Clinical research study
From the Western Vascular Society
Systemic inflammation, coagulopathy, and acute renal insufficiency following endovascular thoracoabdominal aortic aneurysm repair

https://doi.org/10.1016/j.jvs.2008.11.102Get rights and content
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Objective

To characterize the inflammatory and coagulopathic response after endovascular thoracoabdominal aortic aneurysm (TAAA) repair and to evaluate the effect of the response on postoperative renal function.

Methods

From July 2005 to June 2008, 42 patients underwent elective endovascular repair of a TAAA using custom designed multi-branched stent-grafts at a single academic institution. Four patients were excluded from the analysis. White blood cell count (WBC), platelet count, prothrombin time (PT), and creatinine were measured in all patients. In the last nine patients, interleukin-6 (IL-6), protein C, Factor V, d-dimers, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) levels were also measured. Change in lab values were expressed as a percentage of baseline values.

Results

The 30-day mortality rate was 5% (2/38). All patients (n = 38) had a higher WBC (mean ± SD: 139 ± 80%, P < .0001), lower platelet count (56 ± 15%, P < .0001), and higher PT (median: 17%, Interquartile range (IQR) 12%-22%, P < .0001) after stent-graft insertion. Twelve of 38 patients (32%) developed postoperative acute renal insufficiency (>50% rise in creatinine). Patients with renal insufficiency had significantly larger changes in WBC (178 ± 100% vs 121 ± 64%, P = .04) and platelet count (64 ± 17% vs 52 ± 12%, P = .02) compared with those without renal insufficiency. All patients (n = 9) had significant increases in NGAL (182 ± 115%, P = .008) after stent-graft insertion. Six of nine patients (67%) had increased cystatin C (35 ± 43%, P = .04) after stent-graft insertion, with a greater rise in those with postoperative renal insufficiency (87 ± 32% vs 8 ± 13%, P = .02). IL-6 levels were markedly increased in all patients (n = 9) after repair (9840 ± 6160%, P = .008). Protein C (35 ± 10%, P = .008) and Factor V levels (28 ± 20%, P = .008) were uniformly decreased, while d-dimers were elevated after repair in all patients (310 ± 213%, P = .008).

Conclusions

Leukocytosis and thrombocytopenia were uniform following endovascular TAAA repair, and the severity of the response correlated with post-operative renal dysfunction. Elevation of a sensitive marker of renal injury (NGAL) suggests that renal injury may occur in all patients after stent-graft insertion.

Cited by (0)

This project was supported by National Institutes of Health (NIH)/National Center for Research Resources (NCRR)/OD University of California, San Francisco (UCSF)-Clinical and Translational Science Institute (CTSI) Grant Number KL2 RR024130 (Dr Hiramoto) and NIH K08 GM-085689 (Dr Cohen). Its contents are the responsibility of the authors and do not necessarily represent the official views of the NIH. This study was also supported in part by grants from the Hellman Award, San Francisco, CA (Dr Hiramoto); the Research Evaluation and Allocation Committee, San Francisco, CA (Dr Hiramoto); the Foundation of Anesthesia Research and Education, Rochester, MN (Dr Niemann); the International Anesthesia Research Society, Cleveland, OH (Dr Niemann); the Foundation for Accelerated Vascular Research, San Francisco, CA (Drs Chang and Chuter); and the Established Investigator Award from the American Heart Association (Dr Shlipak). The Clinicaltrials.gov number is: NCT00483249.

Conflict of interest: Dr. Chuter has licensed patents to Cook Medical, Inc. and receives travel and research support from Cook Medical, Inc.

Copyright © 2009 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.