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.     

Surgery after failed percutaneous renal artery angioplasty.

PURPOSE: This retrospective review describes the surgical management of 51 patients after failed percutaneous renal artery angioplasty (F-PTRA). METHODS: From January 1987 through June 1998, 51 consecutive patients underwent surgical repair of either atherosclerotic (32 patients) or fibromuscular dysplastic (FMD; 19 patients) renovascular vascular disease after F-PTRA. These patients form the basis of this report. Surgical repair was performed for hypertension (29 patients with atherosclerosis: mean blood pressure, 205 +/- 34/110 +/- 23 mm Hg; 18 patients with FMD: mean blood pressure, 194 +/- 24/118 +/- 18 mm Hg) or ischemic nephropathy (20 patients with atherosclerosis: mean serum creatinine level, 2.0 +/- 0.8 mg/dL; three patients with FMD: mean serum creatinine level, 2.0 +/- 1.1 mg/dL). Emergency operation was required in four patients for acute renal artery thrombosis (one patient with atherosclerosis, one patient with FMD), renal artery rupture (one patient with atherosclerosis), or infected pseudoaneurysm (one patient with atherosclerosis). Operative management, blood pressure and renal function response to operation, and dialysis-free survival rate were examined and compared with 487 patients (441 patients with atherosclerosis, 46 patients with FMD) treated by operation alone. RESULTS: Among the patients with atherosclerotic renovascular disease, there were three postoperative deaths (9.4%) after repair for F-PTRA. Secondary operative repair was associated with emergent repair or nephrectomy in 16% of cases, while more extensive renal artery exposure and more complex operative management was required in 50% of patients with atherosclerosis and 65% of patients with FMD repaired electively. Among the 28 operative survivors with hypertension and atherosclerotic renovascular disease, blood pressure benefit after F-PTRA was significantly lower when compared with patients with atherosclerosis who underwent treatment with operation only (57% vs 89%; P <.001). However, blood pressure benefit in the 19 patients with FMD did not differ (89% vs 96%). Among the 28 patients with atherosclerosis, preoperative estimated glomerular filtration rate (EGFR) as compared with postoperative EGFR was significantly increased (47.4 +/- 4.2 mL/min/1.73m(2) vs 56. 6 +/- 5.1 mL/min/1.73m(2); P =.002). However, EGFR prior to PTRA was not significantly different from postoperative EGFR (51.6 +/- 3.4 mL/min/1.73m(2) vs 56.6 +/- 4.9 mL/min/1.73m(2); P =.121). As compared with patients with atherosclerosis who underwent treatment with operation alone, there was no difference in the dialysis-free survival rate. CONCLUSION: Operative repair after F-PTRA was altered in 59% of the patients with atherosclerosis and in 68% of patients with FMD. Blood pressure benefit for patients with FMD was unchanged after F-PTRA. However, the blood pressure benefit was significantly decreased among patients with atherosclerosis. Decreased EGFR after F-PTRA was recovered with operative renal artery repair. However, postoperative EGFR as compared with EGFR prior to PTRA was unchanged. Blood pressure and renal function response after F-PTRA for atherosclerotic renovascular disease warrants further study.     

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.     

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.     

Reconstructive surgery of the renal arteries in Takayasu's disease

Between 1977 and 1989, 24 patients (19 women and 5 men) with Takayasu's disease underwent renal artery restoration. Mean age was 32.9 years (range 15 to 60 years). All patients were hypertensive and three had moderate, chronic renal failure. Renal artery lesions were unilateral in two patients (8%), bilateral in 17 patients (71%), and unilateral in a solitary kidney in five (21%). Associated lesions of the thoracic or abdominal aorta or both were found in 22 patients (92%). Lesions of the visceral arteries found located in 21 patients (87%) and of the supraaortic trunks in 16 (67%). Initial revascularization of the supraaortic trunks was performed in four patients (17%). Renal artery revascularization was unilateral in 11 patients (46%) and bilateral in 13 (54%). Concomitant aortic reconstruction was performed in 21 patients (87%), visceral artery reconstruction in 17 patients (71%), and supraaortic surgery in seven (29%). One patient who underwent combined aortic and renal artery restoration, and in whom visceral artery involvement had been neglected, died postoperatively of heart failure and intestinal infarction. Three patients were lost to follow-up. Twenty patients have been followed for a mean of 61.3 months (range 4 to 124 months). One patient died at 89 months of intestinal infarction secondary to embolization originating from a false aortic aneurysm. Five repeat renal revascularizations were required in four patients. Hypertension is presently cured in 12 patients (63%), improved in six (31%), and unchanged in one (6%). Even though surgical treatment of arterial lesions in Takayasu's disease often includes complex and repeat revascularization procedures, satisfactory long-term results suggest the use of renal artery reconstruction in this affliction. Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Strasbourg, France, June 23–24, 1989.     

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.     

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.     

Should percutaneous transluminal renal artery angioplasty be applied to ostial renal artery atherosclerosis?

Purpose: The purpose of this study was to review the results of percutaneous transluminal renal artery angioplasty (PTRA) in patients with atherosclerosis to assess safety, anatomic and functional outcome, and differences in outcome between ostial and nonostial lesions.Methods: We used retrospective review of 52 consecutive patients who had undergone attempted PTRA for renal artery atherosclerosis during the calendar years 1987 to 1992.Results: Fifty-two patients had 60 renal arteries on whom PTRA was attempted. The mean age was 68 years. Atherosclerosis was generalized in 81% of the patients. The indication for angioplasty was salvage of functioning renal parenchyma in 81% of patients. Eight patients were undergoing dialysis at the time of attempted PTRA. Five arteries (8%) could not be dilated. There were one cardiac death and two arterial complications requiring surgery within 30 days. Thirty-five percent of patients with available angiograms had an anatomic improvement above a threshold of one stenotic group (30% to 40% diameter improvement), with residual stenosis of less than 50%. Half of patients treated for hypertension had improvement in their hypertension. Overall, there was no change in creatinine levels before and after the procedure. Four of eight patients undergoing dialysis at the time of PTRA were able to discontinue dialysis during follow-up. Four patients (11%) required surgical bypass and five patients (14%) required chronic dialysis during follow-up.Conclusions: Modest success at low risk can be expected from PTRA in a group of patients with severe atherosclerosis. No significant difference in results between ostial and nonostial lesions was noted. (J VASC SURG 1995;21:909-15.)     

Indication, surgical technique and outcome of orthotopic renal transplantation

PURPOSE: We review the indication, surgical technique and outcome of orthotopic renal transplantation. MATERIALS AND METHODS: The medical records of 1,000 patients who underwent renal transplantation at our institution between August 24, 1993 and August 1, 2000, as well as orthotopic renal transplantation were reviewed. RESULTS: Orthotopic renal transplantation was performed in 4 males and 1 female with severe iliac atherosclerosis or retained bilateral iliac fossa kidney transplant. Mean patient age was 56 years. There were 2 patients who received kidneys from living related donors, and 3 underwent cadaveric renal transplantation. Left orthotopic renal transplantation was successful in 4 cases, and 1 was converted to iliac fossa renal transplant because of a pulseless splenic artery and renal artery thrombosis after native renal endarterectomy. Orthotopic renal revascularization was done with splenic artery in 2, native renal artery in 2 and left renal vein in all 4 patients. Urinary tract reconstruction was performed with stented (2) or nonstented (2) ureteroureterostomy. Antibody induction, purine antagonists, calcineurin inhibitors and glucocorticoids were used for immunosuppression. Mean preoperative and 1-month postoperative serum creatinine was 7.9 and 1.3 mg./dl., respectively. Patient and graft survival was 100% during followup, which ranged from 6 months to 5 years. CONCLUSIONS: Despite the technical challenges, orthotopic renal transplantation in patients with unsuitable pelvic vessels can result in excellent patient and graft survival.     

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.     

Split renal function outcome after renal angioplasty in patients with unilateral renal artery stenosis

The general use of bilateral rather than separate renal function evaluation has led to the publication of conflicting results concerning the effect of percutaneous transluminal renal angioplasty (PTRA) on renal function, especially in patients with atherosclerotic renal artery stenosis. The aim of this study was to evaluate prospectively, in standardized conditions, split renal function (SRF) and GFR outcome after successful PTRA, by measuring single kidney GFR with synchronous inulin or (51)Cr-ethylenediaminetetraacetic acid clearance and (99m)Tc-diethylenetriamine pentaacetic acid scintigraphy, in a well-defined population of patients with unilateral renal artery stenosis. Thirty-two consecutive hypertensive patients (18 with atherosclerotic and 14 with dysplastic disease) with significant unilateral stenosis of the main native renal artery (> or = 60%) and normal renal function were included in the study. Renal and angiographic follow-up evaluations were performed 6 mo after PTRA. PTRA alone or combined with stenting (n = 2) was technically successful in all patients. Repeat PTRA was necessary in two patients, evaluated 6 mo after the second PTRA. Six mo after PTRA, total GFR had increased slightly but significantly in the 29 patients with positive lateralization indices. SRF and single-kidney GFR of the stenotic kidney increased significantly, whereas concurrently the GFR and SRF of the nonstenotic kidney decreased significantly. Six mo after successful PTRA reducing renal ischemia, a reversal of both the hypoperfusion of the stenotic side and the hyperperfusion of the nonstenotic side was observed, which was accompanied by a slight increase in total GFR.     

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.     

Renal artery revascularization with polytetrafluoroethylene bypass graft

Between January 1979 and December 1986, a total of 74 renal revascularizations were performed in 68 patients using the reinforced expanded polytetrafluoroethylene prosthetic graft. These 74 revascularizations represent 29% of 251 surgical renal revascularizations performed during the same period of time. Eight patients had a total of nine revascularizations in the emergency setting (group I) for ruptured suprarenal aneurysm or acute thrombosis of the renal arteries. Only one patient survived and six years later, his anatomic and functional results are satisfactory. Sixty-five revascularizations were performed electively in 60 patients (group II). This group consisted of 19 renal revascularizations alone, and 46 combined aortic and renal revascularizations. One patient died of respiratory complications two months after operation after his thoracoabdominal aneurysm was cured. Early repeat postoperative arteriography showed that six reconstructions had occluded (three major renal arteries, three polar arteries). One patient was lost to follow-up. The remaining patients were followed for a mean of 41 months. Follow-up arteriograms obtained during 1987 showed that there were two late occlusions and two distal anastomotic stenoses. Actuarial patency was 85 +/- 10% at 72 months. Polytetrafluoroethylene prosthetic grafts constitute a reliable material for renal revascularization and combined aortic and renal reconstruction in certain anatomic conditions.     

Evaluating patients with renal failure for renal artery stenosis with gadolinium-enhanced magnetic resonance angiography

The incidence and prevalence of end-stage renal disease (ESRD) continues to increase, especially in the elderly population. The role of renovascular disease in contributing to ESRD is still not well defined. The objective of this study was to determine the utility of gadolinium (Gd)-enhanced magnetic resonance angiography (MRA) in evaluating elderly patients with renal insufficiency for renal artery stenosis (RAS). A 7-month prospective study conducted in a tertiary referral center evaluated 40 consecutive patients with progressive renal insufficiency (18 men and 22 women; mean age, 70 +/- 5.6 [standard deviation] years) and high clinical suspicion for renovascular disease with Gd-enhanced MRA. Digital subtraction angiography (DSA) was obtained in only those patients with significant RAS detected by MRA. Twelve patients had significant RAS. Six of these patients had percutaneous transluminal renal angioplasty (PTRA), five patients had renal artery bypass surgery, and one patient had a stent placed after PTRA. Seventy-eight renal arteries were satisfactorily evaluated by MRA. Twenty-two renal arteries were evaluated by both MRA and DSA. Of the 12 significant stenoses detected by the MRA, 11 were confirmed by DSA and 1 was confirmed at the time of surgical revascularization. It is concluded that Gd-enhanced MRA is a useful test for the evaluation of RAS in patients with compromised renal function.     

Angioplasty does not affect subsequent operative renal artery revascularization

BACKGROUND: Although increased application of percutaneous renal artery angioplasty and stenting has facilitated nonoperative renal revascularization, patient outcomes after failed angioplasty are not established. METHODS: Renal artery revascularization was performed in 31 patients (38 arteries) from 1993 to 1999. Twenty patients underwent primary surgical repair, and 11 patients underwent secondary reconstruction after angioplasty (n = 7) or angioplasty and stenting (n = 4). Before operation, all patients had severe hypertension (blood pressure 166+/-5.2/92 +/- 2.7 mm Hg) that required an average of 3.0 +/- 0.2 medications for control. In addition, 12 patients (primary 45% vs secondary 27%; P = NS) had evidence of renal insufficiency (creatinine > or =1.7 mg/dL). RESULTS: There was no difference between primary and secondary procedures in the length of hospital stay (12+/- 1.4 vs. 12+/-3.2 days; P = NS), major morbidity (10% vs. 18%; P = NS) or perioperative mortality (overall mortality 2 of 31; primary 5% vs secondary 9%; P = NS). The majority of patients demonstrated improvement or cure of hypertension (primary 94% vs secondary 90%; P = NS) and stable or decreased creatinine (primary 74% vs secondary 82%; P = not significant). Overall survival (mean follow-up 22+/-3.5 months) was 89%+/-5.7%. CONCLUSIONS: Although this surgical series does not address the true outcomes of renal artery angioplasty, the results suggest that renal artery angioplasty does not prejudice subsequent surgical outcomes in patients who are carefully followed after angioplasty.     

Use of the thoracic aorta for renal arterial reconstruction

Purpose: Thoracic aortorenal bypass is a new technique for surgical renal revascularization in patients with severe atherosclerosis of the abdominal aorta. In such cases, the thoracic aorta is often free of disease.Methods: From 1989 to 1992, thoracic aortorenal bypass was performed in 23 patients with hypertension, abdominal aortic atherosclerosis, and celiac artery stenosis; in 21 patients, renal artery stenosis was present bilaterally or in a solitary kidney.Results: There was one operative death. Among the remaining 22 patients, hypertension was cured or improved after operation in 19 (86%), and renal function was improved or stable in 21 (95%).Conclusions: Thoracic aortorenal bypass has several advantages and is a useful alternative to abdominal aortic replacement in selected older patients who require renal arterial reconstruction. (J VASC SURG 1994;19:605-9.)     

Clinical outcome and health care costs in renal revascularization--percutaneous transluminal renal angioplasty versus reconstructive surgery.

Clinical outcome and health care costs related to investigation, treatment with either percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery, and follow-up of patients with renovascular hypertension with or without uraemia were analysed in 21 PTRA-treated and 16 operated patients. Most renal artery stenoses were atherosclerotic. Nineteen PTRAs were successful or partly successful and two failed; the patients were operated on without delay. All surgical reconstructions were successful. In the PTRA group six restenoses occurred after 4-24 months. Four were treated with re-PTRA and two were operated on. No recurrence occurred in the operated group. At the end of follow-up (median 48, range 9-84 months) primary patency in the PTRA group was 69 per cent and in the operated group 100 per cent. Secondary patency in the PTRA group was 100 per cent. With regard to hypertension, including primary and secondary results, 19 out of 21 (90 per cent) patients were improved in the PTRA group and 13 out of 16 (81 per cent) in the operated group. The diagnostic and preprocedure costs were the same in both groups, whereas the procedure and postprocedure costs were lower in the PTRA group. However, the follow-up costs were considerably higher because of recurrences and their treatment in the PTRA group. The total median cost of reconstructive surgery was 12 per cent higher than for PTRA, a non-significant difference.     

Angioplasty of the renal artery: antihypertensive and renal effects

Percutaneous transluminal angioplasty of the renal artery (PTRA) has been increasingly used over the past 20 years for treating renovascular hypertension (RVH). From the experience gathered so far it is justified to state that this technique is the first choice for patients with fibromuscular renal artery stenosis (RAS) because their cure rate is 50% and 42% improve. In contrast in patients with atherosclerotic RAS the cure rate after PTRA is 8-10% although 40-50% still improve. Since PTRA is associated with a 23% rate of major/minor complications and 30% restenosis (23% requiring stent implantation), it is obvious that in patients with atherosclerotic RAS the decision to attempt this procedure must be taken after careful selection of those who may actually benefit from the dilation. PTRA can be used more extensively for salvaging the function of the ischemic kidney than for treating hypertension because of the progressive nature of the atherosclerotic RAS and the lack of effective agents against such progression. After PTRA 35% of patients have some improvement in renal function and another 35% are stabilized. Yet most studies addressing the renal effects of PTRA suffer the limitation of having used serum creatinine levels as an indicator of glomerular filtration rate (GFR). More recent studies which used radioisotopic techniques to evaluate the changes of GFR induced by PTRA in the stenotic kidney indicate that after a successful procedure the increase is, on average, 8-10 ml/min. Interestingly it appears that this improvement is slower in kidneys of patients with atherosclerotic RAS than in those with fibromuscular RAS.     

The role of arterial reconstruction in spontaneous renal artery dissection

Spontaneous renal artery dissection is an uncommon cause of renovascular hypertension, usually associated with fibromuscular dysplasia. Among reported nonautopsy cases (N = 80), arterial reconstruction has seldom been attempted (N = 21) and the outcome has frequently been poor (48% clinical failure rate). This is attributed in part to the frequent involvement of renal artery branches by the dissection. Furthermore, the report of spontaneous reversion to normotension among patients treated medically has also clouded the role of surgery in this disease. Since progress in the technique of renal artery repair now allows successful treatment of anatomically complex lesions, we reviewed our experience with arterial reconstruction in the management of spontaneous renal artery dissection to determine the frequency of and factors correlating with cure after operative repair. Ten patients (eight men, two women; mean age, 39.3 +/- 5.9 years) were admitted with severe hypertension (10/10), often associated with neurologic symptoms, hematuria, or flank pain (8/10). Serum creatinine was elevated in only two patients. Angiography demonstrated changes consistent with fibromuscular dysplasia in 7 of 10 patients and evidence of dissection in 6 of 10. Bilateral disease was present in three patients. Only five patients had a single renal artery on the involved side. The dissection extended into the primary branches in 8 of 10 patients and involved both renal arteries in four of the five patients with two arteries. Histologic study confirmed fibromuscular dysplasia in six and intramural dissection in all operative specimens. Five patients underwent revascularization (in one case requiring the ex vivo technique), with use of hypogastric artery as a conduit in four of five or resection and primary reanastomosis in one of five. Three patients became normotensive, and two returned to their previous level of blood pressure control. Follow-up averaged 14.5 years. Two patients underwent nephrectomy after exploration demonstrated nonreconstructible vessels, and two underwent nephrectomy when intraoperative assessment of the kidney showed that revascularization had failed to adequately reverse extensive renal ischemia. After a mean follow-up of 14.6 years these patients remain normotensive, although two require antihypertensive medications. One patient was treated medically and is currently hypertensive off all medications. Nine of 10 patients have maintained a normal serum creatinine during follow-up. We conclude that renal revascularization is frequently successful in spontaneous renal artery dissection (five of seven, 71.4%) and results in sustained relief of hypertension with maximal conservation of renal tissue. This is important because of the young age at onset and the not infrequent occurrence of bilateral fibromuscular dysplasia, and even of dissection.(ABSTRACT TRUNCATED AT 400 WORDS)     

Branch renal artery repair with cold perfusion protection

PURPOSE: This retrospective review describes the use and clinical outcome of cold perfusion protection during branch renal artery (RA) repair in 77 consecutive patients. METHODS: From July 1987 through November 2006, 874 patients had open operative RA repair to 1312 kidneys. Seventy-seven patients (62 women, 15 men; mean age, 44 +/- 17 years) had branch RA reconstruction using ex vivo or in situ cold perfusion protection for 78 kidneys. Demographic data and surgical technique were examined. Blood pressure response and renal function were estimated. Patency of repair was determined by angiography and renal duplex ultrasound (RDUS) imaging. Primary RA patency was estimated by life-table methods. RESULTS: Seventy-eight RAs were repaired using ex vivo (49 kidneys) or in situ (29 kidneys) cold perfusion protection. Bilateral RA repair was performed in eight patients, with 13 repairs to solitary kidneys. RA disease included aneurysm (RAA) in 50, fibromuscular dysplasia (FMD) in 37, atherosclerosis in 5, and arteritis in 2; 16 patients had both FMD and RAA. Hypertension was present in 93.5% (mean blood pressure, 184 +/- 35/107 +/- 19 mm Hg; mean of 1.9 +/- 1.1 drugs). RA repair included bypass using saphenous vein in 69, hypogastric artery in 3, polytetrafluoroethylene (PTFE) in 2, composite vein/PTFE in 2, cephalic vein in 1, or aneurysmorrhaphy in 1. The eight bilateral RA repairs were staged. One patient required bilateral cold perfusion protection. One planned nephrectomy was performed at the time of contralateral ex vivo reconstruction. No primary nephrectomies were required for intended reconstruction. Each RA reconstruction required branch dissection and reconstruction (mean of 2.8 +/- 1.6 branches were repaired). Mean cold ischemia time was 125 +/- 40 minutes. Each kidney was reconstructed in an orthotopic fashion. Five early failures of repair required three nephrectomies and one operative revision. Based on postoperative angiography or RDUS, or both, primary patency of RA repair at 12 months was 85% +/- 5%; assisted primary patency was 93% +/- 4%. Among patients with preoperative hypertension, 15% were cured, 65% were improved, and 20% were considered failed. Early renal function was improved in 35%, unchanged in 48%, and worse in 17%. Four patients had perioperative acute tubular necrosis. No patient progressed to dialysis-dependence. CONCLUSION: Both ex vivo and in situ cold perfusion protection extend the safe renal ischemia time for complex branch RA repair and avoid the need for nephrectomy.