8.28; 95% confidence interval, 2.62-26.13; P ≤ .001). Proteinuria was a better predictor of mortality than a preoperative estimated glomerular filtration rate of <60 mL/min/1.73 m², which was not significantly associated with this adverse event (P = .060). The presence of significant proteinuria preoperatively is associated with reduced 1- and 5-year survival after F/BEVAR procedure in patients undergoing repair for complex anatomy aortic aneurysms. Preoperative proteinuria can be used to aid in preoperative risk assessment of either survival or kidney function deterioration after F/BEVAR.