Supraceliac aortorenal bypass

Supraceliac aortorenal bypass R y a n T. H a g i n o , M D , R. J a m e s Valentine, M D , and G. Patrick Clagett, M D , Dallas, Tex. Purpose: To determine the efficacy and durability of supraceliac aortorenal bypass grafting for symptomaUc atherosclerotie renal artery disease. Methods: Retrospective review of a 10-year, single-instituUon experience. Results: Seventeen patients underwent 27 bypass procedures (seven tmilateral, 10 bilateral) for atherosclerotic renovascular hypertension. The patients' mean ag e was 62.7 + 8.8 years. Diffuse aortoiliac and visceral atherosclerosis was confirmed on arteriogram; most (88%) celiac axis branches and all infrarenal aortas and common iliac arteries were found unsuitable for use as a donor vessel. Twenty-six bypass procedures (96%) were performed with autologous vein grafts. Seventeen bypass procedures (63%) were performed during partial aortic occlusion. There were no operative deaths or early occlusions. Postoperative complicafions occurred in four pafients (24%). The mean duration of follow-up was 28 - 19 months (range, 2 to 69 months). By life table analysis, the 5-year primary patency and assisted primary patency rates were 95% and 100%, respectively. The mean systolic blood pressure decreased from 180 -+ 38 m m H g to 135 _+ 20 m m H g (p = 0.0003), and the mean diastolic blood pressure decreased from 96 + 16 m m H g to 77 + 9 m m H g (p = 0.0002). The number of antihypertensive medications decreased from 2.8 -+ 1.2 to 1.4 - 1.0 (p = 0.002). Significant improvement in serum creatinine level was seen among paUents with preoperative renal instrfficiency. Hypertension was cured in 29%, improved in 53%, and unchanged in 18%. During late follow-up, only four paUents (24%) required subsequent aortic reconstruction. Conclusion: Supraceliac aortorenal bypass grafting is a safe and durable alternative for renal artery revascularization. This technique should be considered in patients who have diffuse infrarenal aortoiliac and visceral artery occlusive disease and reqtfire renal revascularization procedures. (J Vase Surg 1997;26:482-91.)

The indications for renal revascularization in patients who have atherosclerosis are becoming better defined.l-4 However, the diffuse nature ofatherosclerosis offen renders the aorta and iliac arterics inadequate as inflow sites for renal artery bypass graffing. Alternatives include combined aortic and renal artery reconstruction or extraanatomic bypass grafting. C o m b i n e d aorfic reconstruction and renal revascularization procedures can be performed with acceptable results in carefully selected patients, s,6 but most reports have documented additive morbidity and mortality rates. 4,7-9 The durability o f celiac axis From the DivisionofVascular Surgery, UniversityofTexas South' western Medical Center. Presented at the Twenty-firstAnnual Meefing of The Southern Association for Vascular Surgery, Coronado, Calif., Jan. 22-25, 1997. Reprint requests: G. Patrick Clagett, MD, Chief of Vascular Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75235-9157. Copyright © 1997 by The Societyfor VascularSurgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/97/$5.00 + 0 24/6/82585 482

branch vessels as sources o f inflow vessels for renal bypass grafts is excellent, ~°-12 provided these arteries are not affected by flow-limiting lesions. We have previously documented that hemodynamically significant celiac artery stenoses are prevalent in patients with advanced (>75% diameter loss) renal artery stenoses, la In those patients with celiac artery stenoses in w h o m combined aortic and renal revascularization is undesirable, we have favored the use o f the supraceliac aorta as an inflow source for renal artery bypass graffing. As described by Fry and Fry, 14 the supraceliac aortorenal bypass procedure seems ideally suited in these circumstances, hut its performance has heretofore been undocumented. The purpose o f this study" was to determine the efficacy and the durability o f the supraceliac aortorenal bypass procedure in patients with atherosclerotic renal artery disease.

PATIENTS AND METHODS The medical records o f patients who underwent supraceliäc aortorenal bypass procedures were examined to determine demogräphics, atherosclerofic risk

I O U R N A L OF VASCULAR SURGERY Volume26, Number3

factors, surgical indications, operative details, and perioperative complications. Supraceliac aortorenal grafts combined with antegrade mesenteric grafts »vere excluded. Early patency was documented by renal angiography or renal duplex scans, and functional success was determined from the records of outpatient clinic visits. Using established criteria for functional blood pressure response, 1~ pafients were considered cured ifthey were normotensive (diastolic blood pressure [DBP] <95 mm Hg) on no medicafion. Therapeutic failures were categorized by an insignificant reduction in DBP (reduction -< 20 mm Hg) and no change in medication requirements from preoperative levels. All others were considered improved. Detailed long-term follow-up was established from outpatient records, records of subsequent hospitalizations, and telephone interviews. Late patency was documented in most cases by renal duplex scans. Preoperative arteriograms were reviewed to determine the degree of renal artery stenosis and to determine the status of possible inflow sources. The visceral and renal artery branches of the aorta, the infrarenal aorta, and the common iliac arteries »vere studied in all patients. The degree of stenosis was calculated by the following formula: 1 - (narrowest diameter of stenosis + diameter of normal segment of the main artery). Arteries were categorized according to previously published criteria: (1) normal; (2) mild (1% to 49% stenosis); (3) moderate (50% to 79% stenosis); (4) severe (80% to 99% stenosis); and (5) occluded. 13a6 Hemodynamically significant stenosis was defined as 50% or greater diameter loss. Stafisfics. Continuous data are expressed as mean _+ standard deviation. Preoperative and late follow-up measurements of systolic blood pressure (SBP), DBP, serum creatinine level, and number of antihypertensive medications were compared using Student's paired t test. Long-term patency and longterm survival rates were calculated using life table analysis. 17 Differences were considered significant if the p value was less than 0.05. Technique o f supraceliac aortorenal bypass grafting. Transperitoneal exposure of the upper abdomen is established through extended, unilateral subcostal incision for unilateral renal artery bypass, bilateral subcostal "chevron" incision for bilateral renal artery reconstruction, or midline incision. 14 Bilateral subcostal or retroperitoneal flank incisions provide excellent exposure even in obese patients. After retracting the left lobe of the liver medially, a 8 to 10 cm length of supraceliac aorta is exposed directly through the gastrohepatic ligament by divid- "

Hagino, Valentine, and Clagett 483

Fig. 1. Postoperative aortogram dcmonstrates bilateral renal artet3, bypass grafts originafing from nondiseased supraceliac aorta. ing the overlying diaphragmatic crus. Dissection is carefully performed close to the aortic wall to avoid injuring periaortic lymphatics and surrounding structures. The right renal artery is exposed under the right renal vein after extended Kocher maneuver. Exposure of the left renal artery is performed either by medial visceral rotation or through a direct midline retroperitoneal approach. The patient is anficoagulated with heparin (150 IU/kg). Intravenous mannitol (12.5 to 25 g) is given; occasionally, furosemide and renal dose dopamine (l to 3 b~g/kg/ min) is given. Using partial or total supraceliac aortic vascular control, the proximal anastomosis is created in an end-to-side manner. We find that small aortas orten require total aorfic control to afford adequate exposure during construction of the proximal anastomosis. Visceral artery control is not mandatory and is not roufinely required. Cardiac monitoring during supraceliac clamping is conaplimented by careful blood pressure control and monitoring with a pulmonary artery catheter or transesophageal echocardiography. Grafts to the right renal artery are conveniently tunneled through the foramen of Winslow, anterior to the vena cava. Grafts to the left renal

484

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Hagino, Valentine, and Clagett

Table I. Major and minor complications Patient (yr)

Operation

Major complication

1 (64)

BilateralSAR

Respiratory failure

2 (62)

Bilateral SAR

3 (70) 4 (64)

Right SAR, Left nephrectomy Right SAR

Intraoperative femoral thromboembolism Postoperative hemorrhage

5 (39) ó (8O)

Right SAR Right SAR

Myocardial infarction

Minor complication

Result Prolonged mechanical ventilation Femoral thromboembolectomy

Plcural effusion Pneumothorax Pneumothorax

Reexploration Tube thoracostomy Tube thoracostomy Tube thoracostomy

SAR, Supraceliacaortorenal bypass.

artery are usually routed behind the body and tail o f the pancreas. In cases performed without medial visceral rotation, left renal artery grafts are passed through a tunnel easily created by blunt finger dissection o f the retropancreatic space. The proximal anastomoses of bilateral renal grafts are created in one o f two configurations: (1) a pantaloon anastomosis where two grafts are sewn together to form a common orifice with the aorta12; or (2) sewing one graft in an end-to-side manner to the proximal portion o f the aortorenal graft to the contralateral side. RESULTS During the past 10 years, 134 patients underwent repair o f atherosclerotic renal artery stenoses. Fortytwo patients (31%) underwent extraanatomic renal bypass procedures (hepatorenal, splenorenal, or supraceliac aortorenal bypass). A total of 17 patients (12.6%) underwent 27 supraceliac aortorenal bypass procedures (seven unilateral, 10 bilateral) for symptomatic renal artery occlusive disease. There »vere nine men (53%) and eight women (47%), with a mean age o f 62.7 + 8.8 years (range, 39 to 80 years). Symptomatic coronary disease was evident in 47%. All patients were hypertensive. The mean SBP was 180 + 38 mm Hg, and the mean DBP was 96 + 16 mm Hg. All patients received antihypertensive medications. Nine patients (53%) had preoperative evidence ofimpaired renal function (seru m creatinine -> 1.3 mg/dl). Additional atherosclerotic risk factors included smoking in 16 patients (94%), diabetes mellitus in three (18%), and hyperlipidemia in five (29%). All bypass procedures were performed for suspected atherosclerotic renovascular hypertension; no prophylactic renal artery bypass procedures were performed for asymptomatic lesions. Seven patients underwent operations after failed renal percutaneous transluminal angioplasty (PTA). Two o f these patients had undergone multiple PTA procedures becanse ofrecurrent stenoses. Preoperative angiograms were available for all

patients. The angiograms documented severe stenoses (n = 24) or occlusions (n = 3) in all 27 renal arteries that were revascularized. Fifteen o f 17 patients (88%) had celiac arteries that were not usable as inflow sources for extraanatomic renal artery revascularization. Twelve patients had hemodynamically significant stenoses in the celiac artcry, and three had other anatomic limitations: failed prior splenorenal bypass graft (n = 1), prior splenectomy (n = 1), and hypoplastic celiac artery (n = 1). None o f the 17 patients had infrarenal aortas or iliac arteries that were suitable for inflow. Fourteen had hemodynamically significant lesions or occlusions (one infrarenal aorta had been previously oversewn after removal of an infected aortofemoral bypass graft; distal perfusion was maintained through extraanatomic axillofemoral bypass graft), two had small ( < 4 cm) aortic aneurysms, and one had undergone a previous aortofemoral bypass procedure and multiple lower abdominal procedures. All normal or mildly diseased c o m m o n iliac arteries that may havc been suitable as an inflow source for bypass grafting were excluded because o f hemodynamically significant infrarenal aortic occlusive disease. Twenty-six bypass grafts were created using nonreversed lower extremity vcins, and one was performcd using a woven Dacron prosthesis. The majority (65%) o f proximal anastomoses were created using partial aortic occlusion. The mean operative time was 349 -+ 67 minutes (fange, 273 to 475 minutes), and the mean intraoperative blood loss was 979 -+ 663 ml (range, 500 to 2500 ml). Simultaneous nephrectomies o f nonfunctioning contralateral kidneys were performed in three patients. Fig. 1 is a postoperative angiogram after a bilateral reconstruction. There were no operative deaths or early graft occlusions. Four major morbid events occurred in four patients (24%). A myocardial infarction occurred in an octogenarian with known coronary disease after unilateral bypass grafting to a solitary func-

JOURNALOFVASCULARSURGERY Volume26, Number3

Hagino, Valentine, and Clagett 485

300 •

150.

p < 0.0005 _

p < 0.0005

250. 125 '

200,

~

100'

i "~ 1 5 0

.~_

75'

I00

Preop

Postop Preop

Postop

5O 50

Fig. 2. Systolic blood pressure response. Dashed line represents mean systolic blood pressure response.

tioning kidney. Postinfarction bradycardia necessitated the placement of a permanent transvenous pacemaker. Other complications are detailed in Table I. The mean duration of follow-up was 28 + 19 months (range, 2 to 69 months). Late blood pressure data and serum creatinine levels were obtained from the patients' last known follow-up examination. Blood pressure responses are summarized in Figs. 2 and 3. After operation, the mean SBP decreased from 180 + 38 mm H g to 135 + 20 mm Hg (p = 0.0003). The mean DBP fell from 96 + 16 mm H g to 77 + 9 mm H g (p = 0.0002). The number of antihypertensive medications decreased from a mean of 2.8 + 1.2 to 1.4 -+ 1.0 (p = 0.002). Hypertension was cured in five patients (29%), improved in nine (53%), and unchanged in three (18%). The mean preoperative creatinine values among all 17 patients were not statistically different from the postoperative values (1.5 + 0.5 m g / d l compared with 1.3 + 0.5 m g / d l ; p = 0.23). However, for the nine patients (53%) with impaired preoperative renal function, the mean serum creatinine level decreased from 1.8 + 0.4 m g / d l to 1.3 + 0.6 m g / d l (p = 0.004). All nine patients with preoperative renal insufficiency had their blood pressure either cured (n = 3) or improved (n = 6) on late follow-up. Long-term graft patency was confirmed by color-

Fig. 3. Diastolic blood pressure response. Dashed line represents mean diastolic blood pressure response.

flow duplex scanning in 22 grafts (81%) and by aortography in two grafts. Three grafts were considered patent on the basis of clinical criteria alone (a graft was considered clinically patent only if the patient was cured or improved and had a unilateral bypass graft to a solitary functioning kidney without evidence of renal insufficiency). One patient had gradual recurrent hypertension 12 months after undergoing a bilateral supraceliac aortorenal bypass procedure. Duplex examination detected a highgrade anastomofic stenosis at the origin of the left bypass graft. Selective arteriography confirmed the severity of the lesion (Fig. 4). Vein patch angioplasty was used to repair the focal stenosis and assist graft patency. Pathologic examination of the lesion was consistent with neoinfimal hyperplasia. Thirty-three months later, the patient remains normotensive and off medication. Overall, the 5-year primary patency rate was 0.95 +- 0.15, and the assisted primary patency rate was 100% by actuarial life table analysis (Fig. 5, Table II). Two late deaths occurred as a result of congestive heart failure and stroke at 12 and 24 months, respectively. Both patients had patent grafts confirmed by arteriogram or duplex sonography within a month before death. Four patients (24%) eventually required vascular surgery for progressive infrarenal aortic disease. Severe lower extremity ischemia necessitated two sub-

JOURNAL OF VASCULAR SURGERY

486

Hagino, Valentine, and Clagett

Fig. 4. Anteropostefior sclecrive angiogram obtaincd 12 months after original bypass procedure shows criucal focal stenosis at origin of left graft. Pathologic examination of lesion revealed intimal hyperplasia.

sequent aortofemoral bypass procedures and one axillobifcmoral bypass procedure. One aortoiliac bypass graft was placed for a small, asymptomatic aortic aneurysm that had increased in sizc. Aortoiliac diseäse was clinically silcnt or minimally symptomatic throughout the follow-up period in the remaining paticnts. DISCUSSION Recent studies have confirmed that the numbcr of renal artery bypass procedures performed for atherosclcrotic renal artery stcnosis is inereasing in parallel with the aging population. 1,4,6,~°,18 Because atherosclcrotic renal artery disease is orten associated with extrarenal occlusive lesions, especially aortoiliac occlusive diseasc, surgeons may be faced with inadcquate inflow sources, which has increased the complexity of surgical repair. L19 Our patients illustrated this dilemma. Preoperative arteriograms demonstrated severe but ~tsymptomatic or minimally symptomatic aortic and aortic branch vessel diseasc. With the exception of orte patient who had undergone a prcvious aortofemoral bypass procedure, no infrarenal aorta or common iliac artery was useable as a donor vessel for rcnal artery bypass grafting. Usually, an aortic graft would provide excellent inflow for a renal artery bypass graft, 1° but that patient had severe lower intraabdominal and retroperitoneal fibrosis

September1997

and adhesions that made dissection treacherous. The celiac artery branches were also unusable in 88% of patients because of hemodynamically significant occlusive disease, asymptomatic occlusions, or prior branch ligation. Extraanatomic visccral-renal bypass grafting was not used in two other patients who had mildly diseased ccliac arteries because of the need for bilateral reconstruction. In addition to being a relative contraindication to celiac branch vessel renal bypass graftäng, u wc find supraceliac aortorenal bypass procedures tcchnically easier to pcrform than simultaneous hepatorenal and splenorenal bypass procedures. The utility of the supraceliac aorta as an inflow site is based on its tendency to be frec of advanced athcrosclerosis. This site has been used successfully in other types ofrcconstruction. The durability ofantegrade aortomesenteric bypass grafts that originate from the supraceliac aorta attests to the usefulness of this portion of the aorta as a donor site. 2°,21 Transplant surgeons have found this vesscl an equally useful location for allograft hepatic artery reimplantation. 22 Similarly, Fry and Fry, and others reported the potential advantages of the supraceliac aorta as an inflow site for renal artery bypass grafting.14,23 Access can be obtained with minimal ditt]culty and usually allows partial aortic occlusion during the proximal anastomosis; this may limit visceral ischcmia time and ameliorate declamping hypotension. We found this maneuver to be possible in the majority of out patients. Operative time and blood loss were acceptable eren though 60% of our rcconstructions were bilateral. Minor morbidity in thrce patients could bc attributed to the high abdominal aortic dissection associated with exposure of the supraceliac aorta (Tabie I). Inadvertent entry into the pleural space through the posterior mediastinum resulted in pneumothorax or effusion that required tube thoracostomy in all three. None of these events, however, resulted in delayed convalescence or long-term functional impairment. Supraceliac aortorenal bypass grafting can achieve results comparable with thosc of isolated aortorenal and visceral-renal artery bypass grafting. The 5-year primary patency rate of 95% and assisted primary patcncy rate of 100% attests to the durability of this procedure. These results are similar to other more traditional methods of revascularization, including extraanatomic bypass grafting, aortorenal bypass grafting, and combined aortic and renal artery reconstructions, s,6,1° Hansen et al. 1 reported among 152 patients who underwent various forms of surgical renal revascularization for atheroocclusive disease,

JOURNAL OF VASCULAR SURGERY Volume 26, Number 3

1

Hagino, Valentine, and Clagett

~

- - - &

. . . . . . .

-m

0.9

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...................

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imi

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,A . . . . . . . . . . . . . .

.A . . . . . .

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~

487

. . . . . . . . .

T

J-

J.

0.8 0.7 0.6 ¢,a

0.5 0.4 0.3

•

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ù ~,--assisted primary patency

0.1

I

I

I

I

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6

12

18

24

30

36

42

48

54

60

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Fig. 5. Life-table graphically depicts primary and assisted primary patency rates. Number of grafts at risk are depicted in Table II.

15% were cured, 75% were improved, and 10% were unchanged. This proportion o f surgically corrected hypertensive patients with atherosclerotic occlusive disease o f the renal vessels is consistent throughout the literature 4,6,H,12,24 and currently remains a standard with which other results can be compared. After supraceliac aortorenal bypass grafting in our patients, significant reductions in SBP, DBP, and in antihypertensive medications were observed (Figs. 2 and 3). Moreover, with hypertension cured or improved in 82% o f cases, a favorable comparison with conventional renal revascularization can be made. M t h o u g h no significant improvement in serum crcatinine level was seen among all patients when considered together, the subgroup that had elevated serum creatinine levels did show significant improvement in renal function and had a gratifying decrease in postoperative creafinine values that were maintained on late follow-up. Another option for correcfing renal artery stenosis is PTA. Although acceptable results may be obtained in pafients with nonatherosclerofic or atherosclerotic, nonorificial lesions, 2s,26 most pafients with diffuse atherosclerosis have osten lesions configuous with aorfic plaque. This was the case in our pafients, most o f whom had bulky aortic disease. PTA o f orificial renal artery lesions is not durable, 24,2s,27 and seven o f our patients had undergone previous fäiled

renal artery PTA procedures. The supraceliac aortorenal bypass procedure proved surprisingly simple in these patients, even in the two who had m ultiplc failed attempts at balloon dilation. Transaortic renal endarterectomy is an effective and durable technique in treating patients with ostial renal artery atherosclerosis.l<20 In patients with focal central aortic occlusive disease, endarterectomy may be an ideal solution. The procedure allows repair o f the renal artery without the need for aortic reconstruction for asymptomatic disease. Unfortunately, in our patients, severe juxtarenal aortic atherosclerosis extended down to the aortic bifurcation or into the iliac vessels. We believed the aortic disease was too extensive for local renal endarterectomy. Adequate treatment would have necessitated complete infrarenal aortoiliac endarterectomy or aortic replacement in all patients with occlusive disease. Simultaneous aortic and renal artery reconstruction may also be performed in selected patients with diffuse atherosclerosis with favorable outcome. 4 6 However, combined procedures, although technically feasible, are associated with a lower rate o f improvement of hypertension than renal revascularizafion alone and should be used with discretion, s,7 Overall morbidity and mortality rates may also be increased.4,7 9 As a result, most authors would contend that simultaneous repair should be undertaken

JOURNAL OF VASCULARSURGERY September 1997

Hagino, Valentine, and Clagett

488

Table

II, A. Primary patency data

No. withdrawn due to Interval (mo) 0 to 1 to 3 to 6 to 9 to • 12 to 15 to 18 to 21 to 24 to 27 to 30 to 33 to 36 to 39 to 42 to 45 to 48 to 51 to 54 to 57 to

Table

1 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60

No. ofgrafts at risk

No. offailed grafts

Duration

Loss to follow-up

27 27 26 24 24 23 19 18 17 13 12 12 10 10 10 7 7 7 4 4 2

0 0 0 0 0

0 0 2 0 0

0 1 0 0 1

1

0

2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 0 0 1 0 2 0 0 3 0 0 3 0 2 0

0 1 2 0 0 0 0 0 0 0 0 0 0 0 0

Death

Interval patency rate

Cumulative patency (%)

SE (%)

0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

1.00 1.00 1.00 1.00 1.00 0.95 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00

100 100 100 100 100 100 95 95 95 95 95 95 95 95 95 95 95 95 95 95 95

0.0 0.0 0.0 0.0 0.0 0.0 4.9 5.0 5.2 5.9 6.1 6.1 6.7 6.7 6.7 8.0 8.0 8.0 10.6 10.6 15.0

I I , B. A s s i s t e d p r i m a r y p a t e n c y d a t a

No. withdrawn due to Interval (mo)

No. ofgrafts at risk

No. offailed grafts

Duration

Loss to follow-up

Death

Interval patency rate

Cumulative patency (%)

SE (%)

0 to 1 1 to 3 3 to ö ö to 9 9 to 12 12 to 15 15 to 18 18 to 21 21 to 24 24 to 27 27 to 30 30 to 33 33 to 36 36 to 39 39 to 42 42 to 45 45 to 48 48 to 51 51 to 54 54 to 57 57 to 60

27 27 2ö 24 24 23 20 19 18 14 13 13 11 11 11 7 7 7 4 4 2

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 2 0 0 0 1 0 0 1 0 2 0 0 4 0 0 3 0 2 0

0 1 0 0 1 2 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 1 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0

1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1,0 1.0 1.0 1.0 1.0 1.0

100 100 100 100 100 100 100 100 100 100 100 100 100 i00 100 100 100 100 100 100 100

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

o n l y i n p a t i e n t s w h o s e s y m p t o m s at e a c h site w o u l d i n d e p e n d e n t l y w a r r a n t s u r g i c a l repair, s,19

never b e c o m e s y m p t o m a t i c . In o n e large c o n t e m p o -

m u l t a n e o u s repair. But t h e aortoiliac lesions m a y

I n t u i t i v e l y , it s e e m s u n r e a s o n a b l e t o r e c o n s t r u c t the aortoiliac system for t h e sole p u r p o s e o f provid-

r a r y series, ~ 62% o f p a t i e n t s w h o u n d e r w e n t r e n a l artery r e c o n s t r u c t i o n for atherosclerotic disease d e m -

ing inflow for renal artery bypass grafting. However, if m o s t o f these paUents s u b s e q u e n t l y r e q u i r e d aorUc r e c o n s t r u c t i o n , a n a r g u m e n t c o u l d b e m a d e f o r si-

onstrated significant aortic atherosclerosis that was considered anatomically severe but minimally symptomatic. T h e authors f o u n d that n o n e o f these pa-

JOURNALOF VASCULARSURGERY Volume26, Number3

tients required subsequent aortic reconstruction. In an earlier report, Hansen and colleagues reported on 47 patients with severe aortoiliac occlusive disease who did not undergo aortic replacement during renN revascularization. Only three eventually required an aortofemoral bypass procedure.: In our series, despite the angiographic severity of visceral artery, renal artery, and aortoiliac occlusive disease, we limited repair to the renal artery lesions. With a mean follow-up of 28 months and more than one third of grafts having follow-up that exceeded 3 years, only four patients required additional procedures to correct progressive, symptomatic aortoiliac occlusive or aneurysmal disease. In spite of the uniform presence of severe extrarenal atherosclerosis, the rernainder continue to have no compelling indications for aortic reconstruction. We find it difficult to predict those patients with anatomically severe but asymptomatic aortic disease who will eventually require further intervention. As a result, we continue to adopt a conservative approach to asymptomatic aortic disease. REFERENCES

1. Hansen KJ, Starr SM, Sands RE, Burkart JM, Plonk GW Jr, Dean RH. Contemporary surgicalmanagement of renovascular disease. J Vasc Surg 1992;16:319-31. 2. Tollefson DFJ, Ernst CB. Natural history of atherosclerotic renal artery stenosis associatedwith aortic disease. J Vasc Surg 1991;14:327-31. 3. Zierler RE, Bergelin RO, Isaacson JA, Strandness DE Jr. Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultrasonography. J Vasc Surg 1994;19:250-8. 4. Hallett JW Jr, Textor SC, Kos PB, Nicpon G, Bower TC, Cherry KJ Jr, et al. Advanced renovascular hypertension and renal insufficiency:trends in medical comorbidity and surgical approach from 1970 to 1993. J Vasc Surg 1995;21:750-60. 5. Benjamin ME, Hansen KJ, Craven TE, Keith DR, Plonk GW, Geary RL, et al. Combined aortic and renal artery surgery: a contemporary experience. Ann Surg 1996;223:555-67. 6. Cambria KP, Brewster DC, L'Italian G, Koustas G, Atamian S, LaMuraglia GM, et al. Simultaneous aortic and renal artery reconstruction: evolution of an eighteen-year experience. I Vasc Surg 1995;21:916-25. 7. Tarazi RY, t-Iertzer NR, Beven EG, O't-Iara PJ, Anton GE, Krajewski LP. Simultaneous aortic reconstruction and renal revascularization: ilsk factors and late results in eighty-nine patients. J Vasc Surg 1987;5:707-14. 8. Dean RH, Keyser JE, Dupont WD, Nadean JH, Meacham PW. Aortic and renal vascular disease: factors affecting the value of combined procedures. Ann Surg 1984;200:336-444. 9. Brothers TE, Elliott BM, Robison JG, RajagopalanPR. Stratification of mortality risk for renal artery surgery. Am Surg 1995;61:45-50. 10. Cambria KP, Brewster DC, L'Italien G, Moncure A, Darling RC Jr, Gertler JP, et al. The durability of differentreconstructive techniques for atherosclerotic renal artery disease. J Vasc Surg 1994;20:76-87. 11. Moncure AC, Brewster DC, Darling RC, Amip RG, Newton

Hagino, Valentine, and Clagett

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

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WD, Abbott WM. Use of the splenic and hepatic arteries for renal revascularization.J Vasc Surg 1986;3:196-203. Reilly JM, Rubin BG, Thompson RW, Allen BT, Anderson CB, Sicard GA. Long-term eff~ctiveness of extraanatomic renal artery revascularization.Surgery 1994;116:784-91. Valentine RJ, Martin JD, Myers SI, Rossi MB, Clagett GP. Asymptomatic celiac and supeilor mesenteric artery stenoses are more prevalent among patients with unsuspected renal artery stenoses. J Vasc Surg 1991;14:195-9. Fry RE, Fry WJ. Supraceliacaortorenal bypasswith saphenous vein for renovascular hypertension. Surg Gyneco! Obstet 1989;168:181-3. Barnes RW, Berson A, Dean R, Ernst CB, Hunt J, KrakoffL, et al. Diagnosis and management of renovascular disease: summary paper. J Vasc Surg 1985;2:453-8. Olin JW, Melia M, Young JR, Graor RA, RisiusB. Prevalence of atherosclerotic renal artery stenosis in patients with atherosclerosis elsewhere. Am J Med 1990;88:46-51. Rutherford RB, Flanigan DP, Gupta SK, Johnston KW, Karmody A, Whittemore AD, et al. Suggested standards for reports dealing with lower extremity ischemia. J Vasc Surg 1986;4:80-94. Novick AC, Ziegelbaum M, Vidt DG, Gifford RW Jr, Pohl MA, Goormastic M, Trends in surgical revascularization for renal artery disease: ten years' experience. JAMA 1987;257: 498-501. Hansen KJ, Lundberg AH, Benjamin ME, CaseyWJ, Craven TE, BleyerAJ, Dean RH. Is renal revascularizationin diabetic patients worthwhile? J Vasc Surg 1996;24:383-93. Rapp JH, Reilly LM, Qvarfordt PG, Goldstone J, Ehrenfeld WK, Stoney RJ. Durability of endarterectomy and antegrade grafts in treatment of chronic visceral ischemia. J Vasc Surg 1986;3:799-806. Beebe HG, MacFarlaneS, Raker EJ. Supraceliacaortomesentefic bypass for intestinal ischemia. J Vasc Surg 1987;5:74954. Shaked AA, TakiffH, Busuttil RW. The use of the supraceliac aorta for hepatic arterial revascularization in transplantation of the liver. Surg Gynecol Obstet 1991;173:198-202. Novick AC, Stewart R, Hodge EE, Goldfarb D. Use of the thoracic aorta for renal arterial reconstruction. J Vasc Surg 1994;19:605-9. Ziegelbaum M, Novick AC, Hayes J, Vidt DG, Risius B, Gifford RW Jr. Management of renal arterial disease in the elderly patient. Surg Gynecol Obstet 1987;165:130-4. Plouin PF, Dame B, Chatellier G, Pannier I, Battaglia C, Raynaud A, et al. Restenosis after a first percutaneous transluminal renal angioplasty.Hypertension 1993;21:89-96. Ramsey LE, Waller PC. Blood pressure response to percutaneous transluminal angioplasty for renovascular hypertension: an overview of published seiles. BMJ 1990;300: 569-72. Cicuto KP, McLean GK, Oleaga JA, Freiman DB, Grossman RA, Ring EJ. Renal artery stenosis: anatomic classificationfor percutaneous transluminal angioplasty. AJR Am J Roentgenol 1981;137:599-601.

Submitted Jan. 29, 1997; accepted Apr. 7, 1997.

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DISCUSSION Dr. Richard P. Cambria (Boston, Mass.). Congratulations to Dr. Hagino on a fine and beautifully illustrated presentation and to the group at Southwestern for focusing our attention on a perhaps underused technique of extraanatomic renal artery reconstruction. The authors performed this operation in 17 patients over a 10-year interval with a low perioperative morbidity rate, admirable short- and long-term graft patency rates, and favorable function responses to revascularization. Their rationale and data reinforce what we and others had emphasized about surgical renal artery reconstruction, namely that most failures occur early and are technical in nature. Therefore, selection o f a particular mode ofreconstruction among the various options should be made in accordance with individual patient anatomy. A few years ago at the combined vascular meetings, we reported on nearly 300 patients who underwent a variety of different renal artery reconstruetion procedures for atherosclerotic disease and demonstrated that the durability of extraanatomic bypass grafting, which in our series was primarily hepatorenal and splenorenal reconstructions, was equivalent to aortorenal bypass grafting. We have not used the procedure described today, but we agree that origination o f aortorenal bypass grafting from a heavily diseased infrarenal aorta is unwise. It has not performed weil in our hands. We also agree that combined aortic and renal artery reconstruction should generally be performed only when independent indications exist for correction ofeach. That is, replacement of the aorta for the sole purpose of originating an aortorenal bypass graft will rarely be required. There are usually better options. However, part o f o u r advocacy ofextraanatomic bypass grafting relates to the fact that these are generally "lesser operations" than central aortic surgery. The hepatorenal bypass procedure can be performed in an hour and a half, with an overall operative insult that approximates that of an open cholecystectomy. I am not sure this consideration applies to the procedure we heard about today. The mean operative time in the authors' 17 patients was nearly 6 honrs, with an average blood turnover of 1 L. However, there were no deaths, and there was minimal morbidity. Furthermore, origination of a graft from a supraceliac aorta from an anterior approach can be ditticult except in very thin patients. Four of the anthors patients, or 25%, reqnired subsequent treatment of their initially ignored aortic disease, and another had a small aneurysm. I suspect we would have performed combined aortic and renal artery reconstruction in these patients, because in contempormT practice the mortality rate of that procedure approximates that ofisolated aortic surgery. I have three questions for the authors. To provide perspective on the relative use of this procedure, what was the total number of renal artery reconstruction procedures performed at your institution over the 10-year interval encompassed in your review? Second, what of transaortic endarterectomy? It is not mentioned in your manuscript.

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We and others have emphasized the reemergence of this operation, which is particularly suited to patients who have bilateral proximal renal artery disease, and in my own practice it has become the procedure of choice for patients who undergo simultaneous bilateral reconstruction for atherosclerotic disease. Is this procedure considered in your practice? Lastly, the authors emphasized that celiac stenosis can preclude use of hepatorenal and splenorenal bypass grafting. They are doubtless aware that the median arcuate ligament orten creates a compression on the celiac artery that can mimic stenosis. Have you used direct inn'aarterial pressure measurements across the celiac artery to either include or exclude it as an appropriate inflow source? Dr. Ryan T. H a g i n o . Thank you, Dr. Cambria. The supraceliac aortorenal bypass procedure makes up approximately 12% to 13% of the procedures performed at our institution over the past l 0 years for the surgical treatment of atherosclerotic renal artery stenosis. Of the 117 other reconstructions, approximately 40% of these were combined aortic and renal revascularizations. Aortorenal bypass procedures made up 25% ofthat group, and visceral to renal bypass procedures, traditional extraanatomic bypass procedures that is, made up approximately 25%. We perform thromboendarterectomy for central aortic disease in approximately 10% o f o u r patients; we continue to use this technique to treat patients who have appropriate anatomy, specifically cëntral aortic occlusive disease. However, we find that in patients who have severe infrarenal aortic occlusive disease, the distal endpoint in the endarterectomy orten is not cosmetically appealing and the endarterectomy ends up extending down to the aortic bifurcation, which necessitates replacement of the infrarenal aorta as weil. As for the mean operative time, the bilateral reconstructions do take longer. Regarding celiac stenoses, our angiographers routinely obtain lateral aortograms when they perform angiography for renal artery stenoses. In this series, all of the lateral aortograms revealed what appeared to be atheroocclusive disease at the celiac artery. Certainly, pressure measurements in someone with median arcuate ligament syndrome before and after division of the ligament would be wise. Dr. Kimberley H a n s e n (Winston-Salem, N.C.). We were squarely in support of your concept regarding direct aortorenal reconstruction over indirect or splanchnorenal reconstruction and have had the opportunity to operate on about 500 people over the past 81/2 years and roughly 800 grafts. In only 2% ofthose have we thought it necessaW to use indirect or splanchnorenal reconstruction, but I had a question regarding the seven patients, I believe, fi'om your abstract that had renal insufficiency. You performed nine bilateral procedures and you would guess that perhaps 50% or 60% of those patients with abnormal renal function before the operation with global renal revascularization might be improved, but none were, at least in the abstract. Do you think that the addition of a supraceliac cross-clamp

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even when you attempt to make that a partial occluding clamp might add additionally to the renal ischemia and thereby limit the retrieval ofyour renal function? Dr. H a g i n o . Yes, I believe that could be a problem. Certainly, a significant minority (40%) of patients required complete supraceliac aortic cross-clamping to reconstruct the proximal anastomosis. I am not sure whether this is a

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significant problem. No improvement in renal function was seen when examining the entire cohort. However, the nine patients with preoperative renal insufficiency, when examined as a separate group, did show significant improvement in renal function in follow-up, In addition, all nine patients had hypertension that was either cured (three patients) or improved (six patients).

Pacific Vascular Research Foundation 1998 Wylie Scholar Award in Academic Vaseular Surgery The Wylie Scholar Award provides, up to 3 years of career development support for a promising young vascular surgeon. The award consists of a grant of $50,000 per year for 3 years. Funding for the second and third years is subject to review of acceptable progress reports. The award is nonrenewable and may be used for research support, essential expenses, and other academic purposes at the discretion of the Scholar and medical institution. The award may not be used for any indirect costs. The candidate must be a vascular surgeon who has completed an accredited residency in general vascular surgery within the past 5 years and who holds a full-time appointment at a medical school accredited by the Liaison Committee on Medical Edncators in the United Stares or the Committee for the Accreditation of Canadian Medical Schools in Canada. The app!icant must be recommended by the administration (the Dean or fiscal officer) of the medical school and the head of the applicant's department or division. Only one candidate is eligible per institution. Applications are due by December 1, 1997, for awards granted July 1, 1998. Applications may be obtained by writing to: Pacific Vascular Research Foundation, Wylie Scholar Award, 601 Montgomerj Street, Suite #900, San Francisco, CA 94111 (415-291-7201).