Autotransplantation for treating renovascular hypertension.

Autotransplantation is presented as a surgical technique for the repair of diseases of the renal artery causing hypertension. Investigation of patients with renovascular hypertension is reviewed stressing the importance of radiologic studies. The author discusses the results obtained in 31 patients who underwent renal autotransplantation. In his experience the procedure has proven to be particularly effective for repairing renal artery stenosis and in patients presenting with severe renovascular hypertension. Associated lesions of the renal artery requiring extensive reconstruction may be repaired with greater safety to both the patient and the kidney using this technique.     

Traumatic renal artery thrombosis with renovascular hypertension

A 15-year-old boy, who tumbled from a fourth-floor window, was transported to our hospital. Enhanced computed tomography (CT) 1.5 h after the injury showed a non-contrasted right kidney, and a repeat CT 6 h after the injury showed a growing retroperitoneal hematoma. The angiography showed complete obstruction of the right renal artery and bleeding from the subcapsular artery, which was successfully embolized. Renovascular hypertension developed on the second day after the injury; therefore, simple nephrectomy was performed.     

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.     

Bilateral renal artery stenosis and renovascular hypertension

Experience with the diagnostic evaluation and operative management of 38 hypertensive patients having bilateral renal revascularization is presented. Twenty-four patients had atherosclerotic occlusions and 14 had fibromuscular dysplasia. Renal vein renin assays (RVRA) and/or split renal function studies (SRFS) were performed in 37 of the 38 patients before operation. Although RVRA was negative in 29 percent and SRFS negative in 31 percent, 24 of 26 patients (92 percent) having both tests done had at least one positive study. Twenty-one patients had simultaneous bilateral repairs and 12 had staged bilateral reconstructions. The incidence of technical failures in these two groups was 21 and 9 percent, respectively. Excluding three uncorrected technical failures and two patients with recurrent branch renal artery lesions, 90 percent of patients with atherosclerosis and all patients with fibromuscular dysplasia had a favorable blood pressure response to operation. This study supports the use of both RVRA and SRFS in the diagnostic evaluation of hypertensive patients with renal artery stenosis. If these functional tests lateralize to one side, repair of that side only is recommended. If the functional studies do not lateralize, operation is suggested only when hypertension is severe and is not controlled readily with medications. In this circumstance reconstruction of the side that appears to be diseased most severely is recommended. Contralateral repair is undertaken only when hypertension persists and when repeat functional studies lateralize to the unoperated side.     

Primary renal artery choriocarcinoma causing secondary renovascular hypertension

INTRODUCTION

Choriocarcinoma is a rare primary germ cell tumour of the ovary composed of cyto- and syncytotrophoblast cells. Most of the choriocarcinomas are normally arising in the gestational trophoblast, gonads and, less frequently, mediastinum, pineal gland and retroperitoneum.

PRESENTATION OF CASE

We report a case of primary choriocarcinoma of renal artery causing secondary renovascular hypertension in a 28 years old woman of reproductive age, presenting with abdominal pain, minimal vaginal bleeding and a delayed menstrual period.

DISCUSSION

Non-gestational choriocarcinomas, are histologically related to the pregnancy related gestational choriocarcinomas. These two subtypes may have to be differentiated according the clinical and radiological findings and DNA analysis may be used for this purpose as well. In many studies, authors have stated that nongestational choriocarcinoma diagnosis could be implemented in situations where the presence of a pregnancy could not be considered like the prepubertal period.

CONCLUSION

Choriocarcinoma should as well be considered among the possibilities in the differential diagnosis of the causes for secondary hypertension, especially within a picture of pregnancy of unknown location, albeit being one of the rarest.     

Bilateral renal artery stenosis/occlusion and renovascular hypertension. Correlation of angiographic findings with blood pressure response after surgery

In a previous study of unilateral renal artery stenosis the angiograms of patients with a favourable blood pressure response after surgery were found to be characterized by a reduction of renal arterial lumen greater than or equal to 90% and/or renal collateral circulation. Ancillary features were post-stenotic dilatation and a reduction of kidney length greater than or equal to 1 cm (Andersson; Andersson, Bergentz, Dymling, Ericsson, Hansson & H?kfelt). This report deals with 32 patients with bilateral renal artery stenosis who were followed 6--54 months after operation. The preoperative angiograms were analysed retrospectively without knowledge of the blood pressure response. In patients with bilateral fibromuscular dysplasia a good correlation was found between the above-mentioned criteria and a favourable blood pressure respone. In patients with bilateral arteriosclerotic stenosis no correlation was found. It was concluded that renal angiography constitutes a valuable predictive test in bilateral non-arteriosclerotic stenosis. In the presence of bilateral arteriosclerotic stenosis the selection of patients for surgery should be based on other parameters such as kidney function, age and general vascular status of the patient.     

Long-term results of renal artery reconstruction with autogenous artery in patients with renovascular hypertension

Renal artery reconstruction for the treatment of renovascular hypertension is preferably performed with an autologous graft when a graft is required. Although satisfactory results with vein grafts have been reported, stenosis and dilatation are not infrequent complications which have been observed only occasionally in arterial grafts. We have analysed our long-term results obtained with autogenous arterial grafts for renal artery reconstruction to determine the functional and anatomical results with regard to these complications. The data from 57 survivors operated on from 1959 through 1983 were analysed. All patients were hypertensive and the average systolic and diastolic blood pressure was 173/109 mmHg (mean number of 2.2 drugs). The renal artery stenosis was caused by arteriosclerosis and fibrodysplasia in 24 and 33 patients, respectively. In situ repair was performed in 30 patients (arterial bypass: 17 patients; splenorenal bypass: 13 patients). Extracorporeal repair of fibrodysplastic branch lesions was performed in 27 patients using branched hypogastric artery grafts (mean number of 2.4 branch anastomoses per kidney). Results were evaluated in the short (mean 8.3 months) and long term (mean 7.5 years) and the blood pressure response classified as either beneficial (cured/improved) or failed. Anatomical results were evaluated by angiography in the short-term in 87% of the patients and the long-term in 70%. A beneficial blood pressure response was obtained in 77% and 86% of patients in the short and long-term, respectively. The average blood pressure level after an interval of several years (long term) was 144/87 mmHg (mean number of 0.9 antihypertensive drugs). After in situ reconstruction, 2 and 1 anatomical failures were observed in the short and long-term, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transluminal vascular stent implantation for a patient with renovascular hypertension due to renal artery stenosis

In recent years, transluminal vascular stents have been implanted in patients with renal artery stenosis. At present, controversy remains as to whether the long-term outcome of stent implantation is better than that of percutaneous transluminal renal angioplasty (PTRA). However, until now, no clinical experience of a stent placement for renal artery stenosis has been reported in our country. We implanted a Palmaz stent in a patient with renovascular hypertenstion due to renal artery restenosis who had already undergone PTRA. The renal function and blood pressure of the patient improved remarkably.     

Reoperation for complications of renal artery reconstructive surgery undertaken for treatment of renovascular hypertension

Seventy-two secondary operations for complications of prior renal artery reconstructive surgery were undertaken in 58 patients. This experience evolved from the management of 373 patients who underwent 425 primary operations for renovascular hypertension. Secondary operations were performed 10 times in pediatric patients following 42 primary procedures (24%); 44 times in adult fibrodysplastic patients following 199 initial operations (22%); and 18 times in atherosclerotic patients after 184 primary operations (10%). The overall reoperation rate was 15.5% (58 of 373 patients). Reoperation typically followed persistent or recurrent hypertension caused by graft thromboses, perianastomotic graft narrowing, or progressive nonanastomotic graft stenoses. Aneurysmal deterioration of vein grafts was an uncommon reason for reoperation. Secondary reconstructions included nephrectomy (31), bypass with vein grafts (15) or prosthetic grafts (8), angioplasty or reimplantation (12), thrombectomy (4), and operative dilation (2). Benefits regarding hypertension control were afforded 91% of these patients. One death occurred among the 72 reoperations, representing a 1.4% operative mortality rate. Reoperative renal artery reconstructive surgery for complications of renal revascularization may present formidable technical problems. Early diagnosis and prompt reoperation with exacting vascular surgical techniques are most likely to provide optimal results.     

Lesions of the dorsal renal artery in surgery for renal pelvic calculus. A potential cause of renovascular hypertension.

2 cases of lesions of the dorsal renal artery in surgery for renal pelvic calculus are described. In 1 of the cases hypertension developed. Anatomic factors and previous operations predispose to this complication. An arterial complication should be suspected when hypertension develops postoperatively. The blood pressure of patients with known renal vascular complications should be checked repeatedly for several months postoperatively. The diagnosis is radiological, renal angiography being the definite procedure although a reduction of kidney size observed at urography may indicate the vascular lesion.     

Abdominal aortic coarctation inducing aortic occlusion and renovascular hypertension.

Abdominal aortic coarctation is a rare, non-atherosclerotic disease. It is a functionally significant at an early age when associated with aortic branch stenosis and renovascular hypertension. The pathogenesis of aortic constrictive lesions remains unknown, but may be related to developmental error or aortic growth arrest and various hypotheses have been reported. When the renal arteries are involved by the coarctation, severe hypertension is common at an early age and in untreated patients, life-threatening complications commonly occur. Patients who reach the age of 40 years generally have the coarctation below the renal arteries but even when the renal arteries are not involved by the coarctation, renovascular disease may still occur due to secondary atherosclerosis. Aortic thrombosis secondary to abdominal aortic coarctation with renovascular disease and lower limb ischemia, occurring in a 63-year old woman, is reported.     

Traumatic renal artery occlusion.

Six cases of complete occlusion of the main renal artery and one case of incomplete renal artery occlusion secondary to blunt abdominal trauma are reported, and the literature reviewed. The reported cases are analyzed as to clinical and radiographic findings, and mechanism of injury. Left renal artery occlusion occurs due to intimal fracture secondary to deceleration forces on the abdomen. Right renal artery occlusion results from direct epigastric trauma and compression of the artery against the vertebral column. An intravenous urogram with nonvisualization of the affected kidney should lead to immediate angiography. Arteriography is diagnostic, showing abrupt occlusion of the renal artery several centimeters beyond its origin, or before occlusion, an intimal flap.     

Surgical treatment of complete renal artery occlusion in pediatric patients

Two children, 8 and 11 years old, presented with severe hypertension secondary to unilateral and bilateral total occlusion of the renal arteries, respectively. The 11-year-old developed sudden anuria requiring hemodialysis. Successful surgical reconstruction allowed recovery of renal function and normal blood pressure in both patients. Routine blood pressure control in the pediatric patient population, high clinical awareness, and judicious use of arteriography, provide the best chance for early diagnosis of renovascular disease. Surgical revascularization or transluminal angioplasty are the treatment modalities of choice in appropriately selected cases of renal artery stenosis. When total occlusion occurs, retrieval or preservation of renal function can be successfully achieved by direct surgical intervention.     

Effect of renal revascularization by splenic artery implantation on experimental renovascular hypertension

The antihypertensive effect of implanting a branch of the splenic artery into the renal cortex of uninephric rats with renal artery stenosis is presented. Systolic blood pressure determinations were performed by Doppler auscultation over the ventral aspect of the tail distal to a sphygmomanometer cuff.     

Progression of medial fibroplasia of the renal artery and the development of renovascular hypertension.

A 33-year-old normotensive white women was rejected as a kidney donor because arteriography disclosed medial fibroplasia of the right renal artery. 44 months later she became hypertensive and arteriography revealed progression of the lesion. When renal venous renin assay demonstrated lateralization, a saphenous vein aortico-distal right renal arterial bypass graft was done; her blood pressure has been normal for more than 2 years since. Such patients should not donate kidneys because the course of renal arterial dysplastic lesions cannot be predicted.