Surgical treatment of renovascular hypertension

The evaluation of patients with inadequate control of diastolic blood pressure for surgically correctable forms of hypertension led to the detection and surgical treatment of 56 patients. Detection was facilitated by the use of hypertensive intravenous pyelography and Hippuran renal Scanning. Aortography proved the presence of renal artery disease and renal vein renin assay established its significance in the etiology of the patients' hypertension. Renal artery reconstruction was performed in 50 patients, including 5 who also had reconstruction of major aortoiliac lesions. The extent of renal artery disease precluded arterial reconstruction in six patients, who required nephrectomy. Two postoperative deaths occurred, for a mortality rate of 3.6 per cent. Improvement in mean diastolic blood pressure for the total group of patients from 118 mm Hg preoperatively to 86 mm Hg postoperatively was achieved. Forty-six patients (85 per cent) have a diastolic blood pressure of 90 mm Hg or less; in 5 patients the diastolic blood pressure is 91 to 100 mm Hg but is at least 20 mm Hg lower than the preorative level.     

Surgical treatment of renovascular hypertension in children.

In fourteen children with renovascular hypertension the most prevalent lesion was fibromuscular dysplasia (nine patients). Nephrectomy was performed in four patients prior to the adoption of reconstructive vascular techniques. Revascularization of a variety of lesions was employed with autogenous arterial grafts, which gave excellent results over a long follow-up period in ten patients. Ex vivo microvascular repair was used in one patient rather than nephrectomy for management of branch artery lesions. These results indicate that careful and precise arterial repairs will yield a high cure rate in children with renovascular hypertension without the sacrifice of renal parenchyma.     

Surgical correction of renovascular hypertension

The role of surgical revascularization in the management of patients with renal artery disease has changed in recent years. This has occurred owing to the advent of transluminal angioplasty as an effective method of treatment for certain patients, improved results of surgical revascularization in older patients with atherosclerosis, an enhanced appreciation of advanced atherosclerotic renal artery disease as a correctable cause of renal failure, and the development of more effective surgical techniques for patients with severe aortic atherosclerosis and branch renal artery disease. Surgical revascularization is at present the treatment of choice for patients with branch renal artery disease, ostial atherosclerotic renal artery disease, a renal artery aneurysm, and patients in whom renal angioplasty has been unsuccessful. Excellent clinical results continue to be achieved with surgical revascularization in properly selected patients.     

Surgical treatment of renovascular hypertension (author's transl)]

Renal artery stenosis was corrected in 50 patients suffering from renovascular hypertension. In 32 cases hypertension returned to normal, 11 patients were improved and hypertension was unchanged in seven cases.     

Surgical management of childhood renovascular hypertension

Renovascular hypertension is more common in hypertensive children and adolescents than in hypertensive adults. This article discusses the diagnostic evaluation, operative therapy, and outcome of patients with renovascular hypertension.     

Surgical correction of posttransplant renovascular hypertension.

The incidence of renovascular hypertension in the transplanted kidney is reported to range between 5 and 15%. A review of 391 consecutive renal transplant patients revealed 16 patients (5.4%) with hypertension secondary to partial obstruction of renal arterial blood flow. The clinical course of this group of patients was marked by early normotension followed by progressive diastolic pressure elevation, with improving renal function and loss of accumulated excess volume. Five etiologic factors are responsible for impaired arterial flow in this group of patients. Indication for operation was based on hypertension and/or impaired renal function. Patch angioplasty using saphenous veins was the procedure of choice in most instances. The average blood pressure was 185 mmHg; systolic/125 mmHg; diastolic preoperatively, compared with 140 mmHg; systolic/90 mmHg: diastolic postoperatively. Twelve of 16 patients had good results, and improvement in renal function was observed in eight patients. Serum renin levels did not correlate well with the operative findings. The use of meticulous technique, combined with maximum use of autogenous tissue, is emphasized.     

Evaluation and long-term outcome of pediatric renovascular hypertension

Seventeen children with renovascular hypertension were managed at the Royal Children's Hospital, Melbourne, over the 20-year period from 1975 to 1996. The age at presentation ranged from 10 days to 18 years. All children presented with severe hypertension with mean systolic blood pressure 7 standard deviations above age-matched averages and mean diastolic blood pressure 5.5 standard deviations above age-matched averages. Neurofibromatosis was the most common etiology (58% of patients) and there were no cases of Takayasu's arteritis. Patients underwent a variety of biochemical and imaging investigations but in all cases renal angiography was necessary for definitive diagnosis and for planning therapy. Ten of the 17 patients had surgical procedures performed. Percutaneous transluminal angioplasty was performed in four patients but led to cure in only one patient following thrombosis of the affected artery producing segmental renal infarction. Other vascular reconstructive procedures, including the use of autologous or synthetic bypass grafts and autotransplantation, produced cure of hypertension in 50% of children with improvement in a further 30%. The long-term outlook for children treated with surgical reconstructive procedures was excellent. One patient underwent surgery for avulsion of an arterial graft following a pubertal growth spurt. No other patient originally cured by surgery has required reoperation with no cases of restenosis at a mean follow-up of 11 years 3 months.     

Autorenal transplantation in the treatment of renovascular hypertension

Autorenal transplantation was performed on 32 renal units including three bilateral transplants, in 29 renovascular hypertensive patients. Aortoarteritis in 18, fibromuscular dysplasia in six, and atherosclerosis in five were the causative renal arterial lesions. Young patients with severe or uncontrolled hypertension but with functioning kidneys were selected for this procedure. Follow-up varied from one to seven years. Twenty-two patients were cured of hypertension, four showed improvement and in three the transplanted kidneys failed to function due to vascular thrombosis postoperatively. There was no death in the series.     

Aortorenal reimplantation in treatment of renovascular hypertension

From 1964 to 1977, 33 patients underwent aortorenal reimplantation as surgical treatment for renovascular hypertension. Over-all results were 13 patients cured (39 per cent), 15 patients improved (46 per cent), and there were 5 failures (15 per cent). The results were equally satisfactory in patients with atherosclerotic or fibrous renal artery disease. Postoperative arterial stenosis or occlusion occurred in 5 patients (15 per cent). Aortorenal reimplantation is an effective method of renal revascularization in properly selected patients, and long-term results are comparable with those of aortorenal bypass.