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Simultaneous Aortic Reconstruction and Bilateral Renal Revascularization: Is This a Safe and Effective Procedure?
KIDNEY TRANSPLANTAT[Ql,; AND RENOVASCULAR HYPERTENSION
1507
can p:irnvide life-saving therapy for these critically m patien.ts. Andrew C. Novick, M.D.
c,:a1.H:nues to yield satisfactory :results in the performance of renal artery bypass surgery. Andrew C. Novick, M.D.
Aortorenal Arterdal Autografts: The Last Two Decades
Simultaneous Aortic Reconstruction and Bilateral Renal Revascularization: Is This a Safe and Effective Procedure?
R. J. STONEY AND P. A. 0LOFSS0N, Department of Surgery, University of California, San Francisco, California
C. S. Ann. Vase. Surg., 2: 169-173, 1988 Arterial autografts were introduced nearly a quarter century ago at the University of California, San Francisco and have proven their value for replacement in many demanding arterial problems. Renal artery fibrodysplasia is one of the more common lesions treated with arterial autograft. Arterial autografts that ideally match the renal artery and its branches are procured from the patient's own internal iliac artery. Either straight or branched configuration are available depending on the replacement requirements. In-situ aortorenal autografts are employed for lesions of the main renal artery or primary branches. Ex vivo repair involves temporary nephrectomy, pulsatile hypothermic perfusion and precise micro-vascular repair with unrestricted exposure, illumination, and an unhurried pace with no threat of renal ischemic insult. Autografts are attached proximally to the side of the aorta and distally to the diseasefree end of the renal artery or a branch. The technique of arterial substitution for ex vivo repairs are identical except for the additional reanastomosis or reattachment of the renal vein. The arterial autograft exhibits the compliance characteristics which resemble a normal artery, maturation when used in the growing child, and durability essential for the long life span of this treated population. When the objective of a renal artery reconstruction is a normal renal arterial system, then the internal iliac artery autograft is the only choice.
Editorial Comment: The authors report experience with 143 patients undergoing renal revascularization in whom an arterial au.tograft was used to replace the diseased renal artery. The study includes 59 patients with branch renal artery disease, of whom 45 underwent ex vivo repair and autotransplantat.ion. The hypogastric artery was used in 92 per cent of these reconstruct.ions, Excellent clinical result§ were achieved with no mortality, only 3 cases of postoperative thrombo§is and with hyperte:1:rnion cured or improved postoperatively in 94 pel'.' cent of the patients. As the authors emphasize, arterial autografts comprise an excellent material for renal artery replacement 011 the basis of similar viscoelastic properties aJ11d longterm durability. The hypogastric artery is the arterial au.tograft of choice and may be used intact with its branches if :necessary. Currently, the major usefulness of this g:raft is in younger patients undergoing extracorpo:real revascularization for branch renal artery disease. The short length of the hypogastric artery often precludes its use for in situ aortorenal bypass to renal artery branches. Patients with fibrous dysplasia of the main renal artery currently are managed with percutaneous transluminal angioplasty. In patients with atherosclerotic renal artery disease the hypogastric artery usually is diseased as well and, thus, it cannot be used as a bypass graft. In such cases the sapherwus vein graft
M. D. MAPLES, T. L. KILGORE, JR., M. H. H. B. TYLER, G. H. MUNDINGER, JR. AND R. E. KENNEDY, Mississippi Baptist Medical Center and St. Dominic-Jackson Memorial Hospital, Jackson, Mississippi O'MARA,
MCMULLAN,
J. Vase. Surg., 8: 357-366, 1988 Between 1982 and 1987, 32 patients with severe autorenal atherosclerosis had simultaneous aortic and bilateral renal revascularization. All patients were hypertensive. Eighteen patients (56 % ) had renal insufficiency with a mean serum creatinine (SC) of 2.8 mg/dl. Nine patients had an aortic aneurysm; the remaining 23 patients had aortoiliac occlusive disease of varying severity. Aortic reconstruction was done with either a straight (six patients) or bifurcated (26 patients) Dacron graft. Renal revascularization was accomplished with either bypass (60 arteries) or transaortic endarterectomy (four arteries). One patient died of pulmonary embolism (operative mortality rate 3 %) . Beneficial blood pressure response was achieved in 28 of 31 survivors, (90%). Among the 18 patients with renal insufficiency, mean SC was 2.80 ± 1.18 mg/dl preoperatively and 1.65 ± 0.48 mg/di postoperatively (p <0.001). Among eight patients with severe renal dysfunction before surgery (SC greater than 3 mg/di), mean SC was 3.90 ± 0.85 mg/dl before and 1.79 ± 0.69 mg/dl after operation (p <0.001). In follow-up extending to 58 months (mean 27.6 months), five late deaths occurred; cumulative survival was 94% at 2 years and 60% at 4 years. There were no instances of worsening hypertension; one patient had deteriorating renal function. These results indicate that severe aortorenal atherosclerosis can be managed with simultaneous aortic reconstruction and bilateral renal revascularization at low operative risk. In addition, there can be high expectation of significant and persisting benefit in both hypertension and renal dysfunction after operation.
Editoria~ Comment: The author§ report on. a relatively small giroup of 32 patients who m:1de:rvvent simultaneous aortic and bilateral renal revascularizati.on. Renal revascula:rization was indicated as treatment for associated hypertension with or without renal insufficiency. Aortic replacement was necessitated by an aortic aneurysm or aortol.liac occlusive disease. The:re was 1 operative death (3 per cent). Of the 31 survivors hypertension was cu:red or improved in 28 (90 per cent) and postoperative .renal function wa§ stable or improved in 29 (93 per cent). The authors conclude that simultaneous aortic reconstruction and bilateral renal revascularization may be done with a low operative risk. They also recommend synchronous bilateral repair in the presence of bilateral renal artery stenosis. While excellent clinical :results were achieved in a difficult group of patients, these findings differ significantly from the prevailing view that is based on several studies involving larger numbers of patients. Data from several major centers for renal artery disease, including our own, 1 have documented operative mortality rates of
1508
KIDNEY TRANSPLANTATION AND RENOVASCULAR HYPERTENSION
10 per cent or more for combined aortic and renal reconstruction. Furthermore, operative mortality with this approach has been greater when both renal arteries are repaired compared to unilateral revascularization. This also was an important finding in the National Cooperative Study on Renovascular Hypertension. 2 In the present study, while there was only 1 operative death 3 patients suffered ischemic cerebral infarction postoperatively and there were 3 other major operative complications. In a careful review of available data on this issue there is little doubt that synchronous aortic and renal reconstruction carries an increased operative risk compared to either procedure done individually. In patients who require revascularization for atherosclerotic renal artery stenosis, avoidance of surgery on the badly diseased aorta has been an important strategy toward limiting operative morbidity and mortality. 3 Alternative techniques, such as hepatorenal and splenorenal bypass, have proved to be safe and effective in such cases. Most patients will achieve significant benefit from unilateral revascularization without the added risk of bilateral simultaneous repair. In patients who also require aortic reconstruction due to an aneurysm or symptomatic aortoiliac occlusive disease I believe that the safest approach is to perform staged renal and aortic repairs. This may not be possible if there is significant disease involving the hepatic and splenic arterial inflow. In this situation the risk of concomitant aortic reconstruction and renal revascularization must be weighed against the gravity of the existing clinical situation on an individual basis. Andrew C. Novick, M.D. 1. Tarazi, R. Y., Hertzer, N. R., Beven, E.G., O'Hara, P. J., Anton, G. E. and Krajewski, L. P.: Simultaneous aortic reconstruction and renal revascularization: risk factors and late results in eighty-nine patients. J. Vase. Surg., 5: 707, 1987.
2. Franklin, S.S., Young, J. D., Jr., Maxwell, M. H., Foster, J. H., Palmer, J.M., Cerny, J. and Varady, P.D.: Operative morbidity and mortality in renovascular disease. J.A.M.A., 231: 1148, 1975. 3. Novick, A. C., Straffon, R. A., Stewart, B. H., Gifford, R. W. and Vidt, D.: Diminished operative morbidity and mortality in renal revascularization. J.A.M.A., 246: 749, 1981.
Results of Renal Artery Balloon Angioplasty Limit its Indications
H. G. BEEBE, K. CHESEBRO, F. MERCHANT AND W. BUSH, Section of Vascular Surgery and Department of Radiology, Virginia Mason Medical Center, Seattle, Washington J. Vase. Surg., 8: 300-306, 1988 Percutaneous transluminal balloon angioplasty (PT A) of 83 renal artery lesions in 55 patients was done because of renal failure in eight patients, hypertension in 35, renal failure and hypertension in 11, and polycythemia in one patient. Early results in 38 patients with arteriosclerosis showed five (13%) were worse and 13 (34%) were unchanged. Twenty patients (53%) with arteriosclerosis were initially cured or improved; however, seven of these patients had recurrence in 4 to 48 months. Ultimately, only 13 of 38 patients with arteriosclerosis (34%) were cured or improved (mean follow-up 22 months). Nine patients with fibromuscular dysplasia required 17 dilatations of arteries (three bilateral and five repeat), resulting in eight patients (89%) who were cured or improved. Selection of
patients with hypertension by medical failure while receiving three or more hypertension medications or by lateralizing renal vein renin values yielded benefit in 17 of 26 patients (65%). Five of six patients with transplant stenosis of the renal artery and hypertension were cured or improved at mean follow-up of 18 months. Overall technical results of 83 artery dilatations were as follows: good, 58 (69%); fair, 10 (12%); poor or unsatisfactory, 16 (19%); these were judged with a blinded radiologic review. No patient suffered main renal artery thrombosis. There were 16 patients with complications of dilatation (morbidity rate of29%). Nine patients subsequently had renal artery surgery from the same day to 64 days later with good results in all patients except one. We conclude that transluminal renal artery dilatation is a technique that should be restricted to use in patients with fibromuscular dysplasia, transplant stenosis, and very few arteriosclerotic lesions.
Editorial Comment: The results with percutaneous transluminal angioplasty as treatment for renal artery stenosis in 55 patients from 1980 to 1985 are reported. The series includes 38 patients with atherosclerosis, 9 with fibrous dysplasia, 2 with atherosclerosis and fibrous dysplasia, and 6 with transplant arterial stenosis. Percutaneous transluminal angioplasty was performed as treatment for renovascular hypertension or renal failure in all but 1 patient. Complications of percutaneous transluminal angioplasty occurred in 16 patients (29 per cent) but only 6 of these (11 per cent) were serious; most of the remainder were minor hematomas. Among the patients with atherosclerosis percutaneous transluminal angioplasty initially was successful in 20 (53 per cent) but 7 of these had recurrent renal artery stenosis. Therefore, a successful clinical outcome ultimately was achieved in only 13 patients (34 per cent). The authors have not reported their results in ostial versus nonostial atherosclerotic lesions separately, although they indicate that the stenosis was within 1 cm. of the renal artery origin in 32 of 38 patients. Percutaneous transluminal angioplasty was successful in 8 of 9 patients (89 per cent) with fibrous dysplasia, including 5 who required repeat dilation. The single failure in this group occurred in a patient with branch renal artery disease. A successful clinical outcome was achieved in 5 of 6 patients (83 per cent) who underwent percutaneous transluminal angioplasty for transplant renal artery stenosis. This experience is consistent with emerging data regarding the role of percutaneous transluminal angioplasty as interventive therapy for renal artery stenosis. In patients with fibrous dysplasia the results of percutaneous transluminal angioplasty have been excellent and comparable to those obtained with surgical revascularization. A similar favorable experience has been observed with percutaneous transluminal angioplasty done to relieve arterial stenosis in a transplant kidney. In patients with atherosclerosis the success rate with percutaneous transluminal angioplasty has been excellent for nonostial plaques located exclusively within the renal artery. However, most (more than 80 per cent) atherosclerotic renal artery plaques are ostial and originate within the aorta. In a majority of these lesions percutaneous transluminal angioplasty either is not technically possible or after dilation the aortic plaque soon returns to its original position, causing recurrent
1507
can p:irnvide life-saving therapy for these critically m patien.ts. Andrew C. Novick, M.D.
c,:a1.H:nues to yield satisfactory :results in the performance of renal artery bypass surgery. Andrew C. Novick, M.D.
Aortorenal Arterdal Autografts: The Last Two Decades
Simultaneous Aortic Reconstruction and Bilateral Renal Revascularization: Is This a Safe and Effective Procedure?
R. J. STONEY AND P. A. 0LOFSS0N, Department of Surgery, University of California, San Francisco, California
C. S. Ann. Vase. Surg., 2: 169-173, 1988 Arterial autografts were introduced nearly a quarter century ago at the University of California, San Francisco and have proven their value for replacement in many demanding arterial problems. Renal artery fibrodysplasia is one of the more common lesions treated with arterial autograft. Arterial autografts that ideally match the renal artery and its branches are procured from the patient's own internal iliac artery. Either straight or branched configuration are available depending on the replacement requirements. In-situ aortorenal autografts are employed for lesions of the main renal artery or primary branches. Ex vivo repair involves temporary nephrectomy, pulsatile hypothermic perfusion and precise micro-vascular repair with unrestricted exposure, illumination, and an unhurried pace with no threat of renal ischemic insult. Autografts are attached proximally to the side of the aorta and distally to the diseasefree end of the renal artery or a branch. The technique of arterial substitution for ex vivo repairs are identical except for the additional reanastomosis or reattachment of the renal vein. The arterial autograft exhibits the compliance characteristics which resemble a normal artery, maturation when used in the growing child, and durability essential for the long life span of this treated population. When the objective of a renal artery reconstruction is a normal renal arterial system, then the internal iliac artery autograft is the only choice.
Editorial Comment: The authors report experience with 143 patients undergoing renal revascularization in whom an arterial au.tograft was used to replace the diseased renal artery. The study includes 59 patients with branch renal artery disease, of whom 45 underwent ex vivo repair and autotransplantat.ion. The hypogastric artery was used in 92 per cent of these reconstruct.ions, Excellent clinical result§ were achieved with no mortality, only 3 cases of postoperative thrombo§is and with hyperte:1:rnion cured or improved postoperatively in 94 pel'.' cent of the patients. As the authors emphasize, arterial autografts comprise an excellent material for renal artery replacement 011 the basis of similar viscoelastic properties aJ11d longterm durability. The hypogastric artery is the arterial au.tograft of choice and may be used intact with its branches if :necessary. Currently, the major usefulness of this g:raft is in younger patients undergoing extracorpo:real revascularization for branch renal artery disease. The short length of the hypogastric artery often precludes its use for in situ aortorenal bypass to renal artery branches. Patients with fibrous dysplasia of the main renal artery currently are managed with percutaneous transluminal angioplasty. In patients with atherosclerotic renal artery disease the hypogastric artery usually is diseased as well and, thus, it cannot be used as a bypass graft. In such cases the sapherwus vein graft
M. D. MAPLES, T. L. KILGORE, JR., M. H. H. B. TYLER, G. H. MUNDINGER, JR. AND R. E. KENNEDY, Mississippi Baptist Medical Center and St. Dominic-Jackson Memorial Hospital, Jackson, Mississippi O'MARA,
MCMULLAN,
J. Vase. Surg., 8: 357-366, 1988 Between 1982 and 1987, 32 patients with severe autorenal atherosclerosis had simultaneous aortic and bilateral renal revascularization. All patients were hypertensive. Eighteen patients (56 % ) had renal insufficiency with a mean serum creatinine (SC) of 2.8 mg/dl. Nine patients had an aortic aneurysm; the remaining 23 patients had aortoiliac occlusive disease of varying severity. Aortic reconstruction was done with either a straight (six patients) or bifurcated (26 patients) Dacron graft. Renal revascularization was accomplished with either bypass (60 arteries) or transaortic endarterectomy (four arteries). One patient died of pulmonary embolism (operative mortality rate 3 %) . Beneficial blood pressure response was achieved in 28 of 31 survivors, (90%). Among the 18 patients with renal insufficiency, mean SC was 2.80 ± 1.18 mg/dl preoperatively and 1.65 ± 0.48 mg/di postoperatively (p <0.001). Among eight patients with severe renal dysfunction before surgery (SC greater than 3 mg/di), mean SC was 3.90 ± 0.85 mg/dl before and 1.79 ± 0.69 mg/dl after operation (p <0.001). In follow-up extending to 58 months (mean 27.6 months), five late deaths occurred; cumulative survival was 94% at 2 years and 60% at 4 years. There were no instances of worsening hypertension; one patient had deteriorating renal function. These results indicate that severe aortorenal atherosclerosis can be managed with simultaneous aortic reconstruction and bilateral renal revascularization at low operative risk. In addition, there can be high expectation of significant and persisting benefit in both hypertension and renal dysfunction after operation.
Editoria~ Comment: The author§ report on. a relatively small giroup of 32 patients who m:1de:rvvent simultaneous aortic and bilateral renal revascularizati.on. Renal revascula:rization was indicated as treatment for associated hypertension with or without renal insufficiency. Aortic replacement was necessitated by an aortic aneurysm or aortol.liac occlusive disease. The:re was 1 operative death (3 per cent). Of the 31 survivors hypertension was cu:red or improved in 28 (90 per cent) and postoperative .renal function wa§ stable or improved in 29 (93 per cent). The authors conclude that simultaneous aortic reconstruction and bilateral renal revascularization may be done with a low operative risk. They also recommend synchronous bilateral repair in the presence of bilateral renal artery stenosis. While excellent clinical :results were achieved in a difficult group of patients, these findings differ significantly from the prevailing view that is based on several studies involving larger numbers of patients. Data from several major centers for renal artery disease, including our own, 1 have documented operative mortality rates of
1508
KIDNEY TRANSPLANTATION AND RENOVASCULAR HYPERTENSION
10 per cent or more for combined aortic and renal reconstruction. Furthermore, operative mortality with this approach has been greater when both renal arteries are repaired compared to unilateral revascularization. This also was an important finding in the National Cooperative Study on Renovascular Hypertension. 2 In the present study, while there was only 1 operative death 3 patients suffered ischemic cerebral infarction postoperatively and there were 3 other major operative complications. In a careful review of available data on this issue there is little doubt that synchronous aortic and renal reconstruction carries an increased operative risk compared to either procedure done individually. In patients who require revascularization for atherosclerotic renal artery stenosis, avoidance of surgery on the badly diseased aorta has been an important strategy toward limiting operative morbidity and mortality. 3 Alternative techniques, such as hepatorenal and splenorenal bypass, have proved to be safe and effective in such cases. Most patients will achieve significant benefit from unilateral revascularization without the added risk of bilateral simultaneous repair. In patients who also require aortic reconstruction due to an aneurysm or symptomatic aortoiliac occlusive disease I believe that the safest approach is to perform staged renal and aortic repairs. This may not be possible if there is significant disease involving the hepatic and splenic arterial inflow. In this situation the risk of concomitant aortic reconstruction and renal revascularization must be weighed against the gravity of the existing clinical situation on an individual basis. Andrew C. Novick, M.D. 1. Tarazi, R. Y., Hertzer, N. R., Beven, E.G., O'Hara, P. J., Anton, G. E. and Krajewski, L. P.: Simultaneous aortic reconstruction and renal revascularization: risk factors and late results in eighty-nine patients. J. Vase. Surg., 5: 707, 1987.
2. Franklin, S.S., Young, J. D., Jr., Maxwell, M. H., Foster, J. H., Palmer, J.M., Cerny, J. and Varady, P.D.: Operative morbidity and mortality in renovascular disease. J.A.M.A., 231: 1148, 1975. 3. Novick, A. C., Straffon, R. A., Stewart, B. H., Gifford, R. W. and Vidt, D.: Diminished operative morbidity and mortality in renal revascularization. J.A.M.A., 246: 749, 1981.
Results of Renal Artery Balloon Angioplasty Limit its Indications
H. G. BEEBE, K. CHESEBRO, F. MERCHANT AND W. BUSH, Section of Vascular Surgery and Department of Radiology, Virginia Mason Medical Center, Seattle, Washington J. Vase. Surg., 8: 300-306, 1988 Percutaneous transluminal balloon angioplasty (PT A) of 83 renal artery lesions in 55 patients was done because of renal failure in eight patients, hypertension in 35, renal failure and hypertension in 11, and polycythemia in one patient. Early results in 38 patients with arteriosclerosis showed five (13%) were worse and 13 (34%) were unchanged. Twenty patients (53%) with arteriosclerosis were initially cured or improved; however, seven of these patients had recurrence in 4 to 48 months. Ultimately, only 13 of 38 patients with arteriosclerosis (34%) were cured or improved (mean follow-up 22 months). Nine patients with fibromuscular dysplasia required 17 dilatations of arteries (three bilateral and five repeat), resulting in eight patients (89%) who were cured or improved. Selection of
patients with hypertension by medical failure while receiving three or more hypertension medications or by lateralizing renal vein renin values yielded benefit in 17 of 26 patients (65%). Five of six patients with transplant stenosis of the renal artery and hypertension were cured or improved at mean follow-up of 18 months. Overall technical results of 83 artery dilatations were as follows: good, 58 (69%); fair, 10 (12%); poor or unsatisfactory, 16 (19%); these were judged with a blinded radiologic review. No patient suffered main renal artery thrombosis. There were 16 patients with complications of dilatation (morbidity rate of29%). Nine patients subsequently had renal artery surgery from the same day to 64 days later with good results in all patients except one. We conclude that transluminal renal artery dilatation is a technique that should be restricted to use in patients with fibromuscular dysplasia, transplant stenosis, and very few arteriosclerotic lesions.
Editorial Comment: The results with percutaneous transluminal angioplasty as treatment for renal artery stenosis in 55 patients from 1980 to 1985 are reported. The series includes 38 patients with atherosclerosis, 9 with fibrous dysplasia, 2 with atherosclerosis and fibrous dysplasia, and 6 with transplant arterial stenosis. Percutaneous transluminal angioplasty was performed as treatment for renovascular hypertension or renal failure in all but 1 patient. Complications of percutaneous transluminal angioplasty occurred in 16 patients (29 per cent) but only 6 of these (11 per cent) were serious; most of the remainder were minor hematomas. Among the patients with atherosclerosis percutaneous transluminal angioplasty initially was successful in 20 (53 per cent) but 7 of these had recurrent renal artery stenosis. Therefore, a successful clinical outcome ultimately was achieved in only 13 patients (34 per cent). The authors have not reported their results in ostial versus nonostial atherosclerotic lesions separately, although they indicate that the stenosis was within 1 cm. of the renal artery origin in 32 of 38 patients. Percutaneous transluminal angioplasty was successful in 8 of 9 patients (89 per cent) with fibrous dysplasia, including 5 who required repeat dilation. The single failure in this group occurred in a patient with branch renal artery disease. A successful clinical outcome was achieved in 5 of 6 patients (83 per cent) who underwent percutaneous transluminal angioplasty for transplant renal artery stenosis. This experience is consistent with emerging data regarding the role of percutaneous transluminal angioplasty as interventive therapy for renal artery stenosis. In patients with fibrous dysplasia the results of percutaneous transluminal angioplasty have been excellent and comparable to those obtained with surgical revascularization. A similar favorable experience has been observed with percutaneous transluminal angioplasty done to relieve arterial stenosis in a transplant kidney. In patients with atherosclerosis the success rate with percutaneous transluminal angioplasty has been excellent for nonostial plaques located exclusively within the renal artery. However, most (more than 80 per cent) atherosclerotic renal artery plaques are ostial and originate within the aorta. In a majority of these lesions percutaneous transluminal angioplasty either is not technically possible or after dilation the aortic plaque soon returns to its original position, causing recurrent