Robot-assisted laparoscopic renal artery aneurysm reconstruction

We report the surgical management of an expanding 2.5-cm left-sided renal artery aneurysm using a robotic-assisted laparoscopic approach. Using the da Vinci surgical robotic system, we resected the aneurysm, and the anterior-inferior branch of the renal artery was reconstructed with an end-to-end anastomosis. The operative time was 360 minutes, hospitalization length of stay was 3 days, and postoperative analgesic requirements were minimal. Follow-up imaging and functional analysis demonstrated resolution of the aneurysm and preservation of renal function. This technique highlights the ability of surgical robotics to expand indications for minimally invasive surgery in complex cases.     

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.     

Simultaneous aortic and renal artery reconstruction

Nine patients presenting with combined aortic and renal artery disease underwent simultaneous infrarenal aortic reconstruction and renal revascularization. Seven patients had aneurysmal and two had occlusive aortic disease in association with unilateral (four cases) or bilateral (five cases) atheromatous renal artery stenosis. The indications for renal revascularization were hypertension (n = 8) refractory to medical treatment or associated with renal functional impairment and chronic renal failure alone (n = 1). Five patients developed postoperative complications with one fatality. Eight patients were followed up for between 7 months and 4 years. Control of blood pressure had improved in six of seven hypertensive patients. Serum creatinine levels were stabilized or had fallen in five patients. Simultaneous aortic and renal artery reconstruction is widely recognized as having a high postoperative morbidity rate but can improve control of hypertension and stabilize renal function in carefully selected patients.     

Ex vivo renal artery reconstruction.

Ex vivo renal artery reconstruction and autotransplantation is a relatively recent addition to the surgical armamentarium for renal vascular hypertension. Ten consecutive patients were considered for this surgical therapy and form the basis of this communication. The patients were treated by a combination of methods including bilateral ex vivo reconstruction, unilateral in situ and contralateral ex vivo reconstruction, and unilateral ex vivo reconstruction and contralateral nephrectomy. Replacement of the diseased segment of the renal artery in all ex vivo reconstruction consisted of arterial autografts including hypogastric artery, splenic artery, common iliac, and external iliac artery. In the ex vivo reconstruction, the ureter was either left intact or was transected and reconstructed by standard ureterovesicle implantation. After surgery all patients became normotensive without antihypertensive medication. Although this is a relatively small series, the uniform good results in these patients with extensive disease suggest that ex vivo renal artery reconstruction is a safe and effective method of treatment. Thus, it should be more widely applicable, expecially in those patients with renal vascular disease who were previously thought to be inoperable or eligible for nephrectomy only.     

Atherosclerotic renal artery stenosis and reconstruction

Renal artery stenosis is common especially in patients with generalized atherosclerosis. It is frequently associated with difficult-to-treat hypertension and with renal failure. There is an ongoing debate about the appropriate screening and treatment of atherosclerotic renal artery stenosis. Advances in imaging and interventional devices offer new opportunities, however, clinicians still have to decide individually in every patient to treat or not to treat stenosis with revascularization. This review evaluates the current literature in order to help the physician to find the right decision in this challenging clinical issue.     

Empirical reconstruction of the renal artery: Long-term outcome

Purpose: Unequivocal indications for renal artery reconstruction remain the presence of significant underlying renal insufficiency or severe hypertension. Thus surgical intervention for renal artery stenosis in the absence of this clinical picture may well be considered empirical and, as a consequence, treatment recommendations are ill-defined. Our experience with reconstruction of the minimally symptomatic or asymptomatic renal artery lesion in association with primary aortic repair over a 10-year period was reviewed.Methods: Thirty-two patients who had atherosclerotic renal artery stenosis ≥70% underwent prophylactic renal revascularization between 1982 and 1992. The patients' median age was 63 years (range, 44 to 79 years); 23 (72%) were men and nine (28%) were women. All had preoperative serum creatinine levels ≤1.7 mg/dl (1.29 ± 0.24 mg/dl) and were receiving either no antihypertensive medication (22%) or only a single agent (78%). Aortoiliac occlusive disease was present in 38% of this population, and aortic aneurysmal disease either alone or in combination with occlusive disease was found in 62%.Results: Operative management included unilateral renal artery repair in 21 patients (66%) and bilateral renal revascularization in the remaining 11 (34%). The median decrease in postoperative serum creatinine level (≥7 days after operation) was 0.81 ± 0.05% (mean postoperative serum creatinine level, 1.27 ± 0.07 mg/dl). The 30-day operative mortality rate was 3.1% (1 of 32). Late follow-up was available for 96% of patients (30 of 31; median, 64 months). Kaplan-Meier life table analysis revealed a 5-year probability of survival of 90.2% (95% confidence interval, 0.802 to 1.00). Stability of renal function was assessed by modeling the change in serum creatinine level over time with the intraclass correlation model. A serum creatinine level (mg/dl) = 1.3348 ± 0.0011 × time (months) demonstrated minimal deterioration of excretory function during the observation period. Furthermore, the blood pressure of the majority of patients (75%) remained normal either with a single agent or without medication. Recurrent stenosis in one patient required treatment by percutaneous transluminal angioplasty.Conclusions: Adjunctive repair of the renal artery may be an appropriate option in selected patients who undergo simultaneous aortic surgery, even in the absence of severe hypertension or renal insufficiency. Surgical intervention can be accomplished with acceptable perioperative morbidity rates, and stability of renal function is sustainable in the majority of patients. (J Vasc Surg 1996:24:406-14.)     

Radial artery as conduit for distal renal artery reconstruction

Reconstruction of the renal artery with both saphenous vein and prosthetic material as bypass graft is durable in atherosclerotic disease. Extensive experience with saphenous vein grafts in pediatric patients and patients without atherosclerosis reveals a disturbing incidence of vein graft aneurysm degeneration. Distal renal artery reconstruction involving small branch vessels is generally not amenable to prosthetic reconstruction. We report a new approach to distal renal artery bypass grafting to avert these limitations. CASE: A 43-year-old man with previously normal blood pressure had malignant hypertension, which proved difficult to control despite use of a beta-blocker and an angiotensin II inhibitor. At renal angiography a fusiform aneurysm was revealed in a posterior branch of the right renal artery. The renal artery aneurysm was resected, and the left radial artery was harvested and used as a sequential aortorenal bypass graft to the two branch renal arteries. The postoperative course was uneventful, and the patient now has normal blood pressure with a calcium channel blocker for maintenance of the radial artery graft. Pathologic analysis revealed a pseudoaneurysm with dissection between the media and external lamella, consistent with fibromuscular dysplasia. CONCLUSION: Autologous artery is the preferred conduit for renal reconstruction in the pediatric population. On the basis of cardiac surgery experience, we used the radial artery and found it to be a technically satisfactory conduit for distal renal reconstruction in a patient without atherosclerosis.     

Simultaneous bilateral renal artery reconstruction and intraoperative renal protection

A 22-year-old Japanese man with bilateral renal artery stenosis associated with hypertension underwent successfull surgery of simultaneous bilateral renal artery reconstruction under conditions of intraoperative renal perfusion with St. Thomas Hospital solution which is used for cardioplegia in open heart surgery. Circulation in the left kidney was interrupted for 58 minutes and that of the right kidney for 35 minutes. The patient fully recovered with no serious impairment of renal function. In addition to these stenotic lesions of the renal artery, there were medial necrosis of the aorta and fibromuscular dysplasia of the superior mesenteric artery. Administration of SQ14,225, an angiotensin I converting enzyme inhibitor, was effective in controlling hypertension during the preoperative period.     

Successful ex vivo renal artery reconstruction and renal autotransplantation

Background : The increasing experience with renal allotransplantation has led to continuing development in vascular surgical techniques. These improvements have enabled complex ex vivo renal artery surgery and renal autotransplantation to be performed. The aims of the present study were to describe the results achieved with renal autotransplantation and ex vivo renal artery reconstruction (RAR) at the Newcastle Transplant Unit, John Hunter Hospital, and to review the current indications for such surgery. Methods : A retrospective review was performed of patients who required renal autotransplantation with or without RAR at John Hunter Hospital, between 1991 and 1999. Data were obtained from the Newcastle Transplant Unit and the Medical Record Department of John Hunter Hospital. Results : Two patients required ex vivo RAR and renal autotransplantation for severe fibromuscular dysplasia (FMD) complicated by stenoses and renal artery branch aneurysms. The third patient required autotransplantation for bilateral retroperitoneal fibrosis. There was one postoperative complication of pelviureteric junction obstruction that was treated successfully with a temporary ureteric stent. All patients demonstrated normal graft function and were normotensive on follow up, which ranged from 2.5 to 5 years. Conclusion : The present review confirms the long‐term benefits of ex vivo RAR and renal autotransplantation that have been demonstrated by previous studies. In transplant units experienced with this surgery it has been shown to be a successful and durable technique for the treatment of a variety of vascular, urologic and other diseases.     

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.     

Intraoperative duplex sonography during renal artery reconstruction

To assess renal duplex sonography as an intraoperative study to detect technical defects during repair, 57 renal artery reconstructions in 35 patients were studied. Sixteen men and 19 women (mean age, 62 years) underwent unilateral (13 patients) or bilateral (22 patients) renal artery repair to 57 kidneys. Methods of repair included aortorenal bypass grafting in 29 cases (20 saphenous vein, 5 polytetrafluoroethylene, 4 Dacron), reimplantation in 7, transrenal thromboendarterectomy with patch angioplasty in 13, and transaortic extraction thromboendarterectomy in 8. Branch renal artery repair was required in six cases (five in vivo, one ex vivo). Fourteen patients had combined aortic replacement (11 patients: 8 abdominal aortic aneurysms, 3 aortic occlusions) or visceral artery reconstruction (three patients: three superior mesenteric artery thromboendarterectomies, one inferior mesenteric artery thromboendarterectomy). Intraoperative renal duplex sonography (mean scan time, 4.5 minutes) was complete in 56 of 57 repairs (98%), and renal duplex sonography was normal in 44 repairs (77%). Overall, B-scan defects were present in 13 repairs (23%). Six of these (11%) were defined as major B-scan defects by Doppler spectra with focal increases in peak systolic velocity greater than or equal to 2.0 meters/sec (major defect, mean renal artery peak systolic velocity, 3.1 m/sec), which prompted immediate operative revision. Seven B-scan defects were defined as minor by Doppler spectra (minor defect, mean renal artery, peak systolic velocity, 0.7 m/sec) and were not revised. Postoperative evaluation (range, 1 to 22 months; mean follow-up, 12.4 months) of 55 renal artery repairs in 34 operative survivors (surface renal duplex sonography, 33 patients; renal angiography, 9 patients) demonstrated 42/43 renal artery repairs with normal intraoperative renal duplex sonography, and 6/6 repairs with minor B-scan defects were patent and free of critical stenosis. Of the 6 renal artery revisions prompted by major B-scan defects, 4 remained patent, 1 stenosed, and 1 occluded. Our experience suggests that intraoperative renal duplex sonography during renal artery repair provides valuable anatomic and physiologic information. Renal artery repairs with normal renal duplex sonography and minor B-scan defects without Doppler spectral changes demonstrated 98% patency without critical stenosis at 12.4 months of mean follow-up. However, major B-scan defects defined by a focal increase in renal artery peak systolic velocity should be considered for immediate correction.     

Delayed reconstruction following post-traumatic renal artery thrombosis

A case of delayed revascularisation surgery three days after a traumatic renal artery thrombosis is presented. Criteria for a successful operation, with saving of the involved organ, are: normal kidney size, intact glomeruli and visualization of the kidney by contrast-medium.     

A case of ex vivo renal artery reconstruction and autotransplantation for renal artery aneurysm

A 74-year male patient was admitted to our department with a left renal artery aneurysm (RAA). It was detected by a computed tomography (CT) scan while performing an examination for hypertension. The diameter of the aneurysm was 25 mm. There was no evidence of calcification. Selective left renal angiography and a 3-dimensional (3D)-CT image revealed a saccular renal aneurysm in the left main renal artery. Because of the risk of rupture, autotransplantation of the left kidney to the left iliac fossa was performed after resecting the aneurysm and reconstructing the left artery under bench surgery. Postoperative 3D-CT revealed no stenosis. This ex-vivo technique and autotransplantation into ipsilateral iliac fossa are both effective and safe for the treatment of RAA.     

External velour dacron grafts in renal artery reconstruction.

Aortorenal interposition grafts were performed in dogs using a new external velour knitted Dacron graft. Encapsulation and endothelialization of these grafts occurs as early as two weeks postoperatively. Complete healing is seen by six weeks, and the cellular lining of these grafts appears to be continuous with, and histologically similar to, the endothelium of contiguous arteries. The healed nonthrombogenic characteristics of this graft material represents a considerable improvement over graft materials of conventional design.