Management of pediatric visceral arterial and aortic coarctation

Two unusual pediatric vascular problems have been managed surgically. The first patient is a five-and-a half-year old girl who presented with renal artery stenosis and aneurysm and renovascular hypertension. This was treated by excision of the aneurysm and reimplantation of the right renal artery. The second patient is a two-year old girl with atresia of the abdominal aorta, superior mesenteric artery (SMA) and both renal arteries. She was treated by PTFE patch graft angioplasty of the aorta, SMA reimplantation and bilateral aorto-renal autogenous saphenous vein bypass.     

Iliorenal bypass for the treatment of type-3 Takayasu's disease. A case report with 10-year follow-up

The case of a 16-year old female with severe renovascular hypertension resulting from type-3 Takayasu's arteritis is reported. The entire thoracic and abdominal aorta was affected by an active inflammatory process and all its branches were stenotic or occluded. After the early failure of a percutaneous balloon angioplasty of the left renal artery, an iliac to renal artery bypass graft using a reversed autologous saphenous vein was performed through a retroperitoneal tunnel The patient is asymptomatic and the graft is patent at 10-year follow-up.     

采用单条大隐静脉行腹主动脉-双侧肾动脉旁路术治疗大动脉炎性肾动脉狭窄

目的:研究采用单条大隐静脉行腹主动脉-双侧肾动脉旁路术治疗大动脉炎性双侧肾动脉狭窄的疗效。方法:回顾性分析采用该术式治疗的11例大动脉炎性双侧肾动脉狭窄的连续临床资料。结果:所有病人术前均表现为难控性高血压,1例需依赖血透生存。11例均顺利完成手术,22条肾动脉即刻复通,无围手术期死亡。平均随访时间为45个月。末次随访时平均血压由术前的195/109 mm Hg降至132/83 mm Hg(P50%的再狭窄。结论:该术式是治疗双侧大动脉炎性肾动脉狭窄之安全、有效的方法;可有效降压和改善肾功能;中远期通畅率高。     

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.     

Emergency gastroduodenal-renal artery bypass. An extra-anatomic approach for salvage of the solitary kidney

A 68-year-old woman had acute anuric renal failure and congestive heart failure. Angiography demonstrated occlusion of the renal artery to the known solitary right kidney and severely ulcerative aortic arteriosclerosis. She underwent an emergency gastroduodenal-renal artery saphenous vein bypass graft with almost immediate restoration of urine output and eventual dramatic improvement in renal function. She remains well two years postoperatively. This is the first report of gastroduodenal-renal bypass performed in the emergency setting for salvage of a solitary kidney.     

Coarctation of the abdominal aorta: current options in surgical management.

Coarctation or hypoplasia of the abdominal aorta is a rare cause of life-threatening hypertension. In most cases the mechanism of hypertension is elevated blood renin levels secondary to associated renal artery stenosis. Medical control of the hypertension is often difficult, and thus patients usually require renal artery revascularization combined with aortic bypass or replacement early in life. Current surgical management should optimize the use of autogenous methods of renal artery reconstruction including saphenous vein aortorenal bypass, splenorenal arterial anastomosis, hepatorenal saphenous vein bypass, and renal autotransplantation. In selected patients the reconstruction can be staged by correction of the renal artery stenosis and postponement of definitive repair of the aortic coarctation until it becomes hemodynamically significant.     

Atherosclerotic renal artery occlusion extending into branches: successful revascularization in situ with a branched saphenous vein graft.

In some patients successful renal revascularization can be done after complete renal artery occlusion. We report on a patient with atherosclerotic occlusion of the renal artery and its branches in whom an aortorenal bypass with a branched saphenous vein graft was performed in situ, with cure of hypertension and reversal of azotemia. This is a useful and versatile technique for replacing the renal artery and its major branches.     

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.     

Improved results with surgical treatment of renovascular hypertension: an individualized approach

During a one-year period, 20 patients were treated for renal artery occlusive lesions causing renovascular hypertension. Diagnosis depended on angiography, isotopic renography, and selective renal vein renin determinations in certain patients. Treatment included saphenous aortorenal bypass, 9 patients; endarterectomy, 3 patients; percutaneous angioplasty, 5 patients; and nephrectomy in 3 patients. There was no operative mortality. Eighty-five percent of the patients were improved or cured of hypertension, and the average number of antihypertensive medications required decreased from 3.1 to 1.6. The mean serum creatinine of all patients decreased from 3.6 mg/dl to 2.2 mg/dl. In one subset of patients expanding suprarenal aneurysms caused renal artery stenosis or occlusion. Aortic replacement with renal artery endarterectomy or bypass is the only treatment option for these patients. High risk patients with normal renal function and a glomerular filtration rate less than 15% in the affected kidney can be treated with nephrectomy. Our results demonstrate that an individualized approach to therapy and attention to operative detail is mandatory for successful treatment of renovascular hypertension.     

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.     

Renovascular hypertension in children. Surgical repair with special reference to the use of reinforced vein grafts

Surgical correction of renovascular hypertension in children is especially challenging because there is high incidence of bilateral renal artery lesions and stenosis of the abdominal aorta. Seventeen patients with severe hypertension, whose ages ranged from 2 to 16 years (mean 10.2 years), had surgical repair of these lesions from 1974 to 1987. Twenty-nine renal artery lesions were repaired. Twelve (71%) were bilateral, five (29%) were unilateral, and eight patients (47%) had abdominal aortic lesions (midaortic stenosis). Twenty-eight saphenous vein grafts and one splenorenal graft were used to bypass the renal artery lesions. The midaortic lesions were bypassed with Dacron grafts from the superceliac aorta to the aortic bifurcation. No operative deaths occurred. Nineteen of the 28 vein grafts were reinforced with a 6 mm diameter tubular Dacron mesh to prevent aneurysmal degeneration seen in three of nine unsupported vein grafts. Follow-up arteriograms were available in 15 patients up to 11 years after operation (mean 5.0 years). There has been no aneurysmal dilatation in the 19 mesh-supported grafts. The ratio of vein graft diameter to the diameter of the native aorta was 1.25 +/- 0.38 (+/- standard deviation) in unsupported grafts and 0.65 +/- 0.09 in mesh-supported grafts, representing a 92% increased diameter in the unsupported grafts. Three vein grafts (10.3%) required percutaneous transluminal angioplasty for late postoperative vein graft stenoses, but no stenotic lesions have developed at the aortic suture lines. One graft occluded 7 years postoperatively after replacement of an aneurysmal vein graft, and one early postoperative graft occlusion occurred, for a graft failure rate of 7%. Seventy-six percent of patients (13 of 17) are normotensive without medication, and 24% (4 of 17) are considered improved with hypertension controlled with a lower dose of medication. Our results attest to the safety and efficacy of this complicated surgery. Saphenous veins, supported by external Dacron mesh, appear to be a suitable graft material for renal reconstruction in this population.     

Off-pump coronary artery bypass grafting in a high-risk dextrocardia patient: a case report

We present an interesting but high-risk case of an obese male patient aged 56 years with dextrocardia and a left diaphragmatic hernia. Anterior myocardial infarction was diagnosed in 1994, and the patient later presented with a history of unstable angina. The diagnosis for this chronic smoker was triple-vessel disease, impaired left ventricular function, chronic renal failure, chronic bronchitis, impaired lung function, pulmonary hypertension, hypertension, diabetes, and chronic active gastritis (EuroSCORE of 10). The patient underwent successful off-pump coronary artery bypass grafting with 3 saphenous vein grafts to the left anterior descending, obtuse marginal, and right posterior descending arteries. He was discharged home 8 days later.     

Pulmonary artery compression by a giant aortocoronary vein graft aneurysm

Late failure of saphenous vein aortocoronary bypass grafts is predominantly due to vein graft atherosclerotic disease. Rarely, saphenous vein aortocoronary bypass grafts undergo aneurysmal degeneration. We report a case of a giant true aneurysm of a saphenous vein aortocoronary bypass graft producing right heart failure from main pulmonary artery compression.     

Percutaneous transluminal angioplasty of coronary saphenous vein bypass grafts

Between December 1981 and August 1983, percutaneous transluminal angioplasty of saphenous vein grafts was performed in 14 men and 4 women, selected because of recurrent anginal symptoms and graft stenosis. The interval from bypass to angioplasty was 41 +/- 36 months. Of 24 lesions, 9 were at the proximal anastomosis, 13 in the distal segment and 2 in the middle segment of the vein graft. The primary success rate was 79%. Failure to cross the stenosis occurred in three patients and failure to dilate in one. The stenosis was reduced from a mean of 82% +/- 13% to 26% +/- 15%. No patient required emergency coronary artery bypass grafting but two underwent elective grafting after the angioplasty had failed. No patient sustained a Q-wave myocardial infarction and all who had a successful angioplasty were asymptomatic or much improved after the procedure. Angiographic follow-up was available in 12 of 14 patients (86%). Six patients had significant symptoms (Canadian Cardiovascular Society class II to III) and five of these had evidence of restenosis. Among the six patients who were asymptomatic, two had angiographic evidence of restenosis. The overall rate of restenosis was 58% (7 of 12). Repeat angioplasty was successful in three of the five patients in whom it was attempted. The authors conclude that percutaneous transluminal angioplasty of a saphenous vein graft for a localized area of stenosis is effective and safe, but there is a high rate of restenosis that possibly is due to intimal fibrous proliferation in saphenous vein grafts.     

Revascularization of the right ischemic kidney by gastroduodenal artery

Hepatorenal bypass can successfully accomplish revascularization of the right renal artery when the aorta or the iliac vessels cannot be used for a standard renal bypass or renal autotransplantation. The use of the hepatic circulation can be increased by the gastroduodenal to renal artery bypass procedure. Herein we report a clinical case of severe hypertension in a patient with a solitary functional kidney and an extensive atheromatous alteration of the aortoiliac segment. It has been corrected by means of a gastroduodenal end-to-side renal saphenous vein bypass graft.     

胃十二指肠－右肾动脉旁路转流术治疗肾动脉狭窄

作者采用自体大隐静脉间置移植，作胃十二指肠动脉旁路转流术，治疗肾动脉狭窄、肾血管性高血压１例。术后随访１年，取得良好控制高血压疗效。作者认为，间置自体大隐静脉的内径不应小于０．４ｃｍ，吻合后移植大隐静脉段无张力。防止受压、成角、扭曲以及缩短缺血时间，是保护肾脏功能和使手术取得成功的关键。     

Renal autotransplantation in the treatment of hypertension and uraemia due to renal artery stenosis.

Four cases of renovascular hypertension cured or improved by renal autotransplantation are described. In one case correction of renal ischaemia resulted in an improvement of renal function. Previous reports of this technique are reviewed and the limitations of the more standard operation of saphenous vein bypass graft are discussed.     

Renovascular hypertension with a solitary kidney associated with retrocaval ureter: a case report

A case of renovascular hypertension in a patient with a congenitally solitary kidney associated with retrocaval ureter is reported. Aortorenal bypass with autogenous saphenous vein graft and concomitant mobilization of the ureter by division and reanastomosis of the inferior vena cava were performed. Pathogenesis of the stenotic lesion of the renal artery was fibromuscular dysplasia. Postoperative improvement of hypertension was not so good as expected. Soon after administration of nifedipine (20mg/day) was started, blood pressure decreased down to 130/80mmHg and had been well controlled. Problems regarding renovascular hypertension with a solitary kidney and surgical treatment of retrocaval ureter are discussed.     

Inadequacy of saphenous vein grafts for cross-femoral venous bypass

A mathematic model of unilateral iliac vein obstruction was used to establish the theoretic basis for selecting saphenous vein or a larger diameter prosthetic cross-femoral venous bypass graft for relief of obstructive venous hypertension. Common femoral vein resting and postexercise peak flows, and common femoral vein and saphenous vein diameters were measured in 18 healthy individuals and used to estimate the pressure gradient (dP) across 20 cm long cross-femoral venous bypass grafts of saphenous vein or 4, 6, 8, 10, and 12 mm prosthetic conduits, in the presence of a transpelvic venous collateral network of varied cross section. The upper limits of normal for the gradients in our model (dPstd) were set at 4 mm Hg for resting flows and 6 mm Hg after exercise. Mean saphenous vein diameter was 4.3 +/- 0.22 mm, which was 36.5% +/- 1.73% of common femoral vein diameter. When the saphenous veins of two thirds of the individuals in our study were used as theoretic cross-femoral venous bypass conduits, greater than 80% of postobstruction peak cross-femoral venous bypass graft flow had to be carried by collaterals to maintain a gradient less than or equal to dPstd. We demonstrated that 4.5 to 6.0 mm diameter saphenous cross-femoral venous bypass grafts would be hemodynamically efficacious in relieving venous hypertension, but only when implanted in parallel with an existing venous collateral network that limited the preoperative dP to 4.5 to 7.5 mm Hg at resting flows and 7.0 to 11.5 mm Hg after exercise; only 44% of saphenous veins were adequate for cross-femoral venous bypass grafts by these criteria.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of surgical bypass and percutaneous balloon dilatation with primary stent placement in the treatment of central venous obstruction in the dialysis patient: One-year follow-up

Central venous stenosis and occlusion are complications that are being observed with increasing frequency as a result of the use of long-term central venous catheters. These complications are especially problematic in patients with end-stage renal disease and functioning ipsilateral arteriovenous (AV) grafts or fistulas (AV grafts). We have previously demonstrated that the 1-year patency rate for simple balloon angioplasty in these patients is less than 10%. To compare the results of surgical treatment vs. percutaneous dilatation with stent placement, we undertook this retrospective study. All patients underwent multiple central venous catheter placements and had functioning ipsilateral AV grafts. Twenty-six patients were divided into two groups. The surgical treatment group included 13 patients: 10 with subclavian vein thrombosis and three with innominate vein thrombosis. All patients in the surgical group had arm swelling and edema. Surgical bypass procedures were performed in these patients using either polytetrafluoroethylene or saphenous vein. The stent group also included 13 patients; all of them had a diagnosis of subclavian or innominate vein obstruction and were treated with percutaneous transluminal angioplasty and placement of either a self-expanding rigid stent (n=6) or a balloon-expandable flexible stent (n=7). Two patients required multiple stent placements. No significant complications occurred in either group. The 1-year mortality rate in both groups was 31%. The percentages of patients who were symptom free at 6 and 12 months were also similar in the two groups. We conclude that surgical bypass and percutaneous transluminal angioplasty with stent placement are both efficacious in the treatment of central venous obstruction.