Outcomes after Thoracic Endovascular Aortic Repair in Patients with Chronic Kidney Disease in the Medicare Population
Chase R. Brown, Zehang Chen, Fabliha Khurshan, Fenton H. McCarthy, Joseph E Bavaria, Peter Groeneveld, Nimesh D Desai
University Of Pennsylvania, Philadelphia, PA
OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has been increasingly performed in higher risk patients with renal failure. The objective was to compare Medicare patients with pre-operative chronic kidney disease (CKD) to patients without CKD to determine differences in post-operative survival and outcomes. METHODS: From 2004 to 2014, 36,917 Medicare patients over 66 years underwent TEVAR. Patient data was extracted from Medicare Provider Analysis and Review (MEDPAR) hospital claims. Patients were grouped into the following categories based on pre-TEVAR renal status: 3,567 (9.7%) had CKD stages I to IV (CKD-I/IV), 1,201 (3.3%) had ESRD or hemodialysis (ESRD/HD), and 32,149 (87.1%) had normal renal function (no-CKD). These groups were then compared to determine differences in all-cause mortality and rates of post-operative complications. Kaplan-Meier with log-rank test and multivariable regression were performed for survival analysis. The incidence of post-operative complications was determined using a cumulative incidence function for competing risks. RESULTS: The mean age was different among groups (no-CKD: 75.4 ± 8.6 years; CKD-I/IV: 77.73 ± 8.1 years; ESRD/HD: 69.75 ± 12.2 years, p<0.001) with a higher proportion of males (no-CKD: 67.0%; ESRD/HD: 63.7%; CKD-I/IV: 72.5%, p<0.001). Patients with ESRD/HD had significantly worse survival compared to CKD-I/IV and no-CKD groups (30 day: no-CKD=93.6%; CKD-I/IV =90.6%; ESRD/HD=86.6%; 1 year: no-CKD=80.7%, CKD-I/IV =67.6%, ESRD/HD=52.4%; 6 years: no-CKD=41.8%, CKD-I/IV =21.6%, ESRD/HD=16.3%, p<0.001). In an adjusted multivariable analysis, predictors of 30-day mortality included ESRD/HD (Odds ratio [OR]: 2.1, p<0.001), CKD-I/IV (OR: 1.5, p<0.001), pre-operative congestive heart failure (OR: 1.6, p<0.001), stroke (OR: 1.56, p<0.001), and aortic rupture (OR: 5.4, p<0.001). Post-operative complications within 30-days of TEVAR were increased among patients with ESRD/HD for myocardial infarction (no-CKD=1.4% CKD-I/IV=2.5%; ESRD/HD=3.4%; p<0.001) and stroke (no-CKD=0.8%; CKD-I/IV =1.1%; ESRD/HD=2.1%, p<0.001). CONCLUSION: In this elderly Medicare population undergoing TEVAR, patients with ESRD/HD have dismal survival and worse post-operative complications, as compared to those with normal kidney function. This data may suggest that patients with ESRD/HD should be cautiously selected for a TEVAR intervention, and the benefits must be carefully weighed against the poor expected survival.
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