Chronic kidney disease classification stratifies

mortality risk after elective stent graft repair of the

thoracic aorta
Massimiliano M. Marrocco-Trischitta, MD, PhD,a Germano Melissano, MD,a Andrea Kahlberg, MD,a
Giliola Calori, MD,b Francesco Setacci, MD,a and Roberto Chiesa, MD,a Milan, Italy

Objective: Risk factors for perioperative and late mortality after thoracic endovascular aortic repair (TEVAR) remain
ill-defined. In this study, we examined the prognostic significance of chronic kidney disease (CKD), a well-known
predictor of death after thoracic aorta open repair, employing a stratification based on CKD stages derived from
glomerular filtration rate (GFR) values.
Methods: A prospective database was evaluated for 179 consecutive patients electively submitted to TEVAR between 1999
and 2007. Preoperative GFR was estimated by using the Cockcroft-Gault equation. Patient groups were stratified into
four quartiles by baseline serum creatinine (SC) and GFR values, with quartile I being the lowest, and quartile IV the
highest, and into the five CKD stages in reverse order (I GFR > 90 ml/min/1.73 m2; II 60-89; III 30-59; IV 15-29;
V < 15). Prognostic significance of preoperative GFR values and CKD stages were investigated by means of univariate and
multivariate analyses, and the Kaplan-Meier log-rank method.
Results: A primary technical success was achieved in 166 of 179 patients (92.7%), and an initial clinical success in 158
(88.3%). Thirty-day mortality was 5% (nine cases). Paraplegia or paraparesis were observed in 11 (6.1%) patients, and
completely resolved in six cases after cerebrospinal fluid drainage. Preoperative GFR quartiles and CKD stages were
significant predictors of 30-day mortality (P ⴝ .004 and P < .0001 respectively), whereas SC quartiles did not affect the
outcome (P ⴝ .12). In particular, GFR quartile I (<60 ml/min/1.73 m2) was associated with a ten-fold greater risk of
perioperative death compared with the other three quartiles (Odds Ratio 11.4, 95% Confidence Interval 2.3-57.0, P ⴝ
.003). Midterm survival was 88.8% (159 of 179) at a mean follow-up of 35.6 ⴞ 23.7 months. Actuarial survival at 60
months was 57.8%, 81.1%, 92.3%, and 100% for GFR quartiles I to IV respectively (P < .0001), and 0.0%, 66.7%, 59.2%,
88.6%, and 100% (P < .0001) for CKD stage V to I respectively. At univariate analyses, age (P ⴝ .019), preoperative SC
quartiles (P ⴝ .001), GFR quartiles (P ⴝ .0002), and CKD stages (P < .0001) were all predictive of mid-term mortality.
At multivariate Cox proportional hazards regression analysis, only CKD stages remained independently associated with
the outcome (P ⴝ .008).
Conclusions: GFR is an accurate prognostic predictor in patients submitted to TEVAR. Also, perioperative and midterm
mortality directly correlate with the severity of CKD stages, allowing a risk stratification model to be employed both for
risk-adjusted preoperative evaluation, and to establish accurate matching criteria for comparative studies. ( J Vasc Surg
2009;49:296-301.)

Thoracic endovascular aortic repair (TEVAR) has been
proven as a feasible alternative to open repair, particularly in
patients considered unsuitable for surgery due to the pres-
ence of significant comorbidities.1,2 Owing to its unques-
tionable lower invasiveness, TEVAR is increasingly gaining
favor also for the treatment of “low-risk” patients, and the
first and so far only completed comparative multicenter
study, namely the Gore TAG trial,3 showed the superiority
of TEVAR over open repair in terms of aneurysm-related
mortality and major adverse events at 5 years.4 Yet, the
follow-up could not be completed for more than 25% of
patients, and the control group included for the most part
From the Department of Vascular Surgery,a and the Statistical Unit,b San
Raffaele Scientific Institute, Università Vita-Salute.
Competition of interest: none.
Reprint requests: Massimiliano M. Marrocco-Trischitta, MD, PhD, Vascu-
lar Surgery, San Raffaele Scientific Institute, Via Olgettina, 60, 20132
Milan, Italy (e-mail: max_marrocco@yahoo.com, marroccotrischitta.
massimiliano@hsr.it).
0741-5214/$36.00
Copyright © 2009 Published by Elsevier Inc. on behalf of The Society for
Vascular Surgery.
doi:10.1016/j.jvs.2008.09.041
296
(53%) historically and retrospectively acquired patients.
Also, TEVAR has so far failed to provide improved all-cause
survival rates,4,5 or quality of life benefits,6 and therefore no
thorough conclusions can be drawn regarding long-term
results.
Careful selection of patients for TEVAR, apart from
anatomic factors, should include the risk of aneurysm-
related death,7 and the prognosis related to concomitant
medical diseases.8 Mean aortic growth rate is 0.10 cm per
year,7 and therefore asymptomatic, small- to moderate-
sized thoracic aortic aneurysms can be safely followed-up.9
This is particularly the case in patients with other debilitat-
ing comorbidities, in whom the risks of TEVAR may ex-
ceed those inherent to conservative treatment.8 As a result,
preoperative risk stratification appears important both for
indication to treatment, and evaluation of postoperative
results.
Chronic kidney disease (CKD) is a well-known deter-
minant of early mortality after thoracoabdominal and de-
scending thoracic aortic open repair,10 and recent studies
have described the higher prognostic value of glomerular
JOURNAL OF VASCULAR SURGERY
Volume 49, Number 2
filtration rate (GFR) compared with serum creatinine (SC)
alone in patients submitted to open thoracoabdominal
aortic aneurysm repair.11
The present study was conducted to determine the
impact on perioperative and midterm mortality of a strati-
fication based on the National Kidney Foundation CKD
stages,12 derived from GFR values, in patients undergoing
elective stent-graft repair of the thoracic aorta.
METHODS
This study was designed as a single-center experience. A
retrospective review was conducted on a prospectively com-
puterized database of all patients undergoing elective
TEVAR at our Institution. Between June 1999 and January
2007, 179 consecutive cases were treated (150 males, mean
age, 70.1 ⫾ 9.0 years). Patients affected with thoracoab-
dominal aortic aneurysm, submitted to hybrid surgery,
were excluded from the analysis because of the presence of
possible confounding factors for preoperative GFR, namely
the involvement of the renal arteries.
Indications for intervention included: atherosclerotic
aneurysm in 150 cases, chronic type B dissection in 17
cases, penetrating ulcer/intramural hematoma in five cases,
and chronic post-traumatic false aneurysm in seven cases.
Mean aortic diameter in case of aneurysmal disease was
61 ⫾ 19 mm. Patients were operated on under general
anesthesia in 111, spinal anesthesia in 60 cases, or local
anesthesia in eight. Access site was femoral in 155 cases, and
aorto-iliac in 24, including five cases of synchronous sur-
gery for AAA.
Patients were stratified by the proximal landing Zone
according to the Ishimaru’s classification.13 Overall, there
were 16 Zone 0, 13 Zone 1, 41 Zone 2, 58 Zone 3, and 51
Zone 4. Debranching of supra-aortic vessels was performed
for Zone 0 and Zone 1 cases as previously described in
detail.14 Selective revascularization of the left subclavian
artery (LSA) was performed in Zone 2 patients.14 Cerebro-
spinal fluid (CSF) drainage was also selectively instituted in
21 (11.7%) patients, as described elsewhere.15
The feasibility of the endoluminal intervention and
sizing of stent grafts were determined with preoperative
computed tomography (CT) scans and aortography.
The endografts implanted were Excluder TAG (WL Gore
and Assoc., Flagstaff, Ariz), Talent and Valiant (AVE/
Medtronic Inc., Santa Rosa, Calif), Endofit (Endomed
Inc., Phoenix, Ariz), Zenith (WilliamCook Europe Aps,
Bjaeverskov, Denmark), and Relay (Bolton Medical Inc.,
Sunrise, Fla). All the procedures were performed in the
operating room, and a portable digital C-arm image inten-
sifier with subtraction angiography and roadmap capabili-
ties was used.
Patients were stratified by preoperative risk factors in-
cluding etiology, proximal landing zone, previous aortic
surgery, diabetes, tobacco use, hypertension, chronic ob-
structive pulmonary disease (COPD), hyperlipidemia, and
by coronary artery disease (CAD), according to the Gold-
man revised cardiac risk index (RCRI).16
Marrocco-Trischitta et al 297
The preoperative GFR value was estimated by using the
Cockcroft-Gault equation17 (140 – age) ⫻ weight/72 ⫻
serum creatinine (where age is in years, actual body weight
is in kg, and serum creatinine is the baseline level obtained
on the day of admission expressed in mg/dL; for women,
the equation is multiplied by 0.85). GFR values are ex-
pressed as mL/min/1.73 m2.
Patients groups were also stratified into four quartiles
by baseline SC and GFR values, with quartile I being the
lowest, and quartile IV the highest, and into the five CKD
stages12 in reverse order (I GFR ⱖ 90 ml/min/1.73 m2 ; II
GFR 60-89 ml/min/1.73 m2; III GFR 30-59 ml/min/
1.73 m2; IV GFR 15-29 ml/min/1.73 m2; V GFR ⬍ 15
ml/min/1.73 m2).
Morbidity and mortality were recorded. Neurologic
deficits were defined as paraplegia or paraparesis according
to the Modified Tarlov scale, and classified as immediate,
when observed immediately or upon awakening, or de-
layed, when occurring after a period of normal neurologic
function.15 Results were described according to the Re-
porting Standards for endovascular aortic aneurysm re-
pair.18 Patients were followed-up at one, six, and 12
months, and yearly thereafter by means of office clinical
evaluation and aortic imaging.
We investigated the influence of demographics and
preoperative risk factors as possible predictors of postoper-
ative outcome (Tables I-III). Univariate statistics were
computed by using contingency table methods. Continu-
ous data were divided into quartiles for contingency table
analysis. Survival outcome was evaluated along a 60-month
distribution of failure times by using Kaplan-Meier esti-
mates. The actuarial survival was computed according to
the Kaplan-Meier log-rank method. Multivariate analysis
was performed by using Cox proportional hazards regres-
sion. The null hypothesis for statistical tests was rejected at
P ⬍ .05. All analyses were run using SAS 8.02 software
(SAS Institute Inc, Cary, NC).
RESULTS
Overall, a primary technical success was achieved in 166
of 179 patients (92.7%), and an initial clinical success in 158
(88.3%). Thirty-day mortality was 5.0% (9 of 179), and due
to intraoperative graft migration (n ⫽ 1), stroke (n ⫽ 3),
multiorgan embolization (n ⫽ 1), myocardial infarction
(n ⫽ 2), and multiple organ failure (n ⫽ 2). Paraplegia or
paraparesis were observed in 11 (6.1%) patients, and in
eight cases the onset was delayed (range, 1 to 35 days). The
neurologic deficit completely resolved in six cases after CSF
drainage. Other postoperative complications included
acute renal failure (ie, SC exceeding the baseline value by
30% and surpassing an absolute level of 2.0 mg/dL)19
reversed without dialysis in five (2.8%) patients, respiratory
failure requiring intubation for ⬎ 48 hours in four (2.2%)
patients, and acute myocardial infarction in two (1.1%)
patients.
Among the variables analyzed, preoperative GFR quar-
tiles and CKD stages were found to be significantly associ-
ated with 30-day mortality (P ⫽ .004 and P ⬍ .0001,
 JOURNAL OF VASCULAR SURGERY
298 Marrocco-Trischitta et al February 2009

Table I. Univariate analyses of risk factors for 30-day mortality

Variable Levels No. patients (%) No. deaths (%) P value*

Overall 179 (100.0) 9 (5.0)

Age ⬍55 12 (6.7) 0 (0.0) .50
55-68 54 (30.4) 2 (3.7)
69-80 99 (55.6) 7 (7.1)
⬎80 13 (7.3) 0 (0.0)
Gender Female 29 (16.2) 1 (3.4) .67
Male 150 (83.8) 8 (5.3)
COPD Yes 104 (58.1) 6 (5.8) .59
No 75 (41.9) 3 (4.0)
CAD† 0 122 (68.2) 4 (3.3) .27
1 35 (19.5) 4 (11.4)
2 20 (11.2) 1 (5.0)
3 2 (1.1) 0 (0.0)
AAA surgery No 141 (78.8) 7 (5.0) .84
Previous 33 (18.4) 2 (6.1)
Simultaneous 5 (2.8) 0 (0.0)
Redo procedure Yes 10 (5.6) 0 (0.0) .45
No 169 (94.4) 9 (5.3)
Zone‡ 0 16 (8.9) 2 (12.5) .40
1 13 (7.3) 0 (0.0)
2 41 (22.9) 3 (7.3)
3 58 (32.4) 3 (5.2)
4 51 (28.5) 1 (2.0)
Etiology ATS 150 (83.8) 8 (5.3) .48
Dissection 17 (9.5) 0 (0.0)
PAU/IMH 5 (2.8) 0 (0.0)
Post-traumatic 7 (3.9) 1 (14.3)
Preop SC [Quartiles] (mg/dL) ⬍0.85 46 (25.7) 2 (4.3) .12
0.85-0.99 42 (23.5) 0 (0.0)
1.00-1.20 46 (25.7) 2 (4.3)
⬎1.20 45 (25.1) 5 (11.1)
Preop. GFR [Quartiles] (mL/min per 1.73 m2) ⬎87.0 45 (25.1) 1 (2.2) .004
73.0-87.0 44 (24.6) 1 (2.3)
60.0-72.9 43 (24.0) 0 (0.0)
⬍60.0 47 (26.3) 7 (14.9)
CKD Stages§ I (GFR ⱖ 90) 38 (21.2) 1 (2.6) ⬍.0001
II (GFR ⫽ 60-89) 94 (52.5) 1 (1.1)
III (GFR ⫽ 30-59) 41 (22.9) 5 (12.2)
IV (GFR ⫽ 15-29) 4 (2.2) 0 (0.0)
V (GFR ⬍ 15) 2 (1.1) 2 (100.0)
AAA, Abdominal aortic aneurysm; ATS, atherosclerotic; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; GFR, glomerular
filtration rate (estimated by using the Cockroft-Gault equation); IMH, intramural hematoma; PAU, penetrating aortic ulcer; SC, serum creatinine.
*␹2 test for independance. Probability of type I statistical error (common P value).
†
Perioperative cardiac risk, according to the Goldman revised cardiac risk index (RCRI).17
‡
Proximal landing zone, according to the Ishimaru’s classification.14
§
Chronic Kidney Disease Stages, according to the National Kidney Foundation guidelines.13

respectively), whereas SC quartiles were not (P ⫽ .12)
(Table I). In particular, GFR quartile I (⬍60 ml/min/1.73
m2) was associated with a ten-fold greater risk of death
compared with the other three quartiles (OR 11.4, 95% CI
2.3-57.0, P ⫽ .003).
Midterm survival was 88.8% (159 of 179) at a mean
follow-up of 35.6 ⫾ 23.7 months. Eleven (6.5%) of 170
initial survivors died during follow-up due to aneurysm
rupture (n ⫽ 2), aortoesophageal fistula nine months after
implantation (n ⫽ 1), abdominal aortic aneurysm rupture
(n ⫽ 1), myocardial infarction (n ⫽ 3), malignancies (n ⫽
2), stroke (n ⫽ 1), and respiratory failure (n ⫽ 1). One
successful surgical conversion was performed following
stent-graft rupture 43 months after TEVAR.
Actuarial survival at 60 months was 57.8%, 81.1%,
92.3%, and 100% for GFR quartiles I to IV respectively
(P ⬍ .0001), and 0.0%, 66.7%, 59.2%, 88.6%, and 100%
(P ⬍ .0001) for CKD stage V to I respectively (Fig).
At univariate analyses, age, preoperative SC quartiles,
GFR quartiles, and CKD stages were all predictive of mid-
term mortality (Table II). Ishimaru’s classification and
COPD showed a mild association with late mortality, but
did not reach statistical significance. Nevertheless, both
factors were conservatively entered in the multivariable
model to eliminate possible confounding factors.
At multivariate Cox proportional hazards regression
analysis, only CKD stages remained independently associ-
ated with mortality (P ⫽ .008) (Table III).
JOURNAL OF VASCULAR SURGERY
Volume 49, Number 2 Marrocco-Trischitta et al 299

Table II. Univariate analyses of risk factors for mid-term mortality

Variable Levels 60-Months mortality¥ P value*

Age ⬍55 0.0% .019

55-68 7.7%
69-80 4.4%
⬎80 23.1%
Gender Female 3.6% .47
Male 7.1%
COPD Yes 10.2% .07
No 1.4%
†
CAD 0 5.9% .29
1 0.0%
2 21.0%
3 0.0%
AAA surgery No 6.0% .61
Previous 8.8%
Simultaneous 0.0%
Redo procedure Yes 0.0% .59
No 6.9%
Zone‡ 0 0.0% .08
1 15.4%
2 5.3%
3 9.3%
4 4.0%
Etiology ATS 7.8% .69
Dissection 0.0%
PAU/IMH 0.0%
Post-traumatic 0.0%
Preop SC [Quartiles] (mg/dL) ⬍0.85 2.4% .001
0.85-0.99 4.5%
1.00-1.20 0.0%
⬎1.20 20.0%
Preop GFR [Quartiles] (mL/min per 1.73 m2) ⬎87.0 0.0% .0002
73.0-87.0 0.0%
60.0-72.9 6.7%
⬍60.0 20.5%
CKD Stages§ I (GFR ⱖ 90) 0.0% ⬍.0001
II (GFR ⫽ 60-89) 3.2%
III (GFR ⫽ 30-59) 20.0%
IV (GFR ⫽ 15-29) 25.0%
V (GFR ⬍ 15)兰 /
AAA, Abdominal aortic aneurysm; ATS, atherosclerotic; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; GFR, glomerular
filtration rate (estimated by using the Cockroft-Gault equation); IMH, intramural hematoma; PAU, penetrating aortic ulcer; SC, serum creatinine.
*Log-Rank test. Probability of type I statistical error (common P value).
†
Perioperative cardiac risk, according to the Goldman revised cardiac risk index (RCRI).17
‡
Proximal landing zone, according to the Ishimaru’s classification.14
§
Chronic Kidney Disease Stages, according to the National Kidney Foundation guidelines.13
¥
Kaplan-Meier estimates. Only 30-day survivors are considered.
兰
There were no 30-day survivors in CKD Stage V (all patients died perioperatively).

Table III. Multiple Cox proportional hazards regression analysis of risk factors for mid-term mortality

Variable Levels Hazard ratio† 95% CI (%) P value*

Age Trend of quartiles 2.08 0.718-6.059 .457

COPD Yes vs No 8.79 0.711-108.749 .090
Zone‡ 0 vs 1, 2, 3, and 4 0.86 0.460-1.600 .630
Preoperative SC Trend of quartiles 2.08 0.718-6.059 .177
CKD Stages§ Trend of stages 8.08 1.706-38.296 .008
CI, Confidence interval; COPD, chronic obstructive pulmonary disease; SC, serum creatinine.
*Cox proportional hazards regression.
†
For dichotomous variables, the hazard ratio represents the increased risk against a reference category whose referent hazard ratio is 1. For continuous data,
the hazard ratio refers to the increase in hazard associated with a one-unit increase in the variable value. Quartiles (1 to 4) are considered as continuous data.
‡
Proximal landing zone, according to the Ishimaru’s classification.14
§
Chronic Kidney Disease Stages, according to the National Kidney Foundation guidelines.13

300 Marrocco-Trischitta et al
Fig. Survival by Chronic Kidney Disease (CKD) stages. At key
time points (0, 24, and 60 months), the number of patients in each
CKD stage is listed above (P ⬍ .0001, Log Rank test). *In CKD
Stage IV, standard error is ⬎10%.
DISCUSSION
Chronic renal insufficiency is an established predictor
of postoperative outcome traditionally estimated with SC.
This is, however, an insensitive index, and particularly in
cases of mild to moderate degrees of renal dysfunction. As
a result, the National Kidney Foundation recommended
the use of estimations of GFR from SC to avoid the
misclassification of patients on the basis of SC alone, and
defined five stages of severity based on the level of
GFR.12,20
In our study, GFR was estimated with the Cockcroft-
Gault equation that is a simple and validated method,12
requires information available in our database, and was
earlier employed to stratify renal function according to the
CKD stages.21 Also, our approach was methodologically
consistent with previous studies on postoperative mortality
after aortic aneurysms repair11,22,23 and coronary artery
bypass grafting.24
Our study confirmed GFR as a more accurate prognos-
tic predictor than SC alone also in patients submitted to
TEVAR. Furthermore, as hypothesized, perioperative and
midterm mortality directly correlated with the severity of
CKD stages, allowing a risk stratification model. The most
relevant decrease in perioperative survival rates was ob-
served in patients with preoperative GFR ⬍60 ml/min/
1.73 m2 (ie, lower GFR quartile), that had a mortality ten
times greater than that of patients with higher GFR values.
Interestingly, this value coincides with the threshold for
definition of CKD,20 that represents a reduction by more
than half of the normal GFR level, and is associated with the
onset of laboratory abnormalities characteristic of kidney
failure.20
The analysis of the exact causal relationship between
CKD and mortality is beyond the scope of this study, and
would require ad hoc studies on a larger number of patients.
However, we can speculate that poor survival rates are
related to the increased risk of adverse cardiovascular events
JOURNAL OF VASCULAR SURGERY
February 2009
in patients affected with CKD.20 In particular, both athero-
sclerosis and large-vessel remodeling are present in these
patients, leading clinically to ischemic heart disease, cere-
brovascular disease, peripheral vascular disease, heart fail-
ure, increased systolic blood pressure, and left ventricular
hypertrophy.20 Notably, even relatively minor renal abnor-
malities, which may remain unrevealed by routine preoper-
ative evaluation, are associated with such a risk.25 In this
respect, the sensitivity of a GFR-based stratification appears
again of great importance. In our study, overall 15 out of
20 deaths were due to myocardial infarction, stroke, mul-
tiorgan embolization, aneurysm rupture, and multiple or-
gan failure.
Previous works demonstrated that TEVAR entails a
relevant morbidity, including stroke, dialysis, and paraple-
gia, and mortality in high-risk patients.8,26-29 However, the
definition of low or high-risk cohorts is practically based on
whether patients are suitable candidates for conventional
open repair. We believe that the development of a consis-
tent and widely shared risk stratification model is necessary
for patient selection among candidates to compassionate
treatment, to identify who, in fact, may not benefit from it,
and also to establish accurate matching criteria for random-
ized or case-control studies in patients at present grossly
defined at “low-risk.”
To our knowledge, the literature does not provide
specific studies on risk factors for mortality after TEVAR,
with the exception of a recent work by Khoynezhadet
et al.30 The authors found only procedural type I endoleak
as an independent risk factor of early mortality, and COPD,
postoperative myocardial infarction, and acute renal failure
as predictors of late death. Chronic renal insufficiency did
not result a significant risk factor, but only preoperative
permanent dialysis dependence was included among the
analyzed variables.30
In conclusion, we recognize some limitations of our
study, including the intrinsic biases related to its retrospec-
tive fashion, even though data were prospectively collected.
Due to the small number of patients, there may be other
significant variables that remained unrevealed as a conse-
quence of Type II errors, even though for this reason we
ran a multivariate analysis including also risk factors that
approached but not reached statistical significance at uni-
variate analysis. In addition, the actuarial analysis is of
limited value due to the small size of the lower CKD stages
groups. Finally, although etiology, extension of aortic pa-
thologies, and adjunctive procedures were taken into ac-
count, our data set included heterogeneous groups of
patients, and therefore a comparison with other studies
from the literature may result difficult.
Nevertheless, we believe that our work provides evi-
dence that patients stratification based on CKD GFR stages
is a reliable and useful prognostic tool to be employed both
for risk-adjusted preoperative evaluation, and comparative
studies regarding the safety and efficacy of ongoing techni-
cal developments, and next generation endografts.
JOURNAL OF VASCULAR SURGERY
Volume 49, Number 2
AUTHOR CONTRIBUTIONS
Conception and design: MMT, AK
Analysis and interpretation: MMT, GM, AK, GC, FS, RC
Data collection: MMT, GM, AK, FS
Writing the article: MMT, GM, AK
Critical revision of the article: MMT, GM, AK, GC, FS, RC
Final approval of the article: MMT, GM, AK, GC, FS, RC
Statistical analysis: GC, AK
Obtained funding: N/A
Overall responsibility: RC
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Submitted Jul 22, 2008; accepted Sept 18, 2008.