肾动脉狭窄的腔内治疗经验

目的探讨腔内治疗肾动脉狭窄的临床疗效及影响因素。方法2003年2月至2005年6月共收治19例肾动脉狭窄患者,分析其中行腔内治疗12例的临床资料。其中动脉硬化9例,多发性大动脉炎1例,纤维肌性发育不良2例。结果本组12例,均有严重高血压,1例肾功能异常。支架置入10例,技术成功率91．7％(11／12)。随访12例,随访时间3—15个月,随访平均6．5个月,患者血压从(172±26／98±15)降至(156±22／88±14)mmHg。高血压治愈2例,改善6例,未愈4例,高血压控制率为66．7％。术后肾功能无明显变化。无并发症和死亡病例。再狭窄1例,再狭窄率为8．3％。结论严格掌握手术适应证,腔内治疗肾动脉狭窄是安全、有效的。     

Treatment of renal artery fibromuscular dysplasia with balloon angioplasty: a prospective follow-up study.

OBJECTIVES: to assess restenosis rates and blood pressure response after percutaneous transluminal renal angioplasty (PTRA) in patients treated for fibromuscular dysplastic renal artery stenosis. METHODS: a prospective 12-month follow-up study of 27 patients with 31 treated renal artery stenosis. Follow-up assessment included colour-coded duplex sonography (CCD) of renal arteries, monitoring of blood pressure, antihypertensive medication, and creatinine measurements before discharge and at 3, 6, and 12 months. Primary end point was defined as a haemodynamically significant restenosis >60% assessed by CCD. RESULTS: there was a cumulative 23% restenosis rate at 12 months. Arterial hypertension was cured or improved in 93% of patients immediately after the intervention and remained cured/improved in 74% of patients at 12 months of follow-up. Renal failure present in five patients before PTRA stabilised or improved in all patients. CONCLUSION: although restenosis rate after PTRA in fibromuscular dysplasia is as high as in non-ostial atherosclerotic lesions, there remains a considerable higher therapeutic effect. Profound pressure response and recurrent arterial hypertension with restenosis support the high probability of a renovascular origin of arterial hypertension in this young and otherwise healthy population compared to patients with atherosclerotic renal artery lesions.     

Fibromuscular dysplasia of the renal artery: Management and outcome

SUMMARY: Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. the outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). the mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months-10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. the other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Reno-vascular hypertension in childhood: a nationwide survey

Renovascular disease accounts for 8–10% of all cases of paediatric hypertension, whereas, in adults, its incidence is approximately 1%. The Turkish Paediatric Hypertension Group aimed to create the first registry database for childhood renovascular hypertension in Turkey. Twenty of the 28 paediatric nephrology centres in Turkey responded to the survey and reported 45 patients (27 girls, 18 boys) with renovascular hypertension between 1990 and 2005. The age at presentation ranged from 20 days to 17 years. The mean blood pressure at the diagnosis was 169/110 mmHg. Chief complaints of symptomatic patients were headache (38%), seizure (18%), epistaxis (4%), growth retardation (4%), cognitive dysfunction (4%), polyuria (2%), palpitation (2%), and hemiplegia (2%). Renovascular hypertension was found incidentally in 11 children. The diagnosis of renovascular hypertension was established with conventional angiography in 39 patients, MR angiography in three, CT angiography in two, and captopril diethylene triamine penta-acetic acid (DTPA) scintigraphy in one patient. Twenty-one children had bilateral renal artery stenosis and 24 had unilateral renal artery stenosis. Of these, 14 (31%) had fibromuscular dysplasia; 12 (27%) Takayasu’s arteritis; six (13%) neurofibromatosis; two (5%) Williams syndrome; one (2%) Kawasaki disease; one (2%) mid-aortic syndrome; one (2%) extrinsic compression to the renal artery, and eight (18%) unspecified bilateral renal artery stenosis. Hypertension was controlled with antihypertensive drugs in 17 patients. Percutaneous transluminal angioplasty (PTRA) or surgery had to be performed in 28 patients: PTRA in 16 patients, PTRA + surgery in one patient and surgery in 11 patients (four nephrectomies). The importance of vasculitic disease, especially Takayasu’s arteritis, should not be underestimated in children with renovascular hypertension.     

Combined renal artery stenosis and aortic aneurysm: Treatment options

The purpose of this study was to analyze outcomes of two different treatment strategies in patients treated for renal artery (RA) stenosis and a coincidental abdominal aortic aneurysm (AAA). A total of 50 patients were encountered who required treatment for concomitant RA stenosis and an AAA from 1980 to 1994. Simultaneous operative aortic and RA reconstruction was done in 32 patients, whereas 18 patients were treated with preoperative percutaneous transluminal renal artery angioplasty (PTRA). The two groups were well matched with respect to age, AAA size, incidence of hypertension, preoperative creatinine level, and creatinine clearance (allp values >0.07). Aortorenal bypass (18 RAs), reimplantation (18 RAs), or endarterectomy (2 RAs) was performed to correct a mean RA stenosis of 88%, whereas 23 RAs (91% mean stenosis) were treated with preoperative PTRA. PTRA failed in four patients with RA stenosis, and they were successfully treated with surgery (3 bypasses and 1 reimplantation). Statistical analysis did not demonstrate a significant difference between these four failed PTRA-patients, the 14 successful PTRA patients, and the 32 RA reconstruction patients in terms of operating time (p=0.15), operative blood loss (p=0.20), intensive care unit days (p=0.71), or total hospital days (p=0.94). Among the 40 patients available for follow-up, hypertension was cured in seven, improved in 10, unchanged in 15, and worse in eight with no difference demonstrated between the groups (p=0.73). These data suggest that preoperative PTRA has no specific advantage over surgical RA reconstruction in patients with concomitant RA stenosis and AAA. Failed PTRA did not preclude or complicate subsequent operative RA revascularization.Presented at the Fourteenth Annual Meeting of the Southern California Vascular Surgical Society, September 15–17, 1995, La Jolla, Calif.     

Renal revascularization in high-risk patients: The role of iliac renal bypass

Between 1984 and 1989, 29 iliac renal artery bypasses were performed in 29 patients (mean age 67.8 years) with severe renovascular disease due to atheroma. The indication for renal artery reconstruction was hypertension in all patients, which was associated with kidney failure in 16 cases. In six cases, reconstruction was performed after failure or complications of percutaneous transluminal angioplasty. The bypass was constructed with polytetrafluoroethylene in 24 cases (83%) and vein graft in five cases (17%). There was no postoperative mortality. All bypasses were found to be patent on duplex scanning or digital subtraction arteriograms. One patient was lost to follow-up. Mean follow-up was 23.2 months. One patient died of acute kidney failure, probably related to occlusion of the bypass. Hypertension improved in 22 cases (79%), was cured in two cases (7%), and remained unchanged in four (14%). Renal function remained unchanged in six cases (40%) and improved in nine (60%). Iliac-to-renal artery bypass seems to be the surgical renal revascularization modality best adapted to high-risk patients or those who have severe atheroma. Additionally, this technique enables rapid treatment of failures or complications of percutaneous transluminal angioplasty of the renal artery.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, May 18–19, 1990, Nancy, France.     

Fibromuscular dysplasia of the renal artery: Management and outcome

Renovascular hypertension may be caused by atherosclerotic disease or less commonly by fibromuscular dysplasia (FMD) of the renal arteries. Fibromuscular dysplasia is the commonest cause of renal artery stenosis in the younger age group and affects women predominantly. A review of our clinical database identified all patients with renovascular hypertension. All relevant clinical, biochemical and radiological findings on those with FMD were noted. The outcome of percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery was evaluated. Eight out of 62 (13%) patients with hypertension secondary to renovascular disease had FMD (all female; bilateral in four; mean age at diagnosis 37.6 years; age range 12–70 years). The mean duration of hypertension before the diagnosis of FMD was 3.3 years (range 3 months–10 years). A renal artery bruit was detected in five, hypertensive retinopathy in three and one had mild renal insufficiency. Twelve PTRAs were attempted on 10 stenotic lesions in six women. This cured the hypertension in three, while the other three have required less antihypertensive therapy. Percutaneous transluminal renal angioplasty was complicated by a trivial renal artery dissection in one, and a small upper pole infarction in another. One patient required a repeat PTRA. The other two women presented before the availability of PTRA and had successful reconstructive surgery. Fibromuscular dysplasia was the cause of hypertension in eight out of 62 (13%) patients with renovascular hypertension. Percutaneous transluminal renal angioplasty has shown encouraging results with a low complication rate. If technically feasible, PTRA should be attempted on all patients with FMD of the renal artery.     

Long-term results after percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis--the importance of intensive follow-up.

The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure gradient and renal venous renin measurement. Patients were scheduled for regular follow-up after the PTRA and a deterioration in blood pressure or renal function was an indication for re-evaluation, and reintervention if necessary. Sixty-five patients had 71 renal artery stenoses where PTRA was attempted. It was technically successful in 59 stenoses and two occlusions and failed in ten (14%). At the end of follow-up (median 56 months [2-99]), the primary patency rate was 55%, 27 had restenosed and four were occluded, all but two within 12 months. Seventeen were treated by a further PTRA and eight by surgical reconstruction. At the end of follow-up the secondary patency after all interventions was 90%. One patient died 1 month after PTRA, and at the end of follow-up 21 patients (32%) had died, most of them (80%) from cardiovascular disease. Multivariate analyses showed a significantly reduced survival rate in patients with multiocular atherosclerosis, renal insufficiency, contralateral renal artery stenosis and ischaemic heart disease. At the end of follow-up 90% of the patients were cured or improved with regard to blood pressure. In patients with impending renal insufficiency renal function was improved in 50% and unchanged in 39%. With this strategy 55% of the patients needed only one treatment with PTRA, 25% needed a re-PTRA and 20% had to be operated on. PTRA can be recommended as initial treatment of atherosclerotic renal artery stenosis provided intensive follow-up and aggressive reintervention are performed when indicated.     

Preservation of renal function by percutaneous transluminal angioplasty in ischaemic renal disease.

BACKGROUND: The purpose of this study was to evaluate the effects of percutaneous transluminal renal angioplasty (PTRA) on preservation of renal function in patients with bilateral renal artery stenoses or stenosis of the artery of one functioning kidney. METHODS: A total of 227 PTRAs of 223 stenoses in 135 patients were performed from 1982 to 1993 in a single centre and retrospectively reviewed. The number of PTRAs per patient was 1.7, range 1-6. Angiographical follow-up was performed in 77%, 120+/-82 days after the first PTRA and 273+/-345 days after the last PTRA. Follow-up of serum creatinine and blood pressure was performed in 85% after 414+/-558 days. Long-term follow-up was performed for dialysis, surgical revascularization, renal transplantation and death, mean follow-up 8.8 years, range 5.5-14.8. RESULTS: The immediate technical success was 90%, and another 5% were improved. The primary patency rate per patient was 43% and the secondary patency rate 64%. Improved renal function was achieved in 23% of the patients, stabilized in 56% and failed in 21%. Stabilized or improved function was higher when baseline serum creatinine was < or =250 micromol/l (85%) than >250 micromol/l (60%). Three of 99 (3%) patients with creatinine < or =250 micromol/l started dialysis during follow-up (41 days, 7.4 and 8 years), as did 13 of 36 (36%) patients with creatinine >250 micromol/l. Blood pressure and the number of antihypertensive drugs decreased in patients with creatinine < or =250 micromol/l, but was unchanged in those with creatinine >250 micromol/l. The 5-year survival rates were 84, 66 and 17% for patients with creatinine <125 micromol/l, 125-250 micromol/l and >250 micromol/l, respectively. Twelve patients (9%) experienced complications, including two deaths. CONCLUSIONS: Our study shows that PTRA improved or preserved the renal function in most patients with normal to moderately impaired renal function. Close follow-up and possibly re-intervention are necessary to obtain satisfactory clinical and angiographical result.     

Percutaneous transluminal renal artery dilatation for fibromuscular dysplasia with special reference to the acute effects on the renin-angiotensin-aldosterone system and blood pressure

Twelve hypertensive patients (mean age 46.6 years, range 37-55 years) with fibromuscular dysplasia of the renal artery were treated with percutaneous transluminal renal angioplasty (PTRA) and the effects on the renin-angiotensin-aldosterone system and blood pressure were studied in the acute phase. The technical result of PTRA measured by angiography and reduction of PRA and aldosterone excretion was satisfactory in 11 patients. In spite of this only three patients were cured of their hypertension and two patients were improved at six months follow-up. During PTRA an immediate rise in plasma renin activity was noted in patients without beta-receptor blockade but not in patients treated with beta-receptor blocking agents suggesting a beta-receptor mediated release. This peak in renin release was not accompanied by any rise in systemic blood pressure. The blood pressure response in the acute phase did not show any regular pattern. We conclude that PTRA can serve as a model for studying effects of 'clamping' and 'declamping' of the renal artery in man.     

Surgical management of atherosclerotic renovascular disease

OBJECTIVE: This review describes the clinical outcome of surgical intervention for atherosclerotic renovascular disease in 500 consecutive patients with hypertension. METHODS: From January 1987 to December 1999, 626 patients underwent operative renal artery (RA) repair at our center. A subgroup of 500 patients (254 women and 246 men; mean age, 65 plus minus 9 years) with hypertension (mean blood pressure, 200 plus minus 35/104 plus minus 21 mm Hg) and atherosclerotic RA disease forms the basis of this report. Hypertension response was determined from preoperative and postoperative blood pressure measurements and medication requirements. Change in renal function was determined with estimated glomerular filtration rates (EGFRs) calculated from serum creatinine levels. Proportional hazards regression models were used for the examination of associations between selected preoperative parameters, blood pressure and renal function response, and eventual dialysis-dependence or death. RESULTS: Two hundred three patients underwent unilateral RA procedures, 297 underwent bilateral RA procedures, and 205 patients underwent combined renal and aortic reconstruction. After surgery, there were 23 deaths (4.6%) in the hospital or within 30 days of surgery. Significant and independent predictors of perioperative death included advanced age (P <.0001; hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.85 to 5.70) and clinical congestive heart failure (P =.013; HR, 3.05; 95% CI, 1.26 to 7.34). Among the patients who survived surgery, hypertension was considered cured in 12%, improved in 73%, and unchanged in 15%. For the entire group, renal function increased significantly after operation (preoperative versus postoperative mean EGFR, 41.1 plus minus 23.9 versus 48.2 plus minus 25.5 mL/min/m(2); P <.0001). For individual patients, with a 20% or more change in EGFR considered significant, 43% had improved renal function (including 28 patients who were removed from dialysis-dependence), 47% had unchanged function, and 10% had worsened function. Preoperative renal insufficiency (P <.001; HR, 2.35; 95% CI, 1.86 to 2.98), diabetes mellitus (P =.007; HR, 2.14; 95% CI, 1.15 to 3.97), prior stroke (P =.042; HR, 1.50; 95% CI, 1.02 to 2.22), and severe aortic occlusive disease (P =.003; HR, 1.69; 95% CI, 1.19 to 2.31) showed significant and independent associations with death or dialysis during the follow-up examination period. After operation, blood pressure cured (P =.014; HR, 0.52; 95% CI, 0.30 to 0.88) and improved renal function (P =.011; HR, 0.40; 95% CI, 0.19 to 0.81) showed significant and independent associations with improved dialysis-free survival rate. All categories of function response and time to death or dialysis showed significant interactions with preoperative EGFR. CONCLUSION: The surgical correction of atherosclerotic renovascular disease resulted in blood pressure benefit and retrieval of renal function in selected patients with hypertension. The patients with cured hypertension or improved EGFR after operation showed increased dialysis-free survival as compared with other patients who underwent surgery.     

Surgical Management of Renal Fibromuscular Dysplasia: Challenges in the Endovascular Era

Percutaneous transluminal renal angioplasty (PTRA) is the primary treatment for renal fibromuscular dysplasia (RFMD). Surgical revascularization is limited to patients who fail or are unsuitable for PTRA. All patients who were operated on with RFMD since the indications for renal PTRA were expanded in our institution were retrospectively reviewed. Outcome included patency, hypertension, and renal function. Twenty-six patients had reconstruction of 32 renal arteries between 1998 and 2004. The mean age was 47.1±14 years; the majority (81%) were female. Six patients had bilateral disease and three had a solitary kidney. Operations were done for hypertension in 25 patients, renal artery aneurysm in 8, and chronic dissection in 1, alone or in combination. Six patients had a failed PTRA and 20 were unsuitable for it. Aortorenal bypass was done most often (n=28) and saphenous vein was the preferred conduit (n=25). The distal anastomosis was to the main renal artery in 13 patients and to the branch arteries in 19. Ex vivo repair was needed in five patients. Five intraoperative revisions were done because of abnormalities on duplex scan. One patient died unexpectedly 42 days after operation from myocardial infarction. Extrarenal complications occurred in five patients. Median follow-up was 2.4 (range, 42 days to 6.3) years and was available in all but one patient (96%). Two bypasses occluded at 3 and 376 days, which resulted in loss of the kidneys. One graft stenosis was treated successfully with PTRA at 239 days. All failures occurred in men. One-year cumulative primary patency was 89±8% and was not adversely affected by prior PTRA or complex repair. Hypertension at 1 year was cured in 27% of the patients and improved in 60%. No patient developed acute or chronic renal failure. Surgical reconstruction for RFMD has excellent short-term patency. Failed PTRA or complex reconstructions did not adversely affect outcome.Presented at the Twenty-ninth Annual Meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 4-5, 2004.     

Surgical treatment of renal artery dissection in 25 patients: indications and results

OBJECTIVE: Results of surgical revascularization in 25 patients with renal artery dissection (RAD) over 14 years, with mean follow-up of 55.3 months (range, 10-111 months), were analyzed. Indications for surgery were renovascular hypertension and preservation or improvement of kidney function. PATIENTS AND METHODS: Two patients (both 20 years of age) underwent emergency surgery after severe trauma; 23 patients (mean age, 41 years) underwent elective surgery in a chronic stage of disease. Preoperative, postoperative, and follow-up examinations included duplex ultrasound scanning, determination of serum creatinine and urea concentrations, and evaluation of blood pressure control. All long-term patients underwent digital subtraction angiography preoperatively and postoperatively. All histologic specimens of resected renal arteries were re-evaluated by two independent pathologists. RESULTS: Histologic re-evaluation confirmed the traumatic origin in 2 patients who underwent emergency surgery and 1 who underwent elective surgery. Renal artery dissection developed spontaneously, with no histologic signs of trauma or fibromuscular dysplasia, in 22 patients. In 17 revascularized kidneys (61%) a kidney infarction had already developed preoperatively, and the kidneys were diminished in size or function. Results of revascularization and improvement of hypertension depended on preoperative extent of renal infarction. Hypertension resolved or improved in 86% of patients without preoperative kidney damage, but in only 38% with preoperatively damaged kidneys. Kidney function was preserved in 23 of 28 revascularized kidneys (82%). During follow-up, late renal artery occlusion developed in 3 kidneys. CONCLUSIONS: Renal artery dissection can be effectively treated with surgical revascularization. Primary nephrectomy should be considered only in patients with a large ischemic kidney infarction, with significant deterioration of kidney function, to effectively cure or improve severe renovascular hypertension.     

Surgical revascularization of renal artery after complicated or failed percutaneous transluminal renal angioplasty

PURPOSE: The purpose of this study was to evaluate the feasibility and effectiveness of surgical reconstruction of the renal artery after complicated or failed percutaneous transluminal renal angioplasty (PTRA). METHODS: This was a retrospective study of 45 consecutive patients who were referred to our centers for surgical renal artery reconstruction after 52 complicated or failed PTRA procedures performed between 1980 and 2003. There were 27 women and 18 men, with a median patient age of 28 years (25th percentile, 13.5 years; 75th percentile, 59.5 years). The mean number of PTRA per artery per patient was 1.4 +/- 0.6. Renal artery stenosis was due to arterial fibrodysplasia in 25 patients, atherosclerosis in 17, and inflammatory arteritis in three. RESULTS: Forty-eight renal artery revascularizations were performed (3 bilateral). The procedure consisted of in situ surgery in 38 patients (79%) and extracorporeal repair in 10 (21%). Primary nephrectomy was required in three patients. One patient did not undergo surgical repair after failed PTRA because of kidney atrophy. Major technical problems were encountered during surgical revascularization in 14 (74%) of the 19 patients treated after complicated PTRA and in four (12%) of the 33 patients treated after failed PTRA. Multiple organ failure led to one death on postoperative day 90 in a patient with atherosclerosis and severe kidney insufficiency. Postoperative thrombosis of the repaired renal artery led to kidney loss in three patients, but only one patient required secondary nephrectomy. Primary patency for the overall series of renal revascularizations was 93.5% +/- 6.5% at 5 years. CONCLUSION: Surgical reconstruction after complicated or failed PTRA is feasible and effective and allows kidney salvage in most patients. Technical problems during surgical revascularization may require extracorporeal repair in some patients. The results of this study underline the need for careful patient selection and skillful PTRA technique.     

Juxtarenal aortic atherosclerosis. Surgical experience and functional result.

Ninety patients underwent combined aortic (90) and renal artery (138 arteries) reconstruction for severe, symptomatic aortic occlusive disease (47 patients), aortic aneurysmal disease (30 patients), and visceral atherosclerosis (13 patients). Transaortic endarterectomy was used for 67% of renal artery reconstructions and 69% of visceral arteries. Aortic reconstruction required prosthetic grafting in 74%. A standard transabdominal approach was used in 72 of 90 patients (80%), and thoraco-retroperitoneal exposure was necessary in 18 patients. Perioperative mortality was 9% (8/90) and morbidity 16% (14/90). Ninety per cent of the patients were evaluated at long-term (mean 32 months). Hypertension was cured or improved at discharge in 82% (59/72), and in 96% hypertension improvement was sustained during the follow-up interval. Renal function was improved or preserved in 93% (40/43) at discharge, and this response was sustained in 84% during the follow-up period. Late mortality (8/74, 11%) was lower than expected and is attributed to the technique of combined repair, the cure and control of hypertension, the prevention of ongoing renal ischemia, and the preservation of renal function.     

Management of renovascular hypertension in the elderly population

This article summarizes our experience with the operative management of renovascular hypertension in a contemporary population of elderly patients. During a recent 18-month period 35 of 74 patients (47%) undergoing an operation for renovascular hypertension at our center were in their seventh (21 patients) or eighth (14 patients) decade of life (mean age, 68 years). There were 17 men and 18 women with blood pressures ranging from 176/90 mm Hg to 280/215 mm Hg (mean, 213/121 mm Hg). Twenty-seven patients (77%) had renal insufficiency (serum creatinine greater than or equal to 1.3 mg/dl). Nineteen patients had severe insufficiency (serum creatinine greater than or equal to 2.0 mg/dl), with five of these patients being dependent on dialysis. Thirty-three of 35 patients (94%) had evidence of organ-specific atherosclerotic damage as manifested by cardiac disease (72%), cerebrovascular disease (37%), or renal insufficiency (77%). Operative management consisted of unilateral revascularization in 17 patients (includes three contralateral nephrectomies), bilateral renal revascularization in 17 patients, and primary nephrectomy in one. Simultaneous aortic replacement was performed in nine patients. There were two operative deaths (5.7%) and two postoperative graft thromboses (4%). Hypertension was cured (three) or improved (27) in 30 of the 33 survivors (91%). Renal function was improved in six and worsened in two patients with severe non-dialysis-dependent renal insufficiency. Three of five patients who were dependent on dialysis before surgery were removed from dialysis after renal revascularization. On follow-up (mean, 10.3 months) we found that five patients had died. This article emphasizes the complexity of atherosclerosis in the current population presenting for operative management of renovascular hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extracorporeal renal artery reconstruction for renovascular hypertension

Extracorporeal reconstruction can be applied to the successful repair of stenoses in the distal renal artery and its hilar branches. This study evaluates the short- and long-term results of extracorporeal renal artery reconstruction in 65 patients, including 5 children, with renovascular hypertension who were treated from 1974 through 1989. The mean age of the patients was 37 years (range, 7 to 67 years). The cause of the stenoses was arteriosclerosis in 8 patients, fibrodysplasia in 54 patients, and miscellaneous in 3. Hypertension was severe before treatment with a mean blood pressure of 187/147 mm Hg that was reduced to a mean of 159/102 mm Hg after medical therapy. Ten patients had renal dysfunction. Results were evaluated both at short-term intervals (mean, 7.9 months; 64 patients) and long-term intervals (mean, 5.9 years; 60 patients), after surgery. Blood pressure responses were classified as beneficial (cured/improved) or failures. Anatomic results were evaluated by angiography in 98% of the patients at the short-term interval and in 77% of the patients at the long-term interval. Extracorporeal renal artery surgery was performed on 78 kidneys among 65 patients (unilateral, 45 patients; bilateral, 13 patients; unilateral extracorporeal and contralateral in situ, 7 patients). In most of the cases autologous arterial graft was used for reconstruction. Early in the series one patient died as a result of the operative procedure (1/65, 1.5%). A beneficial blood pressure response occurred in 53 patients (53/65; 82%) at the short-term interval and in 49 patients (49/61; 80%) at the long-term interval, with the average blood pressure at the short-term interval being 138/85 mm Hg and at the long-term interval being 139/85 mm Hg. Renal function improved in all patients with preoperative renal dysfunction. Graft stenosis or occlusion of the main renal artery was neither observed at the short-term interval nor at the long-term interval. However, residual stenoses were observed in 9 of the 163 reconstructed distal branches (5.5%). Extracorporeal renal artery reconstruction with autologous arterial grafts can be effectively applied to lesions of the distal main renal artery and its hilar branches with durable functional results.     

Improved results of vascular reconstruction in pediatric and young adult patients with renovascular hypertension

From 1955 to 1988, 56 patients 21 years old or younger underwent surgical treatment for renovascular hypertension at our clinic. The cause of renal artery disease was fibrous dysplasia in 53 patients, Takayasu's arteritis in 2 or an arterial aneurysm in 1. Bilateral or branch renal artery disease, and extrarenal arterial disease were present in 16, 23 and 11 patients, respectively. The results of 28 patients treated from 1955 to 1977 (group 1) were compared to those of 28 patients treated from 1978 to 1988 (group 2). Hypertension was cured or improved postoperatively in 83% of the patients from group 1 and in 96% from group 2 (p = 0.07). However, this outcome was achieved through surgical revascularization in only 48% of the patients from group 1 compared to 96% from group 2 (p = 0.0002). A multivariate analysis revealed that the only significant variable related to clinical outcome was the era of treatment, which reflects the improved technical efficacy of revascularization during the last decade. Aortorenal bypass and renal autotransplantation have emerged as the preferred revascularization operations. It currently is possible to achieve amelioration of hypertension and preservation of renal function in most young patients with renal artery disease.     

Percutaneous Balloon Angioplasty of Renovascular Hypertension in Pediatric Cases

Purpose : To investigate effectiveness of percutaneous transluminal renal angioplasty (PTRA) in treatment of renal artery stenoses due to Takayasu arteritis (TA), fibromuscular dysplasia (FMD) and neurofibromatosis (NF). Materials-methods : Between December 1991-October 2006, 20 pediatric cases (age range 3–18 years, meanly 12.5 year) with at least 60% stenoses were underwent PTRA. Main presenting symptom was hypertension. The aetiologies were TA in 12, and FMD in 5, NF in three cases.

Results : Totally, 46 procedures were performed on 35 stenotic segments of 20 cases. A technically good result was obtained in 21/24 arteries of TA patients, 7/7 arteries of FMD patients, and 1/3 arteries of NF1 patients. Clinical follow-up for a mean of 55.7 months revealed 100% success in all cases. Delayed clinical response was seen in two cases with Nf1. Restenosis was detected 5/12 of TA patients, 1/5 of FMD patients and 1/3 NF1 patients.

Conclusion : PTRA can be safely performed resulting in excellent angiographic and clinical results. It should be first choice in renal artery stenosis in pediatric age when medical treatment fails to control renovascular hypertension or renal function is decreasing although initial results might be not encouraging in NF1.     

Splenorenal bypass in the treatment of renal artery stenosis: experience with sixty-nine cases

From 1962 to 1984 splenorenal bypass was performed in 69 patients with renal artery disease caused by either atherosclerosis (n = 54) or fibrous dysplasia (n = 15). Renal revascularization was performed to control hypertension in 27 patients, to preserve renal function in nine patients, and for both of these reasons in 33 patients. The mean follow-up interval is 5.4 years. Postoperatively hypertension was cured or improved in 52 of 60 patients (87%); the serum creatine level was improved or stable in 37 of 42 patients (88%) who underwent revascularization to preserve renal function. Postoperative graft thrombosis (n = 2) or stenosis (n = 3) occurred in five patients (7%). Splenorenal bypass is an excellent method of revascularization of the left renal artery, particularly for patients with a troublesome aorta that precludes performance of an aortorenal bypass.