Successful revascularization of an occluded renal artery after prolonged anuria

Renal atherosclerosis and fibromuscular dysplasia are the most common causes of curable human renovascular hypertension and renal failure. Vascular reconstruction often preserves renal function, but renal failure is rarely reversed, especially after days of anuria. We report a case of a 23-year-old woman who as a child underwent a nephrectomy for congenital hydroureter and renal hypoplasia. She later experienced fibromuscular dysplasia of the remaining renal artery, which ultimately progressed to a complete occlusion and 31 days of total anuria. The patient was revascularized, and within 2 months renal function returned with a blood urea nitrogen and creatinine of 9.0 and 1.0 mg/dl, respectively. After a follow-up of 6 months the patient's blood pressure remained 120/80 to 130/80 mm Hg without administration of hypertension medication. In this report we emphasize that under selected circumstances a kidney can survive prolonged ischemia and that delayed revascularization may reestablish renal function.     

Late revascularization of the renal artery: what are the prognostic criteria?]

Two patients with non functioning silent kidney on excretory urography and renal artery occlusion on angiography, underwent renal artery revascularization without severe hypertension or renal failure. Angiographic appearance of collateral circulation, histologic evidence of intact viable glomeruli and a normal sized kidney are necessary for successful results. Renal blood flow was restored in the two patients but one had slight return of function and the other patient showed no evidence of improvement. Both patients presented criteria for revascularization. The first case was a minor success on the renal scintigraphy. The return of renal function did not occur in the second case because of preexisting renal pathology. We therefore recommend histologic examination before every renal artery revascularization for chronic occlusion.     

Atherosclerotic renovascular disease: diagnosis and treatment

The technical expertise and tools required to treat renovascular obstruction have become commonplace, and many series of patients revascularized with surgery, balloon angioplasty or endovascular stenting have been reported. Nevertheless, although hypertension and renal failure are easy to diagnose, their cause often remains elusive. Evidence is developing that patients with hypertension and atherosclerotic renal artery stenosis may often have hypertension and renovascular disease but not hypertension because of renovascular disease. As a result, diagnosis and therapy are increasingly directed towards the preservation of renal function, and the future of renal revascularization will depend on how well potential therapies address this goal.     

Renovascular hypertension following surgical repair of dissecting aneurysm of the thoracic aorta

A critically ill patient with refractory renovascular hypertension following successful intrathoracic repair of a type I aortic dissection was treated successfully with gelfoam embolization of the left kidney. Renal artery stenosis secondary to aortic dissection can exacerbate pre-existent hypertension in the preoperative or postoperative periods and can be diagnosed angiographically. Unilateral renal artery embolization may provide a safe alternative to nephrectomy for renovascular hypertension in cases where surgery is not feasible.     

Spontaneous dissection of renal artery: long-term results of extracorporeal reconstruction and autotransplantation1

PURPOSE: We undertook this study to assess the outcome of spontaneous dissection of the renal artery and its branches surgically treated with extracorporeal reconstruction and autotransplantation. SUBJECTS: Between 1975 and 1996, 15 consecutive patients (19 kidneys) with spontaneous renal artery dissection underwent renal artery reconstruction. Fourteen patients had accelerated hypertension. Five patients had impaired renal function. In 14 patients the dissection was associated with fibrodysplasia, and in 1 patient it was related to arteriosclerosis. INTERVENTION: In 17 kidneys extracorporeal reconstruction and autotransplantation was used. The renal artery of 1 kidney was reconstructed in situ. One primary nephrectomy was performed. RESULTS: There were no operative deaths or major morbidity. All but 1 reconstruction was successful (94.4%). Results at follow-up (range, 1-8 years) were favorable in 14 patients; 79% had satisfactory blood pressure control, and all patients had normal renal function, including those with impaired renal function preoperatively. CONCLUSIONS: Extracorporeal reconstruction and autotransplantation can be effectively used in patients with spontaneous renal artery dissection located in or extending into the distal branches. Early recognition and appreciation of the clinical presentation of spontaneous renal artery dissection are important.     

Long-term outcome after surgical kidney revascularization for fibromuscular dysplasia and atherosclerotic renal artery stenosis

PURPOSE: At a time of minimally invasive surgery in urology, the role of surgical kidney revascularization in the management of renal artery disease has changed during the last decade. Our experience with surgical kidney revascularization, and the long-term clinical outcomes of fibromuscular dysplasia (FMD) and atherosclerotic renal artery stenosis are reviewed. MATERIALS AND METHODS: The study group comprised 140 patients with renovascular hypertension, 72 with FMD and 68 with atherosclerotic renal artery disease, who underwent surgical revascularization between 1982 and 1999. The indications for surgical revascularization were the treatment of hypertension and the preservation of renal function in 17 patients with renal artery occlusion, 55 with ostial stenosis, 52 with branch stenosis, 6 with bilateral artery stenosis, 7 with solitary kidney renal artery stenosis and 3 with solitary kidney renal artery occlusion. RESULTS: Postoperative blood pressure and renal function were monitored for 1 to 17 years (mean 11.3). Long-term blood pressure control was observed in 93% of patients with FMD and in 71% of those with atherosclerosis. Improvement or stabilization of renal function was observed in 92% of patients with FMD and in 68% of those with atherosclerosis. The preoperative estimated glomerular filtration rate compared to postoperative was significantly increased in both groups. CONCLUSIONS: Surgical kidney revascularization is effective in secondary hypertension with a high long-term efficacy in the normalization of blood pressure and in the preservation of renal function, especially in patients with a solitary or 1 functional kidney.     

Predictive Factors and Therapeutic Approach of Renovascular Disease: Four Years’ Follow-Up

Background. There is no consensus about the renal function outcome after revascularization with stenting in atherosclerotic renovascular disease. In the present study, the outcome in BP control and renal function in patients with renovascular disease treated with percutaneous angioplasty and stent placement is compared with the outcome in patients with renovascular disease treated with medical treatment only. Additionally, the impact of oxidative stress and eosinophil count in peripheral blood as predictors of renal function deterioration in renovascular disease irrespective of treatment is investigated. Methods. Eighty-two patients with renovascular disease were enrolled into a follow-up study (47.5±35.4 months). Thirty-six patients (group 1) underwent revascularization and stenting, and 46 patients (group 2) were on medical treatment only. In all patients, serum creatinine concentration, eosinophil count (EO) in peripheral blood, and estimation of oxidative stress with dROMs test were determined before and at the end of the follow-up. Results. In revascularized patients (group 1), hypertension was cured in 11.1% and improved in 66.6%. Renal function improved in 30.5% and worsened in 36.2% of patients. In the medical treatment arm (group 2), hypertension improved in 71.4% of the patients. Renal function remained stable in 69.8% of patients and worsened in 30.2%. Cox regression analysis showed that higher levels of eosinophil count and higher levels of ROS, irrespectively of mode of treatment, were associated with renal function deterioration (i.e., serum creatinine increase more than 20% during follow-up). Conclusions. Revascularization was not superior to medical treatment in renal survival but had a greater positive impact on blood pressure control. Eosinophil count and oxidative stress were the stronger predictive factors for serum creatinine increase.     

Kidney transplantation in the treatment of hypertension]

Renal autotransplantation seems to be of great value as a means of renal revascularization in hypertension of renovascular origin, especially in those cases in which the preceding angioplastic procedure have resulted in failure or in cases with peripheral or difficult stenoses of the renal artery. One case is reported with a coarctation of the abdominal aorta involving both kidney arteries. The patient was treated by bypass operation and kidney autotransplantation. Two years later both kidneys are functioning normally and the patient is normotensive.     

The role of arterial reconstruction in spontaneous renal artery dissection

Spontaneous renal artery dissection is an uncommon cause of renovascular hypertension, usually associated with fibromuscular dysplasia. Among reported nonautopsy cases (N = 80), arterial reconstruction has seldom been attempted (N = 21) and the outcome has frequently been poor (48% clinical failure rate). This is attributed in part to the frequent involvement of renal artery branches by the dissection. Furthermore, the report of spontaneous reversion to normotension among patients treated medically has also clouded the role of surgery in this disease. Since progress in the technique of renal artery repair now allows successful treatment of anatomically complex lesions, we reviewed our experience with arterial reconstruction in the management of spontaneous renal artery dissection to determine the frequency of and factors correlating with cure after operative repair. Ten patients (eight men, two women; mean age, 39.3 +/- 5.9 years) were admitted with severe hypertension (10/10), often associated with neurologic symptoms, hematuria, or flank pain (8/10). Serum creatinine was elevated in only two patients. Angiography demonstrated changes consistent with fibromuscular dysplasia in 7 of 10 patients and evidence of dissection in 6 of 10. Bilateral disease was present in three patients. Only five patients had a single renal artery on the involved side. The dissection extended into the primary branches in 8 of 10 patients and involved both renal arteries in four of the five patients with two arteries. Histologic study confirmed fibromuscular dysplasia in six and intramural dissection in all operative specimens. Five patients underwent revascularization (in one case requiring the ex vivo technique), with use of hypogastric artery as a conduit in four of five or resection and primary reanastomosis in one of five. Three patients became normotensive, and two returned to their previous level of blood pressure control. Follow-up averaged 14.5 years. Two patients underwent nephrectomy after exploration demonstrated nonreconstructible vessels, and two underwent nephrectomy when intraoperative assessment of the kidney showed that revascularization had failed to adequately reverse extensive renal ischemia. After a mean follow-up of 14.6 years these patients remain normotensive, although two require antihypertensive medications. One patient was treated medically and is currently hypertensive off all medications. Nine of 10 patients have maintained a normal serum creatinine during follow-up. We conclude that renal revascularization is frequently successful in spontaneous renal artery dissection (five of seven, 71.4%) and results in sustained relief of hypertension with maximal conservation of renal tissue. This is important because of the young age at onset and the not infrequent occurrence of bilateral fibromuscular dysplasia, and even of dissection.(ABSTRACT TRUNCATED AT 400 WORDS)     

Extraparenchymal Renal Artery Aneurysms: Is Hypertension an Indication for Revascularization Surgery?

We report here the surgical management of extraparenchymal renal artery aneurysms associated with hypertension and the results of this treatment. From January 1978 through December 1999, 19 consecutive patients with 23 extraparenchymal renal artery aneurysms underwent surgery with renal revascularization techniques. Of these 19 patients, 89.5% had systemic hypertension, and 12 of 16 patients had associated renovascular hypertension. Twenty of the aneurysms were patent, one was chronically thrombosed, and one patient presented with acute thrombosis of abdominal aortic and bilateral renal aneurysms; 11 of the 20 patent cases had significant stenosis in the preoperative arteriography. Seventeen aneurysms (74%) were located on the main trunk of the renal artery. Response of hypertension and renal function were examined. Surgical technique patency was evaluated by life-table methods. Our basic surgical indication for extraparenchymal renal artery aneurysms in this series was renovascular hypertension. Nonrenal hypertension alone does not indicate surgery. We consider the saphenous vein to be the graft of choice for renal revascularization.     

Extra-anatomic renal revascularization in patients with renal artery stenosis and abdominal aortic occlusion

Thirteen patients with atherosclerotic renal artery stenosis and total abdominal aortic occlusion underwent extra-anatomic surgical renal revascularization without aortic replacement. Renal artery stenosis was present unilaterally (n = 2), bilaterally (n = 7), or in a solitary kidney (n = 4). Surgical renal revascularization was indicated for treatment of severe hypertension in all patients and for preservation of renal function in 10 patients. The level of abdominal aortic occlusion was suprarenal (n = 3), perirenal (n = 2), or infrarenal (n = 8). All patients had extensive collateral vascular supply to the lower extremities with absent (n = 7) or mild (n = 6) claudication. Surgical renal ervascularization was achieved with hepatorenal bypass (n = 6), mesenterorenal bypass (n = 4), or splenorenal bypass (n = 3). None of the patients underwent concomitant aortic replacement. There were no operative deaths. Postoperatively, hypertension was improved in 10 patients, unchanged in 2 patients, and worse in 1 patient. Renal function was improved in 8 patients, stable in 2 patients, and worse in 3 patients. After surgical renal revascularization, no patient required aortic replacement, while 1 patient underwent extra-anatomic revascularization of the lower extremities. We conclude that some patients with renal artery stenosis and abdominal aortic occlusion can be managed by surgical renal revascularization alone without a more extensive and potentially hazardous aortic replacement. In these patients, extra-anatomic techniques can allow safe and successful surgical renal revascularization while avoiding surgery on the diseased aorta.     

Spontaneous dissection of branch renal artery- is conservative management safe and effective?

PURPOSE: We analyzed the long-term results of conservative management for spontaneous branch renal artery dissection. MATERIALS AND METHODS: In the last 6 years 8 patients were treated for acute spontaneous branch renal artery dissection at our department. The diagnosis was established by angiography, which showed primary branch artery dissection in all cases. All patients were treated with antihypertensive and platelet anti-aggregate therapy. None of them underwent surgery. After treatment patients were evaluated for blood pressure and renal function and by abdominal computerized tomography angiography with 3-dimensional reconstruction. RESULTS: Median followup was 72.3 months. In 6 patients blood pressure was controlled with a single antihypertensive agent. In another patient 3 antihypertensive agents were required. The remaining patient continued to have labile hypertension because of poor compliance with treatment. Renal function was normal in 7 patients. Control computerized tomography angiography showed proximal arterial remodeling in 6 patients and persistent occlusion of primary branches in 2. CONCLUSIONS: In our experience conservative management of spontaneous branch renal artery dissection is safe and effective. Surgical treatment should be proposed at the acute stage only in patients with malignant hypertension or renal failure and at the chronic stage in those with refractory renovascular hypertension.     

Renovascular hypertension in children: current concepts in evaluation and treatment

Since 1981, we have evaluated and treated 22 children with renovascular hypertension (RVH). Seventeen patients had stenosis of their native renal arteries, and five had stenosis of the artery in a transplanted kidney. RVH was caused by fibromuscular dysplasia in 13 patients, by trauma in 2 patients, and by arteritis in 2 patients. Among the patients who had transplanted kidneys, three had technical causes for stenosis and two had stenosis due to rejection. The disease was unilateral in 10 patients, bilateral in 5, and present in a solitary kidney in 7, including the five renal transplants. Diagnostic studies that strongly suggested the presence of renovascular disease were an initial diastolic blood pressure greater than 100 mm Hg, an elevated peripheral vein renin activity level, and an abnormal renal scan if the patient's hypertension was being controlled with an angiotensin-converting enzyme inhibitor (ACEI). Only the renal arteriogram was 100% accurate in confirming the presence of RVH. Percutaneous angiographic correction was attempted in 13 patients and resulted in lasting improvement of the hypertension in five (38%). Surgical revascularization was attempted in 17 children, including the 8 with failed angioplasty, with improvement or cure of the hypertension in 15 patients (88%). Combining percutaneous transluminal angioplasty (PTA) and surgical results gave 20 of 22 patients (91%) with cure or improvement of their hypertension. Four of 27 affected kidneys (15%) could not be revascularized and were removed. We conclude from this series of patients that despite improvements in noninvasive studies, renal arteriogram remains the only study that is 100% accurate in evaluating children for RVH.(ABSTRACT TRUNCATED AT 250 WORDS)     

Renal autotransplantation and extra-corporeal surgery

Renal autotransplantation with/without extra-corporeal surgery was performed in 53 patients between September, 1975 and december, 1987. Original disease was obstructive disease of the upper urinary tract in 25 patients, renovascular hypertension and renal vascular disease in 13, renal calculous disease in 12 and renal cell carcinoma in 3. Ten of the 53 patients had solitary kidneys. Three patients died on 14, 21 and 49 postoperative days of massive bleeding with disseminated intravascular coagulopathy caused by the rupture of transplant arterial anastomosis (1 patient with urinary obstructive disease) and sepsis caused by wound infection (2 patients with renal calculous disease). Two kidneys were removed on operative day and 8 postoperative days due to arterial thrombosis in 2 patients with aneurysm of intrarenal artery. The deterioration of renal function was observed in previously damaged kidneys of two patients with extensively damaged ureter. No other severe complications were observed. In 23 of 24 patients with the obstructive disease of the upper urinary tract, disappearance or improvement of the obstructive change was observed after surgery. All 5 patients with renovascular hypertension showed normo-tension without administration of antihypertensive drugs after surgery. In 3 of 5 patients with an aneurysm of the intrarenal artery, the aneurysm was removed and reconstruction of the artery was performed successfully. Two patients with arterio-venous fistula and one patient with nut cracker syndrome had no severe hematuria with bladder tamponade after surgery. Ten of 12 patients with renal calculous disease were treated successfully without residual calculi by this procedure. Three patients who had solitary kidney with renal cell carcinoma were treated successfully by this procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Renal artery dissection.

Renal artery dissections are stenotic or occlusive lesions most often observed in hypertensive patients with underlying atherosclerosis or fibromuscular disease. Acute dissections may present spontaneously, as a complication of diagnostic or therapeutic angiography or as an agonal event associated with overwhelming systemic illness. Chronic dissections may produce renovascular hypertension or be entirely asymptomatic. Fourteen renal artery dissections have been encountered in nine patients treated at Vanderbilt University Medical Center during the past decade. Eleven dissections have been found in seven patients with renovascular hypertension. Seven of these dissections were chronic (six functional, one silent) and four acute (two spontaneous, two secondary to angiography). Three agonal dissections were found in two additional patients postmortem: one at autopsy and bilateral dissections found at the time of cadaveric donor nephrectomy. Ten bypass procedures, including five complex branch reconstructions of which three were performed ex vivo, have been performed with 100% immediate patency and maintenance or improvement of renal function. Long-term follow-up of these patients has shown sustained patency of the reconstructed renal arteries, excellent blood pressure control, and normal renal function in all. Nephrectomy has not been required and there have been no associated deaths. Seventy-seven additional renal artery dissections in 72 patients collected from previous reports have been analyzed. Patient survival (55/72, 76.4%) and preservation of the involved kidney in surviving patients (26/55, 47.3%) were low in these earlier series. In addition, renal failure was associated with 59% of the deaths. The lethality of renal artery dissections and the ease and success of revascularization, which preserves renal function and ameliorates associated renovascular hypertension, emphasize the need for an aggressive approach to the recognition and treatment of this entity. Therapy should be directed toward arterial reconstructions and the preservation of functioning renal tissue.     

Blunt renal artery injury: incidence, diagnosis, and management.

Renal artery injury is a rare complication of blunt abdominal trauma. Increasing use of CT scans to evaluate blunt abdominal trauma identifies more blunt renal artery injuries (BRAIs) that may have otherwise been missed. We identified patients with BRAI to examine the incidence and to evaluate the current diagnosis and management strategies. Patients admitted from 1986 to 2000 at a regional Level I trauma center sustaining BRAI were evaluated. Patients undergoing revascularization or nonoperative management were followed for renovascular hypertension. Twenty-eight patients with BRAI were identified out of 36,938 blunt trauma admissions between 1986 and 2000 (incidence 0.08%). Most renal artery injuries were diagnosed by CT scans (93%) with seven confirmatory angiograms. Nine patients had nephrectomy (one bilateral), and three patients with unilateral injuries were revascularized. Sixteen were managed nonoperatively including one patient who had endovascular stent placement. Three patients died from shock and sepsis. Follow-up for all patients ranged from one month to 8 years. Two patients developed hypertension: one who was revascularized (33%) and one was managed nonoperatively (6%). The frequency of diagnosis of BRAI is increasing because of the increased use of CT. Nonoperative management of unilateral injuries can be successful with a 6 per cent risk for developing renovascular hypertension. The role of endovascular stenting is promising, and further study is necessary.     

Renal autotransplantation versus bypass techniques for renovascular hypertension

From 1972 to 1983, 78 patients underwent surgical treatment for renovascular hypertension caused by a lesion limited to the trunk of the renal artery. Forty-five of these patients underwent aortorenal bypass (24 saphenous grafts and 21 arterial hypogastric grafts); 36 patients (80%) had either a relief of the hypertension or were improved. Graft closure occurred in five cases. Thirty-three patients were treated by autotransplantation of the kidney. After resection of the lesion, the renal artery was anastomosed end-to-end to the hypogastric artery or end-to-side to the common iliac artery and the renal vein and side-to-side to the iliac vein or the origin of the vena cava. In this group all patients but one (97%) had relief of the hypertension or were improved. No thrombosis was observed. Late angiography was performed 5 years after surgery in 19 patients (nine autotransplantations and 10 bypass operations): patients who underwent autotransplantation had no alteration of the renal vessels whereas four patients who underwent bypass operations had dilatation of the saphenous vein bypass. Renal autotransplantation was superior to the bypass technique in the surgical treatment of renovascular hypertension caused by lesions of the trunk of the renal artery and may represent a better alternative in the surgical treatment of this condition.     

Surgical renal artery reconstruction after percutaneous transluminal angioplasty

Percutaneous transluminal renal angioplasty (PTRA) is a controversial treatment for renal artery stenosis. This article discusses whether or not a prior attempt at PTRA compromises a subsequent elective or emergent surgical revascularization. Thirteen patients had surgical renal artery reconstruction after one or more PTRAs. Eight of the patients were treated because of atherosclerotic renal artery disease whereas five had a form of fibromuscular dysplasia. Five patients had renal artery injury directly related to the angioplasty. Four of these kidneys were saved. Eight patients were treated from 6 to 920 days after PTRA because of recurrent stenosis or occlusion of the renal artery. Only one of these kidneys was lost, an attempt at revascularization of a small kidney that failed to resume function. A prior attempt at PTRA did not compromise the ability of subsequent surgical revascularization to ameliorate hypertension. We conclude that surgical renal revascularization is not made less likely to succeed by a previous attempt at PTRA; even if the renal artery is thrombosed or perforated during the procedure, a reasonable chance of renal salvage is obtained by immediate surgical revascularization.     

Captopril renal scintigraphy--an advance in the detection and treatment of renovascular hypertension

Despite the risks associated with renovascular hypertension and the durable benefits of revascularization, the detection of patients with renovascular hypertension and the selection of those who will benefit from interventional therapy remains a challenge. We have previously documented the reliability of captopril renal scintigraphy in predicting angiographically significant renal artery stenosis in patients suspected of having renovascular hypertension. In the present study we report our recent experience with this noninvasive technique in predicting outcome after revascularization. Captopril renal scintigraphy involves the administration of 50 mg of captopril 3 hours after a baseline technitium-99m diethylenetriaminepentaacetic acid renal scan and 1 hour before a repeat captopril renal scintigraphy scan. Nineteen of the last 70 patients with clinically suspected renovascular hypertension undergoing captopril renal scintigraphy had abnormal renal scan outcomes, and 17 had a decrease in flow or function after captopril (positive captopril renal scintigraphy). Eight of these 17 with abnormal findings on captopril renal scintigraphy underwent revascularization, and the hypertension was cured or improved in six of the eight: two of three after surgical bypass grafting and four of five after angioplasty. In the seven surviving patients with abnormal renal scan results but no change with captopril (negative captopril renal scintigraphy), improvement in hypertension after treatment occurred in only one: one of two after nephrectomy, zero of three after bypass surgery, and zero of two after angioplasty (p less than 0.05). We conclude that captopril renal scintigraphy is an accurate predictor of hypertension response to revascularization. Further evaluation of this new noninvasive technique for assessing patients with suspected renovascular hypertension appears warranted.     

Use of the splenic and hepatic arteries for renal revascularization

During a 16-year period at the Massachusetts General Hospital 77 patients underwent 79 procedures (29 hepatorenal bypasses, 50 splenorenal arterial anastomoses) for treatment of renovascular hypertension, renal preservation, or both. The procedure was chosen primarily to avoid a diseased or scarred aorta in 41, to allow a staged approach to bilateral renal artery stenoses or multiple vascular lesions in 17, as a "lesser operation" for five poor-risk patients, for complex problems including trauma, mycotic aneurysm, aortic dissection, thoracoabdominal aneurysm, and renal artery aneurysm in five, and as the procedure of choice in 11 patients. The perioperative mortality rate was 6% for the 77 patients studied. No hepatic dysfunction was seen. Deterioration of renal function occurred on three occasions but only in patients with bilateral simultaneous repair. Cure or improvement of hypertension was achieved in 52 of 63 patients and renal function preserved or improved in 67 of 77 patients. Long-term functional results remain good during follow-up periods up to 14 years. Our experience indicates that use of the hepatic or splenic artery may provide a safe and largely successful alternative for renal revascularization in selected circumstances.