Adult: Aorta
Proximal aortic repair in dialysis patients: A national database analysis

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Abstract

Objectives

Dialysis is a well-established risk factor for morbidity and mortality after cardiovascular procedures. However, little is known regarding the outcomes of proximal aortic surgery in this high-risk cohort.

Methods

Perioperative (in-hospital or 30-day mortality) and 10-year outcomes were analyzed for all the patients who underwent open proximal aortic repair with the diagnosis of nonruptured thoracic aortic aneurysm (aneurysm, n = 325) or type A aortic dissection (dissection, n = 461) from 1987 to 2015 using the US Renal Data System database.

Results

In patients with aneurysm, perioperative mortality was 12.6%. The 10-year mortality was 81% ± 3%. Age 65 years or more (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.03 to 1.78; P = .03), chronic obstructive pulmonary disease (HR, 1.68; 95% CI, 1.01-2.82; P = .047), and Black race (HR, 1.46; 95% CI, 1.09-1.97; P = .01) were independently associated with worse 10-year mortality. In patients with dissection, perioperative mortality was 24.3% and 10-year mortality was 87.9% ± 2.2%. Age 65 years or more (HR, 1.49; 95% CI, 1.19-1.86; P < .001), congestive heart failure (HR, 1.39; 95% CI, 1.11-2.57; P = .004), and diabetes mellitus as the cause of dialysis (HR, 1.75; 95% CI, 1.2-2.57; P = .004) were independently associated with worse 10-year mortality. Black race (HR, 0.74; 95% CI, 0.6-0.92; P = .008) was associated with a better outcome.

Conclusions

We described challenging perioperative and 10-year outcomes for dialysis patients undergoing proximal aortic repair. The present study suggests the need for careful patient selection in the elective repair of proximal aortic aneurysm for dialysis-dependent patients, whereas it affirms the feasibility of emergency surgery for acute type A aortic dissections.

Section snippets

Materials and Methods

The New York-Presbyterian/Queens Institutional Review Board approved this study with waiver of consent on March 26, 2019 (Institutional Review Board File Number: 12300319).

Aneurysm Group

During the study period, 325 patients underwent proximal thoracic aortic repair for nonruptured thoracic aortic aneurysm. The median age of patients was 60.9 years (IQR, 50.0-68.8), and 134 patients (41.2%) were aged 65 years or older. Among 325 patients, 246 (88.8%) had hypertension and 64 (23.1%) had CHF. White race was more prevalent (226 [69.5%]) than Black race (85 [26.2%]). Concomitant CABG was performed in 111 patients (34.2%), and concomitant AVR was performed in 209 patients (64.3%).

Discussion

By using a large national database, we reveal an alarmingly high perioperative and 10-year mortality in dialysis-dependent patients after proximal aortic repair for thoracic aortic aneurysm or dissection (Figure 3).

The aneurysm cohort in the present study reveals critical data that may help inform guidance for prophylactic open repair of proximal aortic aneurysm. A recent analysis of the STS database revealed 8807 elective aortic root replacement cases.15 Perioperative mortality was 2.2%.

Conclusions

Perioperative and 10-year outcomes of dialysis patients undergoing proximal aortic repair are poor regardless of the indication. The present study may call for cautious patient selection particularly for elective repair of proximal aortic aneurysm in dialysis patients, whereas it could support emergency surgery for acute type A aortic dissection. Further institutional study is warranted to investigate an appropriate surgical candidate for these pathologies in dialysis patients.

References (29)

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This abstract was accepted for the American Association for Thoracic Surgery Aortic Symposium and ranked among the top 15% of abstracts, which is a category of Director's Choice this year. Unfortunately, the meeting was canceled.

Institutional Review Board File Number 12300319 approved on March 26, 2019.

The data reported here have been supplied by the United States Renal Data System (USRDS). The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government.

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