Posterolateral exposure for renal artery reconstruction

Anterior approaches to the renal arteries are complicated by the intervening renal veins, inferior vena cava, and abdominal viscera. We describe techniques of direct posterolateral access to both right and left renal arteries by use of an extended retroperitoneal exposure. This approach allows for grafting from the aorta or iliac artery on either side and is particularly suitable on the left side for direct retropancreatic splenorenal artery anastomosis, which is described in detail. It is also useful for distal reconstruction of branch renal arteries, renal artery embolectomy, and autotransplantation "bench surgery." We have used this approach in 28 patients with no operative deaths and two reconstructive occlusions.     

Aortoenteric fistula treated with endovascular aortic stent-graft and bilateral chimney stent-grafts to renal arteries

We report a patient with secondary aortoenteric fistula (AEF) presenting with a rectal bleeding. The patient had multiple comorbidities, precluding major open vascular surgery. We opted to perform a two-stage procedure, where an endovascular stent-graft was first deployed to exclude the AEF from the systemic circulation. As the AEF was at the proximal anastomosis of the previous Dacron graft and close to the renal artery ostia, chimney stent-grafts were placed in both renal arteries to maintain their patency. The second stage of the procedure involved a laparotomy to repair the defect in the duodenum to prevent further contamination from bowel contents.     

Management of multiple embolization arising from atrial myxoma

This study reports detailed surgery procedures on a patient with cardiac myxoma and multiple embolization in the aortic artery, lower extremities, and the superior mesenteric and renal arteries, which is quite uncommon. As the first step in the surgery, conventional thrombectomy was used to remove emboli in abdominal aorta and bilateral lower extremities based on single-lumen Fogarty catheters accessed through bilateral femoral arteries. As the second step, double-lumen Fogarty catheters and percutaneous aspiration thromboembolectomy accessed by bilateral femoral arteries again were used in combination to restore blood flow in the visceral artery and renal arteries without the need of laparotomy. Compared with traditional methods relying on laparotomy, the method by combining Fogarty catheters with percutaneous aspiration thromboembolectomy is less invasive and time consuming, and is a promising method in dealing with multiple embolization arising from cardiac myxoma.     

Surgical treatment of vasorenal hypertension in non-specific aorto-arteritis]

An injury to the renal arteries was found in 119 patients with non-specific aorto-arteritis and high arterial hypertension by means of angiography. 66 patients were operated upon (75 operations). The reconstruction of one renal artery was carried out upon 31 patients, 30 patients underwent the reconstruction of both renal arteries. 6 patients were subjected to the primary nephrectomy, and 6 others to the secondary one. The blood flow along the aorta and visceral arteries was restored in 31 cases in one-stage operation together with the reconstruction of the renal arteries. In recent years the postoperative mortality has constituted 4.3%. Excellent and good results have been obtained in 83.6% of cases.     

Staged reconstruction for middle aortic syndrome

BACKGROUND/PURPOSE: Middle aortic syndrome is a rare condition that involves narrowing of the abdominal aorta and its visceral branches. The authors propose staged vascular repair to minimize renal ischemia and facilitate use of native arterial tissue for reconstruction. METHODS: Three adolescents (age 8(1/2), 12(1/2), 13(1/2)) presented with severe hypertension. Subsequent evaluation showed coarctation of the abdominal aorta extending above the celiac axis. All 3 patients had bilateral renal artery stenoses. There also were tight stenoses of the celiac or superior mesenteric arteries. In the first stage the right renal artery stenosis was relieved. In the youngest patient, this was accomplished by balloon angioplasty. However, in the other 2, right renal autotransplantation was performed to the right iliac vessels using end-to-side anastomoses of the renal artery and vein. Cold perfusion was used. The second stage was performed 2 to 5 months later via a thoracoabdominal approach in 2 patients. A Dacron tube graft was utilized from above the coarctation to the iliac bifurcation. The left renal arteries were detached and anastomosed end to side to the bypass graft. In 1 child there were actually 3 separate renal arteries that required reimplantation. In the youngest patient the aortic narrowing was relieved by a long Dacron patch aortoplasty and interposition of an internal iliac artery graft to the left renal artery. RESULTS: All 3 patients recovered well and returned to full activities. There was no measurable rise of BUN or serum creatinine postoperatively. Postoperative renal scans showed good renal perfusion bilaterally. Follow-up results 2 to 10 years later continue to show well functioning reconstructions. CONCLUSION: A staged approach is an effective reconstruction for children with middle aortic syndrome which minimizes risk to renal function.     

New technique to facilitate renal revascularization with use of telescoping self-expanding stent grafts: VORTEC

This article describes a new, less invasive prosthetic graft anastomotic technique that uses self-expanding stent grafts that are "telescoped" into aortic branches. This method, the VORTEC (Viabahn Open Revascularization TEChnique), obviates the need for potentially difficult complete vessel exposure and graft anastomoses, thereby reducing the duration of flow interruption and simplifying the performance of complex aortic reconstructions and so-called debranching procedures requiring reconstruction of major branches such as renal arteries. Minimal exposure of one surface of the renal artery allowed introduction and deployment of a self-expanding Viabahn (W.L. Gore & Associates, Flagstaff, AZ) device using the Seldinger technique. The Viabahn devices used were 5 to 8 mm in diameter and 5 to 15 cm in length depending on individual anatomy (assessed by preoperative computed tomographic angiography). Overall, 82 renal arteries have been revascularized in 58 patients using the VORTEC. The technical success rate was 100%, with all of the stent grafts implanted as intended with maintenance of flow. The patency rates were 97% after 30 days and 96% after a mean follow-up of 18 months (range 1-38 months). The VORTEC allows performance of safe and expeditious revascularization of renal arteries. This new technique may represent significant improvement over the standard approach of surgical exposure and sutured anastomosis.     

A Novel Technique for Reconstruction of Multiple Renal Arteries in Live Donor Kidney Transplantation: A Case Report and Literature Review

BackgroundReconstruction for three renal arteries from a living donor becomes a real challenge as the limited material can be used when compared with diseased donors. Therefore, in this report we introduce a novel technique by using the gonadal vein as a Carrel patch for reconstruction with three renal arteries. The other techniques will also be reviewed in this report.MethodsThe living donor is a 51-year-old woman with three renal arteries on the left side and one renal artery on the right side, but with early branching 15 mm from the origin. The recipient is her husband, a 56-year-old with end-stage kidney disease secondary to type II diabetes. A left laparoscopic donor nephrectomy was performed successfully. The three renal arteries were anastomosed to the gonadal vein patch in a parallel fashion. Thereafter, the gonadal vein patch was anastomosed to the side of external iliac artery. The renal vein was anastomosed to the side of external iliac vein.ResultsThe kidney was reperfused rapidly and uniformly. The kidney functioned immediately. Doppler ultrasound and renal nuclear scans revealed that the perfusion of the kidney was normal. The creatinine level was 158 umol/L at day 7 and stable at 140 umol/L during the 2-month follow-up examination.ConclusionsThe gonadal vein can be used as a Carrel patch for multiple renal artery reconstruction, in particular, for more than two renal arteries. This technique provides a new approach for the reconstruction of multiple renal arteries in living donor kidney transplantations.     

64层螺旋CT血管成像及三维重建后处理技术对活体供肾血管的评估

目的 评价64层螺旋CT血管成像及三维重建后处理技术对活体供肾血管术前评估的临床价值.方法 回顾性分析2011年1月至2013年3月临沂市人民医院泌尿外科61例亲属活体肾移植供者术前64层螺旋CT血管成像及三维重建影像资料,观察供肾实质、肾动脉、肾静脉和肾盂、输尿管排泄系统,并与术中所见结果进行对照分析.结果 64层螺旋CT血管成像及三维重建图像基本清晰显示所有供者的双肾解剖结构及毗邻关系情况.肾实质密度及肾动脉管径、形态均正常,其中47例双肾均为单支肾动脉,4例左肾为2支肾动脉,5例右肾为2支肾动脉,5例双肾均为2支肾动脉.53例容积再现结合最大密度投影图像对输尿管排泄系统显示较好,49例表面遮盖成像图像较好地显示了肾动脉主干的起源、管径、形态及与周围组织的解剖关系,肾动脉CT仿真内镜成像能清晰显示腹主动脉、双肾动脉开口及肾动脉管腔.61例供者均行单侧肾切除术,术前血管成像结果与术中所见基本吻合.结论 64层螺旋CT血管成像及三维重建后处理技术能真实反映肾血管的解剖及毗邻关系,在某种程度上完全可以替代数字减影血管造影,可作为术前评估活体供肾血管的有效方法.     

Transplantation of the kidney with numerous arteries from a living relative-donor

Among 99 operations for transplantation of a kidney from a living kindred donor 6 were carried out with the use of kidneys which had many arteries. Five patients received a kidney with 2 arteries, and one patient, a kidney with 3 arteries. The donors were: a mother (1), a father (2), a sister (2), a brother (1). The left kidney was transplanted in all cases. In 5 patients kidney implantation was preceded by extracorporeal reconstruction on the arteries of the kidney (accessory arteries were anastomosed end-to-side with the main trunk of the renal artery) carried out under conditions of cold storage. In one female patient first the kidney was implanted by the standard method whereas the artery of the lower pole was anastomosed end-to-end with the inferior epigastric artery by means of microsurgical techniques. The transplants functioned well from the first day after the operation in all patients. In one patient the transplant was rejected 2 years and 7 months after the operation. The others function satisfactorily. The longest follow-up period is 5 years and 8 months, the shortest, 9 months. It is concluded that transplantation of a kidney with numerous arteries from a living kindred donor is an effective method for the treatment of patients suffering from the terminal stage of chronic renal insufficiency.     

Atherosclerotic lesions of the aorta and renal arteries: Results of simultaneous surgical treatment

Between 1975 and 1985, 43 patients underwent simultaneous aortic and renal artery reconstruction. Twenty-two patients had infrarenal abdominal aortic aneurysms and 21 had aortoiliac occlusive disease. In addition, 40 patients had severe lesions of one or both renal arteries and three patients had a lesion in an accessory renal artery. Hypertension was present in 29 patients, 15 of whom had impaired renal function. Four patients had chronic renal insufficiency without hypertension. Ten patients underwent prophylactic renal artery reconstruction. Infrarenal aortic repair was carried out simultaneously with thromboendarterectomy of one or both renal arteries, or reimplantation of a renal artery into the aorta, in two cases with contralateral nephrectomy. In one patient, the celiac and superior mesenteric arteries were also bypassed. Three patients (7%) died in the immediate postoperative period, two of these from myocardial infarction. Long-term survival was studied in 37 patients. Sixty-seven percent of patients with preoperative hypertension and less than 50% of those with preoperative renal insufficiency had good results.     

Reconstruction of Multiple Renal Arteries During Simultaneous Pancreas and Kidney Transplantation: A Case Report

We present a case of a multiple renal artery reconstruction during simultaneous pancreas and kidney transplantation. The kidney graft had 6 renal arteries, the aorta patch was 10 cm long, and there were two renal veins. To perform anastomoses to the left external iliac vessels we had to reconstruct the renal arterial and venal patches. The results of the transplantation were very good. Both grafts had satisfactory function, even though a control computed tomography performed a year after transplantation revealed infarction of a lower renal pole. Anatomical anomalies should not be a contraindication for transplantation, although transplants involving a multiplicity of vessels is a challenge for surgeons and requires both knowledge and microsurgical skills.     

Kidney grafts with multiple renal arteries is no longer a relative contraindication with advance in surgical techniques of laparoscopic donor nephrectomy

Objectives

Kidney grafts with multiple renal arteries were considered as a relative contraindication. We retrospectively reviewed our experience of kidney grafts with multiple renal arteries to clarify the usefulness of these grafts.

Methods

Between September 2002 and June 2011, 100 laparoscopic donor nephrectomies (LDNs) were performed consecutively. Three-dimensional computed tomographic angiography was routinely performed preoperatively. Donor demographics, operative characteristics, donor and recipients perioperative complications, and donor and recipient outcomes were reviewed retrospectively.

Results

Eighty-nine donors had single (group A1) and 11 donors had multiple renal arteries (group B1). Multiple arteries caused by application of the vascular stapler were found in another six donors. Overall, 17 kidney grafts required bench arterial reconstruction (group B2). The other 83 donors with single renal artery did not require further arterial reconstruction (group A2). There was a significant increase of warm ischemic time in the group of multiple renal arteries. There were no significant difference between groups A1 and B1 in regard to donor demographics, operative characteristics, and donor outcome. Kidney grafts requiring vascular reconstruction experienced equal immediate and long-term allograft outcomes with those of group A2. The actuarial 1-, 3-, and 5-year allograft survival rates were also comparable in both groups (95.4%, 92.6%, 92.6% in group A2 and 100%, 100%, 100% in group B2).

Conclusion

LDN in the presence of multiple renal arteries is feasible and safe. Both immediate and long-term allograft outcomes are comparable between kidney grafts with and without vascular reconstruction. Kidney grafts with multiple renal arteries are no longer a relative contraindication with advanced LDN surgical techniques.     

The approach to the infradiaphragmatic and adrenal aorta

The progressive selection of the patient reserved to open surgery is determined by the preference of the endovascular option on the treatment of abdominal aortic aneurysm. This fact probably will cause a reduction of the number of cases singularly approachable by the infrarenal way while will prevail the need of control and clamping of the infradiaphragmatic and adrenal aorta. The approach to the infradiaphragmatic and adrenal aorta introduces technical and physiopathologic problems related to the hold interconnection between the vessel and the surrounding structures, particularly those visceral. The choice of the approach is determined by the surgical gesture that is had to perform. The simple supraceliac aortic clamping or the wrapping of bypass on the visceral arteries can be made by an anterior approach, supramesocolic transperitoneal, while the correction of an juxtarenal or adrenal aneurysm can be performed by a submesocolic approach. The extraperitoneal approach offers a complete vision of this part of aorta, without the pancreas or left renal veins interposition, but it allows a bad control of the iliac and right renal arteries. The surgeon has to have familiarity with both the approaches, to be able to perform his own intervention in the simplest and effective way.     

Abdominal Aortic Aneurysm with Coexistent Horseshoe Kidney

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.     

Operative strategy for thoracoabdominal aortic aneurysm with concomitant reconstruction of four main abdominal branches]

A thoracoabdominal aortic aneurysm (TAAA) involving major abdominal branches remains still difficult to be managed. From 1983 to 1990, we successfully operated five such cases. Our operative strategy for TAAA which necessitates concomitant reconstruction of four major abdominal branches is i) to utilize temporary bypass to maintain distal perfusion during aortic cross-clamping, ii) to reconstruct bilateral renal arteries prior to aortic clamping in order to shorten renal ischemic time as much as possible, iii) to reconstruct celiac and superior mesenteric arteries by Crawford's method, iv) to reconstruct two pairs of intercostal arteries by using diagonal anastomosis in the proximal site, and v) to divide the left renal vein temporarily for easy manipulation of renal arteries. All five cases were recovered uneventfully. This procedure, in which the renal ischemic time is saved as short as possible, is considered a safe and reasonable one for thoracoabdominal aortic aneurysms.     

Laparoscopic hysterectomy

Our paper presents the experience gained in nearly 12 years by the General Surgery Clinic of "Sfantul Ioan" Hospital, Bucharest in the field of laparoscopic hysterectomy. The period of time is quite long compared to the evolving of mini-invasive techniques and also unequal towards the experience of the surgeons who perform these procedure. The total number of hysterectomies was 1491 from which 251 by laparoscopic approach, the rest being made by the classic methods (most of them by laparotomy and some by vaginal approach). In the statistic we have included 15 myomectomies, 4 cases of radical hysterectomy with pelvic lymphadenectomy and 4 cases of complete hysterectomy after partial procedures made by laparotomy. The indications were represented mostly by uterine fibroma (82.07%), but also by uterine prolapse (13.14%), uterine bleeding, cervix severe dysplasia, uterine and cervix neoplasia (stage I) or associated to ovariectomy related to breast cancer. The paper analyses the results looking at the incidents and accidents (hemorrhagic, ureteral, urinary bladder or rectal lesions) and also postoperative complications (we had three reinterventions, two by laparoscopy and one by laparotomy). We also recorded one death not directly as a consequence of surgery, but as a diagnosis error. Regarding the surgical technique we initially chose the laparoscopic assisted vaginal hysterectomy. Afterwards by gaining experience we started treating the uterine pedicle and now we settled for the integral laparoscopic procedure. In our opinion laparoscopic hysterectomy represents all the advantages of mini-invasive approach. The technological development, but essentially the experience gained by surgeons are the key factors in accepting and promulgating the technique.     

Tissue expander-stimulated lengthening of arteries for the treatment of midaortic syndrome in children

Background

Midaortic syndrome (MAS) is a rare condition characterized by stenosis of the abdominal aorta. Patients with disease refractory to medical management will usually require either endovascular therapy or surgery with use of prosthetic graft material for bypass or patch angioplasty. We report our early experience with a novel approach using a tissue expander (TE) to lengthen the normal native arteries in children with MAS, allowing primary aortic repair without the need for prosthetic graft material.

The use of virtual resources in preoperative preparation of infrarenal aneurysms: exploring the OsiriX's potential

Introduction

In the past few years, the increase of endovascular surgeons'' interest on tomography image edition through softwares is marked specially when it concerns to its use on preoperatory study for endovascular aneurysm repair. It is presumed that the bigger the number of informations extracted from the tomography exam and its three-dimensional reconstruction, the smaller is the need of patient''s exposure to contrast, as well as the its exposure and the surgical team to radiation. Concepts of image manipulation on the OsiriX software with volume reconstruction of tridimensional tomographic scans of virtual fluoroscopy were used.

Methods

Through manipulation of multi-slice tomography images under three-dimensional reconstruction on software, it was able to modify values of the exam''s dose-irradiated distribution. These volume reconstruction presets were saved as Virtual Fluoroscopy, reproducible upon any OsiriX platform. It was able to construct a biplanar image appearing to the patient''s operatory fluoroscopy. When compared to the intraoperatory angiography, the images were alike.

Discussion

Dose-irradiated distribution data manipulation allowed to visualize as opaque bone surfaces and transparent low-dose radiation''s areas (viscerae). Thus, under previously marked renal arteries, it was possible to predict it''s anatomical positioning related to visualization under real fluoroscopy. Foretelling the better positioning of the C-arm through this technique enables to obtain images with the minimum influence of parallax effect. It is believed that it supports to assess the renal arteries topographic positioning on a bi-dimensional intraoperatory image. The need of frequent angiographies to localize the renal arteries is reduced, decreasing the exposure to contrast on vulnerable patients.     

Extra‐anatomical splanchnic revascularization for hybrid treatment of thoracoabdominal aortic aneurysms

Treatment of thoracoabdominal aortic aneurysms with endovascular or conventional surgical techniques is burdened by high risk in older patients. Furthermore, the standard hybrid approach might be not feasible in case of severe atherosclerotic disease of the peripheral vessels. This report describes an alternative hybrid procedure which consists of an innovative mini‐invasive thoracic approach combined with laparotomy to perform antegrade revascularization of the visceral arteries from the ascending aorta, followed by endovascular treatment.     

Is duplex scanning the best screening test for renal artery stenosis?

Screening for renal artery stenosis is indicated in patients with suspected renovascular hypertension or ischemic nephropathy to identify those who could benefit from renal artery interventions. The critical requirements for a clinically useful screening test include safety, low cost, and a high sensitivity or low false-negative rate. Arteriography remains the "gold standard" for the anatomic diagnosis of renal artery disease, but it is unsuitable for screening because of its high cost and invasive nature. Although renal duplex scanning technically is difficult, experienced laboratories have been able to achieve sensitivities and specificities in the range of 93% to 98% for identification of stenoses in the main renal arteries. Renal duplex scanning also provides a method for assessing the renal parenchyma and predicting the clinical outcome of renal revascularization. The principal limitation of renal duplex scanning is failure to identify accessory renal arteries. The finding of one or more widely patent main renal arteries makes ischemic nephropathy unlikely, because this condition results from "total" renal ischemia. However, renovascular hypertension can be present with normal main renal arteries when there are isolated stenoses involving accessory renal arteries, so further testing may be indicated in selected hypertensive patients with normal main renal arteries by duplex scanning. Currently, duplex scanning in a qualified vascular laboratory arguably is the best screening test for renal artery stenosis. Other methods for assessing the renal arteries, particularly spiral computed tomography and magnetic resonance angiography, are evolving rapidly and also may play a role in screening of selected patients.