Atheroembolic renal disease: effect on morbidity and survival after revascularization for atherosclerotic renal artery stenosis

PURPOSE: Atheroembolic renal disease is increasingly found in older patients with general atherosclerosis. We evaluated the impact of atheroembolic renal disease on morbidity and survival after surgical revascularization for atherosclerotic renal artery stenosis. MATERIALS AND METHODS: The study group comprised 44 patients who underwent surgical revascularization for atherosclerotic renal artery stenosis and concomitant intraoperative renal biopsy. Renal biopsy specimens were reviewed by a pathologist and evaluated for the presence or absence of atheroemboli, and the presence and severity of arteriolar nephrosclerosis. Postoperative patient data were reviewed to evaluate survival, and the incidence of renal and systemic morbid events. Patients were followed for 1 to 14.5 years (median 6.2) after surgical revascularization. RESULTS: Atheroembolic renal disease was identified in the intraoperative biopsy specimen in 16 patients (36%, group 1) and was absent in 28 (64%, group 2), termed groups 1 and 2. Atheroembolic renal disease correlated significantly with decreased patient survival. The 5-year survival in groups 1 and 2 was 54 and 85%, respectively (p = 0.011). Similarly the incidence of systemic atherosclerotic complications was significantly higher in group 1 than group 2 (86 versus 58%, p <0.05). In addition, renal or renovascular complications developed in more group 1 than group 2 patients (p = 0.07). There was no significant association between the presence or severity of arteriolar nephrosclerosis and postoperative survival or morbid events. CONCLUSIONS: Our results indicate that atheroembolic renal disease is associated with decreased survival and an increased incidence of atherosclerotic morbid events after surgical revascularization for atherosclerotic renal artery stenosis. This information may be useful for therapeutic decision making in patients with atherosclerotic renal artery stenosis.     

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.     

Surgical and radiological management of renovascular hypertension in a developing country

PURPOSE: We determined the long-term outcome of radiological and surgical intervention in young patients with renovascular hypertension. MATERIALS AND METHODS: Between 1989 and 2001, 85 patients with a mean age +/- SD of 21 +/- 10.3 years, including 59 with Takayasu's arteritis (TA) and 26 with fibromuscular dysplasia (FMD), underwent radiological (percutaneous transluminal angioplasty) or surgical treatment for renovascular hypertension due to renal artery stenosis. The technical success, complications and clinical response of each treatment were compared. RESULTS: Of the patients 29 with TA and 20 with FMD underwent a total of 56 balloon angioplasties. Technical success was achieved in 94.58 renal units with a clinical response in 41 patients (83.9%). However, the re-stenosis rate was 24.13% in TA and 10% in FMD cases. A total of 41 surgical procedures were performed in the 28 and 7 patients with TA and FMD, respectively, including aortorenal bypass with vein in 12, and with a polytetrafluoroethylene graft in 4, lienorenal bypass in 4, iliorenal bypass in 2, gastroduodenal bypass in 1, autotransplantation in 1, nephrectomy in 14 and partial nephrectomy in 2. The clinical response rate to renal revascularization procedures was 94.4%, whereas it was only 50.0% for nephrectomy/partial nephrectomy during a median followup of 42 months (range 9 to 96). CONCLUSIONS: Percutaneous transluminal angioplasty and renal revascularization provide comparable long-term results in the management of renal artery stenosis due to TA and FMD. Although it is technically complex, surgery for TA is safe and effective. However, the rate of re-stenosis following angioplasty for TA is higher compared with FMD.     

The role of renal autotransplantation in pediatric and young adult patients with renal artery disease

From 1977 to 1984, renal autotransplantation was attempted in 16 pediatric and young adult patients with renal artery disease, ranging in age from 10 months to 21 years. Renal revascularization was indicated as treatment for severe hypertension in 15 patients and to prevent rupture of an arterial aneurysm in one patient. The reasons for undertaking renal autotransplantation were branch renal artery disease requiring extracorporeal revascularization (n = 14), abdominal aortic hypoplasia (n = 1), and renal artery disease in a small infant (n = 1). Renal revascularization was successfully accomplished in 14 of 16 patients, including one patient who underwent staged bilateral extracorporeal repairs. Obliteration of the inferior vena cava and iliac veins precluded autotransplantation in one patient and a nephrectomy was done. In one patient extracorporeal ligation of an inaccessible renal arterial branch was accomplished with autotransplantation. Currently all 16 patients are normotensive with excellent renal function. Extracorporeal surgery and autotransplantation have been important additions to the surgical armamentarium for renal artery disease.     

The role of renal autotransplantation in complex urological reconstruction

From 1972 to 1988, 108 patients underwent renal autotransplantation for renal artery disease (67), ureteral replacement (27), or renal cell carcinoma present bilaterally or in a solitary kidney (14). The most common indication for renal autotransplantation was to allow extracorporeal repair of complex branch renal artery lesions. Of the 54 patients in this group technically satisfactory branch renal arterial reconstruction and a successful clinical outcome were achieved in 52 (96%). Renal autotransplantation is the treatment of choice in these patients and also in selected children with main renal artery disease. Renal autotransplantation provided excellent results in 25 of 27 patients (92%) who required replacement of all or a major portion of the ureter. Over-all renal function was well preserved in these patients and only 1 has experienced chronic bacteriuria. Renal autotransplantation is a useful alternative to ileal interposition in this setting. Extracorporeal partial nephrectomy and renal autotransplantation were successful in 12 of 14 patients (85%) undergoing a nephron-sparing operation for renal cell carcinoma. In situ techniques are associated with less morbidity and currently are preferred in this group.     

Renovascular hypertension. 8 years experience of a vascular surgery centre

AIM: The aim of this study was to evaluate the technical success and clinical outcome of surgical revascularization, angioplasty and/or stenting for renal artery stenosis (RAS) in patients with renovascular hypertension (RVH). The secondary aim was to identify independent negative predictors of blood pressure control after successful renal revascularization. METHODS: From January 1998 to July 2006, we treated 97 cases of RAS in 83 RVH patients. Inclusion criteria were RAS > or =80% associated with hypertension refractory to medical control with at least three drugs including a diuretic. Therapeutic options were surgical revascularization in 15 cases (11 renal endarterectomies, 4 aortorenal bypasses) and endoluminal treatment in 82 (14 balloon angioplasties, 68 stents). RESULTS: Technical success was 100% for both surgical and endovascular procedures; 13 cases of restenosis (> or =80%) were detected: 12 (14.6%) in the endoluminal group and one (6.6%) in the surgical group (P=0.68). During the follow-up period (average 37 months, range 6-94), blood pressure control improved in 43% of patients, disease stabilized in 37% and the natural course of RVH deteriorated in 20%. Multivariate Cox regression analysis showed that only a long history of antihypertensive drug use was a predictor of inefficacy of blood pressure control after revascularization (P<0.04). CONCLUSION: The complete resolution of RVH associated with severe RAS appears unrealistic in several cases. Early and long-term results in terms of technical success and restenosis were acceptable and similar for surgical and endovascular renal intervention. An early diagnosis of RVH could improve the control of hypertension after successful renal revascularization.     

Therapeutical aspects of intrarenal artery aneurysms

The relative infrequency of aneurysms of the branches of the renal artery produces some indecision as to the surgeon's therapeutical choice. The purpose of this study is to carefully examine the indications for surgical treatment and to select precise therapeutical criteria on the basis of 8 patients in whom aneurysms of the main renal artery or of its branches were diagnosed from 1978 to 1986. In 1 patient, the disease was bilateral with a ruptured main artery aneurysm. 5 aneurysms were treated surgically (the ruptured one by nephrectomy, 2 by ex situ revascularization and 2 by in situ revascularization). In the remaining cases, only periodical controls were performed. In 4 surgically treated patients, angiographic follow-up demonstrated a regular renal revascularization and in 1 patient a thrombosis on the site of the anastomosis. On the basis of personal experience, surgical treatment is required for aneurysms larger than 1.5 cm in size without or with partial calcification, aneurysms occurring in pregnant women or in patients likely to conceive in the future, expanding aneurysms, and renin-mediated hypertension. The introduction of microsurgical techniques and renal preservation makes it possible for the urologist to chose between various therapeutical means for the treatment of intrarenal aneurysms. Reconstruction of anatomical continuity of the arterial supply avoiding unnecessary operative demolishment is feasible.     

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.     

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.     

Renal Artery Revascularization in Combination with Infrarenal Aortic Reconstruction

Associated stenosis of one or both renal arteries is not uncommon in patients with infrarenal aortic disease (aneurysm or occlusive disease) requiring surgical repair. The purpose of this retrospective study was to analyze the short- and long-term outcome of concomitant renal artery and aortic reconstruction. The present series includes 39 consecutive concomitant procedures. Simultaneous aortic and renal artery reconstruction was performed in a total of 39 (7.2%) of the 540 patients who underwent elective infrarenal abdominal aortic repair between 1987 and 1996. There were 33 men and 6 women with a mean age of 66.7 years. Twenty-eight patients presented hypertension and 7 presented renal insufficiency associated with hypertension. In all cases, the indication for operative treatment was aortic disease, i.e., aortic aneurysm in 20 cases and occlusive aortoiliac disease in 19 cases. A total of 51 renal artery revascularization procedures were performed, including bypass in 40 cases, transposition in 7, and endarterectomy in 4. Combined aortic and renal artery reconstruction gives good short- and long-term results comparable to those of isolated aortic surgery. On the basis of these findings, we think that concomitant repair is the strategy of choice for patients presenting renal artery stenosis associated with infrarenal aortic disease requiring surgical therapy.     

The occluded renal artery: An ongoing surgical challenge

Nephrectomy and revascularization are currently the preferred options in the management of the chronically occluded renal artery in patients with renovascular hypertension or renal insufficiency. We review our experience with these two options including early and late functional outcome. Between December 1982 and August 1993, chronic occlusion of the main renal artery was documented in 30 patients. Patients were categorized with respect to surgical intervention: group I underwent nephrectomy (on the occluded side) plus contralateral revascularization and group II underwent revascularization of the occluded renal artery. The median age at the time of operative intervention was 63 years; 53% of the patients were women and 47% were men. Hypertension was poorly controlled (>-3 medications) in 19 patients, and the preoperative serum creatinine level was > 1.8 mg/dl in 24 patients (mean 2.6±1.4 mg/dl). There were 16 patients in group I and 14 patients in group II, and there were no perioperative deaths. Estimated glomerular filtration rate (>-7 days after operation) was either unchanged or improved in 15 of 16 patients in group I and in 13 of 14 in group II, one of whom became dialysis dependent. Follow-up data were available for 25 of 30 (83%) patients (mean 45 months; range 1 to 108 months). Excluding one early failure, 10 of 13 patients in group I and 7 of 11 in group II did not have end-stage renal disease at last follow-up. Overall, hypertension was cured or improved in 16 of 21 patients. Revascularization as the preferred method of treatment of the occluded renal artery offers the prospect of renal salvage. Nonetheless, in the majority of properly selected patients, adequate renal function may be sustained and satisfactory blood pressure control achieved after nephrectomy with contralateral revascularization.Presented at the Eighteenth Annual Meeting of the Southern Association for Vascular Surgery, Scottsdale, Ariz., January 26–29, 1994.     

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.     

Post-Transplant Renal Artery Stenosis: Impact of Therapy on Long-Term Kidney Function and Blood Pressure Control

Purpose

We assessed the long-term outcome of different treatment methods for transplant renal artery stenosis.

Materials and Methods

Outcome data for 23 patients with transplant renal artery stenosis treated during a 16-year period were reviewed and analyzed.

Results

There was a higher incidence of renal artery stenosis in cadaveric donor kidneys compared to living donor kidneys (2 percent versus 0.3 percent, p less than 2), and in cadaveric kidneys from pediatric donors less than 5 years old compared to those from adults (13.2 percent versus 1.3 percent, p less than 0.01). Six patients underwent primary medical treatment for renal artery stenosis, with a successful outcome in 4 (mean followup plus or minus standard error 57 plus/minus 22 months) and failure in 2. Of the patients 16 were treated with percutaneous transluminal angioplasty, including 12 who were cured or improved with respect to hypertension (followup 44.7 plus/minus 7.6 months). Five patients underwent surgical revascularization for renal artery stenosis with postoperative improvement of hypertension (followup 18.8 plus/minus 11.6 months). Overall, 21 of 23 patients (91 percent) were treated successfully for transplant renal artery stenosis with cure or improvement of associated hypertension. Posttreatment renal function was stable or improved in 18 patients, while renal function deteriorated due to parenchymal disease in 3.

Conclusions

Most patients with transplant renal artery stenosis can be treated successfully. Percutaneous transluminal angioplasty is the initial interventive treatment of choice for high grade renal artery stenosis. Surgical revascularization is indicated if percutaneous transluminal angioplasty cannot be done or is unsuccessful.     

Evaluation and preparation for surgical treatment of renal artery disease

The diagnosis of renovascular disease and renovascular hypertension is outlined. A comparison and analysis of the advantages of three forms of treatment are made. These include medical management, percutaneous transluminal coronary angioplasty, and surgical intervention. Selection of patients for revascularization to preserve renal function is discussed, and guidelines for determining renal salvageability are presented. Surgical revascularization is the treatment of choice for patients with ostial atherosclerotic renal artery disease, branch renal artery disease, or a renal artery aneurysm.     

Middle aortic syndrome. Effectiveness and durability of complex arterial revascularization techniques.

Middle aortic syndrome typically occurs as severe hypertension in young patients who have weak or absent femoral pulses and an abdominal bruit. It results from a diffuse narrowing of the distal thoracic and abdominal aorta, commonly involving the visceral and renal arteries. The clinical presentation, angiographic assessment, and surgical outcome of 10 patients (mean age: 19.5 years) who underwent one-stage revascularization for middle aortic syndrome were reviewed to determine the effectiveness and durability of one-stage revascularization techniques to relieve these complications. All patients were hypertensive (mean blood pressure: 176 mmHg); six (60%) had severe, poorly controlled hypertension, two of whom had previous failed operations for renovascular hypertension and one who presented with malignant hypertension and acute renal failure. Five patients had disabling myocardial insufficiency, only one of whom had documented coronary artery disease. Four patients had intermittent claudication. Aortography showed variable length high-grade midaortic stenosis, nine had visceral artery involvement, and eight had renal artery involvement. All patients underwent one-stage revascularization by a variety of autogenous and prosthetic techniques. The postoperative recovery was uncomplicated in eight of nine patients and was often associated with dramatic reduction in blood pressure. There was a single death from disruption of the thoracic anastomosis in a patient who had diffuse cystic medial necrosis of the aorta. Arterial biopsy in nine patients indicated evidence for both acquired and congenital origins of the midaortic stenosis. Late follow-up evaluation (mean: 4.1 years) showed normal growth and development, preservation of renal function, and relief of myocardial insufficiency in all patients. Seven patients (77%) are cured of their hypertension, and two (23%) have only mild hypertension. These results indicate that one-stage revascularization of patients with middle aortic syndrome can result in effective and durable relief of these severe life-threatening complications.     

Use of the gastroduodenal artery in right renal artery revascularization

Of 15 patients having revascularization of the right renal artery with the use of the hepatic circulation from May 1984 through March 1987 at the Massachusetts General Hospital, eight patients had this accomplished with end-to-end anastomosis of the gastroduodenal artery and right renal artery. Operative indications were acute azotemic renal failure (three patients), poorly controlled renovascular hypertension (four patients), and staged repair of bilateral renal artery disease (one patient). All revascularizations were successful in restoring renal function or rendering hypertension manageable and were assessed by means of renal flow scans, celiac angiography, or return of function in those patients with a solitary, functioning kidney. All patients survived the operation with one late death caused by myocardial infarction after abdominal aortic aneurysm repair. The gastroduodenal artery may be used as the source for arterial inflow in revascularization of the right renal artery by end-to-end anastomosis in approximately 50% of instances, conferring the advantage of the use of only one anastomosis and obviating the long-term possibility of vein graft failure.     

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.     

Total arterial coronary revascularization and factors influencing in-hospital mortality.

OBJECTIVE: To determine if arterial conduit selection or more efficient arterial revascularization techniques influence in-hospital mortality. METHODS: Data from patients undergoing coronary artery bypass surgery at Royal Melbourne Hospital, Australia, between 1 January 1996 and 30 June 1998 (n = 1681) was collected prospectively. Logistic regression analysis was performed. RESULTS: Independent preoperative predictors of increased in-hospital mortality included renal failure, redo coronary artery surgery and intra-aortic balloon pump use. In-hospital mortality for total arterial revascularization 0.7%, radial artery use 0.9%, pedicled arterial revascularization 0.2%, composite arterial conduit 0.4%, and the exclusive Y graft operation 0.3%. These were all associated with reduced in-hospital mortality. Mortality when vein graft was used was 2.9%. Most patients received total arterial revascularization, which was considered the primary surgical strategy. CONCLUSION: Total arterial revascularization, radial artery use and complex arterial reconstructions were associated with reduced in-hospital mortality. Preoperative renal failure, intra-aortic balloon pump use and redo coronary surgery predicted greater in-hospital mortality.     

Renal and aortic localizations in Takayasu's disease

AIM OF THE STUDY: The aim of this work was to study the localizations of Takayasu's disease to the aorta and the renal arteries, the long-term results of their surgical treatment and the evolution of the disease with time. PATIENTS AND METHODS: From 1972 to 2000, 23 patients (16 females, 7 males) with aortic and/or renal lesions were operated on. Mean age was 19.5 +/- 12.4 years. Despite heavy medical treatment, all had severe and uncontrollable hypertension. Eighteen patients had associated lesions of the aorta and renal arteries, 5 had isolated lesions of the renal artery, 10 had lesions of mesenteric arteries, 6 had lesions of supra-aortic trunks. Percutaneous transluminal angioplasty of the renal artery (ies) was attempted in 4 cases and was unsuccessful in all. Due to bilateral lesions in 12 patients, the surgical treatment consisted of 3 nephrectomies and 32 artery repairs of which 23 were performed by conventional in situ surgery and 9 by extracorporeal repair. An aortic bypass was performed in 7 patients and revascularization of other visceral arteries in 3. The follow-up extends from 1 to 18 years (mean: 5). RESULTS: There was no mortality. Three postoperative thromboses of repairs occurred: 2 of renal artery and 1 of mesenteric artery. Immediate results on blood pressure control were as follows: complete cure in 18 patients (78%), improvement in 3 (13%) and failure in 2 (9%). During the follow-up, evolution of the disease was observed in 10 patients (43%): 4 repeat stenoses of renal arteries due to aggravation of aortic lesions requiring reoperation in 2 patients, 3 aggravation of aortic lesions requiring an aortic bypass in 1 patient, 1 coronary insufficiency requiring a coronary bypass at 8.5 years. During the long-term follow up, due to secondary anatomical deteriorations, the results of surgery on blood pressure control were as follow: complete cure in 14 patients (61%), improvement in 4 (17%), failure in 5 (22%). CONCLUSION: Surgical treatment of reno-aortic lesions in Takayasu's disease must be reserved to patients whose arterial hypertension is uncontrollable despite heavy medical treatment. Results are altered by the evolution of the disease either locally or in other territories and that may require several operations. Due to frequently occurring late degeneration of repairs, surgical therapy must be carefully decided and patients' follow-up must be prolonged.     

Successful delayed bilateral renal revascularization during active phase of Takayasu's arteritis

Successful bilateral renal revascularization was performed 24 days after the development of angiotensin converting enzyme-inhibitor–induced bilateral renal artery thrombosis and anuric acute renal failure in a patient with Takayasu's arteritis. Excellent results were obtained after an unusually long ischemic time for a patient with active-phase disease. The outcome suggests that aggressive surgical revascularization can benefit patients with renal failure caused by renal arterial occlusion during the active phase of Takayasu's arteritis. (J Vasc Surg 1998;27:552-4.)