Total iodine contrast-free strategy for the endovascular management of abdominal aortic aneurysms in chronic kidney disease patients: a pilot study.

OBJECTIVES: To retrospectively evaluate the feasibility and effectiveness of the endovascular treatment of patients with abdominal aortic aneurysm (AAA) and chronic kidney disease (CKD) without the need for using iodinated contrast media (ICM) throughout the diagnostic, therapeutic and follow-up pathway.

METHODS: A retrospective review of prospectively collected data concerning 251 consecutive patients presenting an abdominal aortic or aorto-iliac aneurysm who underwent endovascular aneurysm repair (EVAR) from January 2019 to November 2022 at our academic institution was performed in order to identify patients with feasible anatomy with respect to manufacturers' instructions for use (IFU) and with CKD. Patients whose preoperative workout included duplex ultrasound (DUS) and plain computed tomography (pCT) for pre-procedural planning were extracted from a dedicated EVAR database. EVAR was performed with the use of carbon dioxide (CO2 ) as contrast media of choice, whereas follow-up examinations consisted of either DUS, pCT or contrast-enhanced ultrasound (CEUS). Primary endpoints were technical success, perioperative mortality and early renal function variations. Secondary endpoints were all-type endoleaks (EL) and reinterventions, mid-term aneurysm-related and kidney-related mortality.

RESULTS: Forty-five patients had CKD and were treated electively (45/251, 17.9%). Of them, seventeen patients were managed with a total ICM-free strategy and constituted the object of the present study (17/45, 37.8%; 17/251, 6.8%). In seven cases an adjunctive planned procedure was performed (7/17, 41.2%). No intraoperative bail-out procedures were needed. This extracted cohort of patients presented similar mean preoperative and postoperative (at discharge) GFRs values, 28.14 (SD 13.09; median 28.06, IQR 20.25) ml/min/1.73m2 and 29.33 (SD 14.61; median 27.35, IQR 22) ml/min/1.73m2 respectively (p= .210). Mean follow-up was 16.4 months (SD 11.89; median 18, IQR 23). During follow-up no graft-related complications occurred in terms of either thrombosis, type I or III EL, aneurysm rupture or conversion. The mean GFR at follow-up was 30.39 ml/min/1.73m2 (SD 14.45; median 30.75, IQR 21.93), with no significant worsening in comparison with pre and postoperative values (p= .327 and p= .856 respectively). No aneurysm- or kidney-related deaths occurred during follow-up.

CONCLUSIONS: Our initial experience shows that total iodine contrast-free AAA endovascular management in patients with CKD may be feasible and safe. Such an approach seems to guarantee the preservation of residual kidney function without increasing the risks of aneurysm-related complication in the early and midterm postoperative period and it could be considered even in case of complex endovascular procedures.