Use of the gastroduodenal artery in right renal artery revascularization

Use of the gastroduodenal artery in right renal artery rcvascularization A. C. Moncure, MD, D. C. Brewster, MD, R. C. Darling, MD, W. M. Abbott, M D , and R. P. Cambria, MD, Boston, Mass. Of 15 patients having revascularization of the right renal artery with the use of the hepatic ciraxlation from May 1984 through March 1987 at the Massachusetts General Hospital, eight patients had this accomplished with end-to-end anastomosis of the gastroduodenal artery and right renal artery. Operative indications were acute azotemic renal failure (three patients), poorly controlled renovas~aflar hypertension (four patients), and staged repair of bilateral renal artery disease (one patient). All revascularizations were successful in restoring renal function or rendering hypertension manageable and were assessed by means of renal flow scans, celiac angiography, or return of function in those patients with a solitary, functioning kidney. All patients survived the operation with one late death caused by myocardial infarction after abdominal aortic aneurysm repair. The gastroduodenal artery may be used as the source for arterial inflow in revascnlarization of the right renal artery by end-to-end anastomosis in approximately 50% of instances, confering the advantage of the use of only one anastomosis and obviating the long-term possibility of vein graft failure. (J VASC SuRG 1988;8:154-9.

The splenic and hepatic arterial circulations have been used to revascularize the left and right renal arteries, respectively. ~ In special circumstances, these procedures have been found to be useful. NOt infrequently, renal artery disease is only one manifestation of severe end-stage generalized atherosderosis and in such circumstances the use of a severely diseased aorta may prove difficult. Aortic clamping may also be deleterious to those patients with severe cardiac disease. Because of the greater risk in bilateral simultaneous renal artery reconstruction or combined procedures such as renal arterial revascularization done with repair of aortic aneurysm or aortoiliac occlusive disease, a staged approach to renal artery reconstruction with an extraanatomic approach is an attractive concept. Finally, a "lesser procedure" in terms of incision, operative time, and operative blood loss is an appropriate alternative to an aortic procedure in renal revascularization. In all of these circumstances, use of the splenic or hepatic arterial circulation to revascularize the renal arteries has been successful. These procedures have also been used for several complex problems requiring renal revascularization, such as mycotic aortic aneurysm, trauma to the renal artery, aortic dissection, and renal artery aneurysm. The utility of the splenic or hepatic arterial systems in these From the General Surgical Services,MassachusettsGeneralHospital, and the Deparmlentof Surgery,HarvardMedicalSchool. Reprint requests: AshbyC. Moncure,MD, MassachusettsGeneral Hospital, Boston, MA 02114. 154

circumstances has bccn well demonstrated; in tcrms of function, this type of revascularization has proved to be durable. With revascularization of the left renal artery the proximal splenic artery is controlled, transected, and anastomosed end to end to the left renal artery, leaving the spleen in situ. Because of fear of hepatic or gallbladder necrosis, generally the right renal artery been revascularized by a vein graft brought from the hepatic artery end to side and anastomosed to the right renal artery end to end. Further experience with use of the hepatic circulation to revascularize the right renal artery has led to the realization that the gastroduodenal artery may be effectively used as a source of arterial inflow in approximately 50% of cases with the hepatic circulation used for right renal artery revascularization. PATIENTS A N D M E T H O D S During the period May 1984 through March 1987, 15 patients at the Massachusetts General Hospital had revascularization of the right renal artery for atherosclerotic narrowing or occlusion with the hepatic circulation used for arterial inflow. Eight of these 15 patients had revascularization of the right renal artery with the gastroduodenal artery, with the use of end-to-end anastomosis without vein graft. Operative indications in the eight patients with prhnary gastroduodenal-right renal artery anastomosis were the immediate treatment of azotemic re-

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Right renal revascularization with gastroduodenal artery 155

% i, A

tery is

Common ~rtery

C Fig. 1. A, Right subcostal incision extends across the midline laterally to the tip of the right eleventh rib. B, Hepatoduodenal ligament overlying the porta hepatis is incised. C, Common hepatic artery and origin of gastroduodenal artery is encircled.

nal failure in patients with chronic refractory congestive heart failure (three patients), the treatment of renovascular hypertension that had been poorly controlled with medication (four patients), and reconstruction of the right renal artery as the first stage in a planned, staged repair of a large abdominal aortic aneurysm with bilateral renal artery ostial disease (one patient). Therefore medical indications for operative treatment were uncontrollable renovascular hypertension in four patients and preservation or retrieval of renal function in four patients. Preoperative evaluation included midstream biplane aortography, with views of the origin of the celiac axis and the renal arteries. In all patients having this procedure, a large, relatively long gastroduodenal artery was seen on the arteriogram. Liver function tests were obtained in all patients and were normal. Selective renin values of the renal vein and inferior vena cava above and below were obtained before operation in those patients under study with poorly controlled hypertension and were appropriately elevated on the side of the diseased renal artery. All patients operated on to control severe renovascular hypertension had preoperative blood pressures from

160/90 to 220/140 mm Hg and were unresponsive to multiple antihypertensive medications used in combination. Postoperative evaluation included blood pressure response, serum creatinine levels, and fiver function studies. Follow-up ranged from 3 to 33 months, all patients being available for follow-up. Patency of the reconstruction was assessed in all except two patients, with renal flow scans (two patients) or celiac angiography (four patients). The patients evaluated with renal flow scans refused postoperative arteriography. Of the two patients not so assessed, one had had contralateral nephrectomy and the second had a nonfunctioning contralateral kidney, both having adequate postoperative renal function and controlled blood pressure, which presumably indicated a good result. All patients having primary anastomosis of the gastroduodenal artery to right renal artery survived the operation, but one died of a myocardial infarction 6 weeks postoperatively after having repair of an abdominal aortic aneurysm. All reconstructions were successful in restoring renal function or rendering hypertension manageable and all reconstructions were patent when assessed postoperatively. Periop-

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Gommon Bile Duc .I Artery

Fig. 2. Kocher's maneuver elevates duodenum, allowing dissection of the gastroduodenal artery to its bifurcation, or until the pancreas is encountered.

erative renal failure and postoperative hepatic dysfunction were not seen. TECHNIQUE The patient is placed in a supine position, the legs are externally rotated, and the abdominal wall, groins, and medial thighs are prepared and draped as a sterile field. A right subcostal incision extending medially across the midline and laterally to the tip of the right eleventh rib (Fig. 1,A) allows access to the porta hcpatis. The hepatoduodcnal ligament is incised (Fig. 1, B) and the common hepatic artery both proximal and distal to the gastroduodenal artery origin is encircled (Fig. 1, C). The descending duodenum is mobilized by Kocher's maneuver (Fig. 2), and dissection is carried along the anterior and right lateral border of the gastroduodenal artery to its bifurcation, or until the pancreas is encountered. It is then encircled and any small branches from it between its origin and its bifurcation are taken between ligatures of fmc silk. If the gastroduodenal artery is 3 cm in length before its bifurcation and if it appears that the internal diameter may be 3.5 m m after dilatation, this vessel may be suitable for primary end-to-end anastomosis to the right renal artery. The inferior vena cava and the right renal vein are identified and the right renal artery is encircled

where found, either immediately cephalad, behind, or caudad to the renal vein (Fig. 3). Frequently the most suitable part of the renal artery with which to work is that part involved with poststenotic dilatation, found immediately beyond the area of stenosis, usually at the renal artery ostium. To make this area available for anastomosis and to acquire as much length of renal artery as possible, the inferior vena cava may be encircled and the proximal right renal artery isolated subjacent to it, along its left border. To ensure the appropriate axial orientation of the right renal artery as it is rotated up to be anastomosed to the gastroduodenal artery, an adventitial stripe of fine silk suture material may be passed along the cephalad border of the renal artery. The origin of the gastroduodenal artery is occluded with a fine bulldog damp and the gastroduodenal artery is transected at its bifurcation and distally ligated. Thcreafter a No. 3 Fogarty embolectomy catheter is passed through the end of the gastroduodenal artery up into the hepatic artery, the balloon inflated with 0.6 ml of sterile injectable saline solution, then brought back through the gastroduodenal artery in the inflated position (Fig. 4). The gastroduodenal artery is quite elastic and can usually be safely dilated without damage to the artery. The occluding bulldog clamp at the origin of the gastroduodenal artery may then be released to assess the adequacy of flow through the artery. The right renal artery, after ligation at its origin and division and perfusion with chilled renal perfusion fluid (342 Osm, 1 L Ringer's lactate solution chilled to 3 ° C, 18 gm mannitol, 20 nag heparin, 500 mg methylprednisolone sodium succinate [Solu, Medrol]), is probed with progressively larger coronary dilators (Fig. 5). It is unwise to dilate this vessel with a Fogarty catheter because the intima is easily split. When allowed to rotate cephalad and if sufficient length is present, the right renal artery is spatulated on its superior surface and anastomosed end to end to the spamlated end of the gastroduodenal artery with an oblique anastomosis of 6-0 polypropylene (Prolene) suture (Fig. 5). If the length is insufficient to allow spamlation of the artery, end-toend anastomosis with interrupted simple everting sutures of 6-0 Prolene without spamlation may be possible. If there is undue tension, a reversed vein graft from the origin of the gastroduodenal artery down to the renal artery may be used. DISCUSSION In 1953, Hurwitt et alp reported a series of successful splanclmic artery anastomoses in dogs and suggested clinical application of these techniques in

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R~ht renal revascularization with gastroduodenal artery 157

Gastroduodenal A r t e r y

Point of "1

Renal

lm

Fig. 3. After identification of the inferior vena cava posterior to the duodenum, the right renal vein is identified, and the neighboring renal artery is encircled. The encircled gastroduodenal artery is gently occluded at its origin, divided at its bifurcation, and ligated distally.

humans for various disease processes. Use of the hepatic circulation for operative management of right renal artery disease was originally described by Libetxino et al? in 1976, and extensive clinical experience with this operation has been reported by Novick et al.4 in 1979, Chibaro et al.s in 1984, and Moncure et al. 1 in 1986. Libertino and Lagneau6 described the use of the gastroduodenal artery for revascularization of the right renal artery in 1983, describing it as an extension of the use of the hepatic circulation when concomitant aortic disease precludes safe use of the aortorenal bypass procedure. They stated that it should only be used in favorable anatomic circumstances and should be considered a variant of the hepatorenal bypass procedure. A major collateral pathway between the celiac axis and the superior mesenteric arterial beds, the gastroduodenal artery has been shown to have the capacity to dilate and to serve as a major source of arterial blood supply to the gastrointestinal tract. In the presence of patent celiac axis, and in the absence of superior mesenteric arterial ostial disease, it may safely be used as the source for arterial inflow and for revascularization of the right renal artery without placing the arterial supply to the intestine in jeopardy. Only one anastomosis is needed (Fig. 6) and the long-term possibility of vein graft failure is obviated, which, although slight, is a recognized entity. Experience with an analogous anatomic reconstruction, the internal mammary artery bypass graft used in revascularization of the coronary circulation has disclosed that the long-term patency of internal mammary artery grafts substantially exceeds that of saphenous vein graft. 7

,'-,._./

Fig. 4. A No. 3 Fogarty embolectomy catheter is passed into the hepatic artery, inflated, and slowly brought back through the gastroduodenal artery.

Preoperative angiography is necessary to exclude stenosis of the celiac trunk and origin of the superior mesenteric artery because it would be unwise to use the gastroduodenal artery in right renal artery revascularization in the face of inadequate inflow through

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Gastroduodenal Artery

, ,,,S" Fig. 6. Postoperative arteriogram shows the common hepatic artery (open arrow) and gastroduodenal-right renal artery end-to-end anastomosis (closed arrow).

Fig. 5. The renal artery after distal occlusion, division, and proximal ligation is probed with coronary dilators, and anastomosed end to end to the gastroduodenal artery.

the celiac trunk. In addition, it would be unwise to remove a major collateral pathway to the superior mesenteric arterial circulation if ostial disease of the superior mesenteric artery is present. Angiography is also used to document anatomic variations involving the celiac axis and superior mesenteric arterial circulations. The arteriogram may suggest that the gastroduodenal artery can be used as the primary inflow vessel for grafting (Fig. 7), but the ultimate decision can only be made during operation. The surgeon must have an alternative plan, which usually involves a reversed saphenous vein graft anastomosed to the side of the common hepatic artery and brought to the right renal artery if the gastroduodenal artery is of insufficient internal diameter or length to allow a primary end-to-end anastomosis. The gastroduodenal artery may be used as the source for arterial inflow in revascularization of the

Fig. 7. Arteriogram demonstrates the proximity and frequently similar diameter of the gastroduodenal artery (open arrow) and right renal artery (closed arrow).

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Right renal revascularization withgastroduodenal artery 159

right renal artery by end-to-end anastomosis in approximately 50% o f cases. Its advantages include the use o f only one anastomosis and the prevention o f the long-term possibility o f vein graft failure.

REFERENCES 1. Moncure AC, Brewster DC, Darling RC, Amip RG, Newton WD, Abbott WM. Use of the splenic and hepatic arteries for renal revascularization. J VASCSURG1986;3:196-203. 2. Hurwitt ES, Altman S, Borow M, Rosenblatt M. Intraabdominal arterial anastomoses. Surgery 1953;34:1043-60. 3. Libertino JA, Zinman L, Breslin DJ, Swinton NW. Hepatorenal artery bypass in the management of renovascular hypertension. J Urol 1976;115:369-72.

4. NovickAC, PalleschiJ, Straffon RA. Experimentaland clinical hepatorenal bypass as a means of revascularizationof the right renal artery. Surg Gynecol Obstet 1979;148:557-61. 5. Chibaro EK, LibervAnoJA, Novick AC. Use of the hepatic circulation for renal revascularization. Ann Surg 1984;199: 406-11. 6. Libertino JA, Lagneau P. A new rnethod of revascularization of the right renal artery by the gastroduodenal artery. Surg Gynecol Obstet 1983;156:221-23. 7. Grondin CM, Campeau L, LesperanceJ, EnjalbertM, Bourassa MG. Comparison of late changes in internal mammary artery and saphenous vein grafts in two consecutive series of patients 10 years after operation. Circulation 1984;70(suppl 1):20812.

L I E B I G F O U N D A T I O N AWARD FOR VASCULAR SURGICAL RESEARCH, 1989 The Liebig Foundation announces the eighth annual competitive award of $5000 for the best essay on a problem in general vascular surgery. The investigative work shall be: 1. Clinical or experimental research 2. Original and unpublished (nor submitted elsewhere for publication) 3. Performed by a house officer in the United States, Canada, or Mexico with senior collaborators acting in a consultive capacity 4. Submitted in English (6 copies of typed manuscript and 6 copies of glossy prints of illustrations) 5. Accompanied by a signed letter from the essayist's superior confirming the status of the essayist and complying with "Instructions to Authors" of the JOURNAL Previous winners were: 1988, Drew L. Kirshner, MD, University of Rochester Medical Center, Rochester, N.Y.; 1987, Peter D. Cahill, MD, Stanford University School of Medicine, Stanford, Calif. The winning essay will be judged for presentation at the June 1989 meeting of the North American Chapter, International Society for Cardiovascular Surgery and will be considered for publication in the JOUKNAL. Further inquiries may be directed to the same address to which the essays must be sent, postmarked before Dec. 31, 1988: Dr. Richard Turner Award Committee Secretary 112 Bauer Drive Oakland, NJ 07436 USA (201) 337-6126