Aortorenal arterial autografts: long-term assessment

Fibrodysplastic popliteal aneurysm and dilatation of pedal artery

We report a case of an asymptomatic popliteal aneurysm due to fibromuscular dysplasia (FMD), associated with suspected FMD of pedal artery on a 63-year-old woman. The popliteal aneurysm was resected. An in situ interposition of a short segment of hypogastric artery was performed to restore the arterial continuity. Popliteal FMD was confirmed by histological findings. Only 5 cases are reported in literature. FMD of pedal artery was suspected on the CT-scan aspect. FMD is a rare cause of popliteal aneurysm. To our knowledge, this is the first report of suspected fibrodysplastic dilatation of a foot artery.

Renovascular disease in children and adolescents

PURPOSE

This retrospective review describes the surgical management of renovascular disease in 25 consecutive children and adolescents with severe hypertension.

METHODS

Patients </=21 years of age (mean age, 11.6 +/- 5.4 years; 12 females, 13 males) underwent repair of 34 renal arteries (RAs), and their management forms the basis of this report. Early and late blood pressure responses were adjusted for gender, age, and height. RA repair was evaluated by angiography, renal duplex sonography (RDS) scanning, or both. Primary patency and survival were estimated by product-limit methods.

RESULTS

Thirty-four RAs among 32 kidneys were repaired. Bilateral renal RA disease to a solitary kidney was present in nine patients. RA lesions included dysplasia (44%), RA hypoplasia (20%), midaortic syndrome (12%), RA aneurysm (12%), dissection (8%), and arteritis (4%). All patients had severe hypertension (>95 th percentile systolic or diastolic pressure adjusted for gender, age, and height). RA repair comprised 25 bypasses (73%) consisting of 28% saphenous vein, 60% hypogastric artery, and 12% polytetrafluoroethylene; 2 patch angioplasties (6%), and 7 reimplantations (21%). Branch RA exposure was required in 28 kidneys (88%), and branch reconstruction was required in 61%. Warm in situ repair was used in 53%, in situ cold perfusion in 24%, and ex vivo cold perfusion in 23%. Of six bilateral RA repairs, one was staged and two patients are awaiting a staged repair. Combined aortic reconstruction was required in three patients. No unplanned nephrectomy was performed. There were no perioperative deaths. Hypertension was cured in 36%, improved in 56%, and failed in 8% at mean follow-up of 46.4 +/- 7.8 months. The mean calculated glomerular filtration rate increased from 82.0 mL/min/1.73 m 2 preoperatively to 98.2 mL/min/1.73 m 2 postoperatively. The postoperative patency of 30 RA reconstructions was evaluated by angiography, RDS scanning, or both. At mean follow-up of 32.8 months (median, 21.2 months), primary RA patency was 91%. No failures were observed after 2 months follow-up. Estimated survival was 100% at 60 months, with one death 9 years after surgery.

CONCLUSIONS

Renovascular hypertension in children and adolescents was caused by a heterogeneous group of lesions. All patients had RA repair, with arterial autografts in most of the RA bypasses. Cold perfusion preservation was used in half of the complex branch RA repairs. These strategies provided 91% primary patency at mean follow-up of 32.8 months, with beneficial blood pressure response in 92%. Surgical repair of clinically significant renovascular disease in children and adolescents is supported by these results.

Descending Thoracic and Thoracoabdominal Aortic Aneurysm in Patients with Takayasu's Disease

From June 1974 to December 2001 we performed operative treatment on 33 patients with descending thoracic or thoracoabdominal aortic aneurysm in association with Takayasu disease. There were 25 men and 8 women with a mean age of 40.2A years (range 16-64A years). Nineteen patients came from North Africa, 6 were from France, and 8 were from various locations in the world. The revealing symptom was hypertension in 12 cases, thoracic or abdominal pain in 7, isolated inflammatory syndrome in 5, neurologic or ocular manifestations in 3, rupture in 3, and embolization to the lower extremity in 1. In the remaining two cases discovery was coincidental. The aneurysm was confined to the thoracic aorta in 10 cases and involved both the thoracic and abdominal aorta in 23 cases. There were 8 type I, 6 type II, 4 type III, and 5 type IV aneurysms according to Crawford's classification. Two patients had undergone previous repair of the thoracoabdominal aorta. Four patients required first-stage treatment of a renal artery lesion to control hypertension. Six patients had associated aneurysms of the proximal aorta, including five treated via the distal elephant trunk technique in first-stage procedures. Aneurysm repair consisted of prosthetic replacement of the thoracoabdominal aorta in 31 cases, exclusion bypass in 1 case, and stent graft placement in 1 case. The procedure was performed with cross-clamping alone in 13 cases, distal perfusion in 17 cases, and deep hypothermic circulatory arrest in 3 cases. Twenty patients (61%) had associated renal and/or intestinal artery lesions that were treated during the same procedure as that for the thoracoabdominal aorta in 19 patients (58%). A total of 24 procedures were performed on renal arteries (17 revascularizations, 7 nephrectomies). Associated supraaortic trunks lesions were present in 15 patients (45%) and were treated in 12 patients, including 8 in first-stage procedures prior to thoracoabdominal aortic aneurysm repair. Three patients died of multiple organ failure, after reoperation in two cases and infection in one case involving prior long-term corticosteroid therapy. Three patients developed paraplegia, including one who had undergone emergency treatment following rupture. Two patients required reoperation, for hematoma in one case and bowel necrosis in one. Four patients developed respiratory complications requiring artificial ventilation for more than 48 hr. During follow-up, two patients died from complications after repair of the proximal aorta and one patient required nephrectomy. Despite the extent of aneurysmal lesions and high frequency of association with visceral and supraaortic vessel lesions, the outcome of surgery in patients presenting with descending thoracic or thoracoabdominal aortic aneurysm in association with Takayasu disease was satisfactory.

Acute lower extremity ischemia in a 7-year-old boy: an unusual case of popliteal entrapment syndrome

Popliteal artery entrapment syndrome is a rare cause of acute limb ischemia that most commonly is seen in young adults. The most significant complications associated with popliteal entrapment include aneurysm formation and acute thrombosis. This case presents the youngest patient ever reported with this syndrome and highlights the advantages of multimodal treatment including thrombolysis, popliteal aneurysm resection, and revascularization. Although a significant body of literature exists on popliteal entrapment syndrome in teenagers and young adults, it has not been reported previously in a patient younger than 11 years. Limb salvage was achieved in this patient with a combination of endovascular and surgical techniques.

Radial artery as conduit for distal renal artery reconstruction

Reconstruction of the renal artery with both saphenous vein and prosthetic material as bypass graft is durable in atherosclerotic disease. Extensive experience with saphenous vein grafts in pediatric patients and patients without atherosclerosis reveals a disturbing incidence of vein graft aneurysm degeneration. Distal renal artery reconstruction involving small branch vessels is generally not amenable to prosthetic reconstruction. We report a new approach to distal renal artery bypass grafting to avert these limitations.

CASE

A 43-year-old man with previously normal blood pressure had malignant hypertension, which proved difficult to control despite use of a beta-blocker and an angiotensin II inhibitor. At renal angiography a fusiform aneurysm was revealed in a posterior branch of the right renal artery. The renal artery aneurysm was resected, and the left radial artery was harvested and used as a sequential aortorenal bypass graft to the two branch renal arteries. The postoperative course was uneventful, and the patient now has normal blood pressure with a calcium channel blocker for maintenance of the radial artery graft. Pathologic analysis revealed a pseudoaneurysm with dissection between the media and external lamella, consistent with fibromuscular dysplasia.

CONCLUSION

Autologous artery is the preferred conduit for renal reconstruction in the pediatric population. On the basis of cardiac surgery experience, we used the radial artery and found it to be a technically satisfactory conduit for distal renal reconstruction in a patient without atherosclerosis.

Use of external iliac artery in renal revascularization surgery: long-term angiographic assessment

PURPOSE

The external iliac artery has physical characteristics, in particular, caliber and length, similar to those of the renal artery and would thus seem to be an ideal substitute for it. However, there are no studies in the literature designed to confirm this possibility. The present study was designed to demonstrate the feasibility of use of the external iliac artery as a substitute for the renal artery in surgical revascularization of renal artery fibrodysplasia and to assess the long-term biologic behavior of the external iliac artery so used.

METHODS

Twelve patients (11 female, 1 male), ages 1 to 43 years (mean, 24.4 years), with severe hypertension underwent aortorenal bypass grafting with use of the external iliac artery to treat preocclusive stenotic lesions (n = 7), complete occlusion (n = 3), or aneurysm (n = 2) of the renal artery. It was considered unnecessary to reestablish circulation in the donor limb in 2 patients (young children), and transposition of the ipsilateral internal iliac artery was performed in 9 patients; in the remaining patient circulation was reestablished with insertion of an iliofemoral prosthesis.

RESULTS

There were no operative deaths. In 1 patient nephrectomy was necessary because of occlusion of the graft as a consequence of technical complications. In 8 patients there was immediate normalization of blood pressure without aid of medication, and in the remaining 3 patients an antihypertensive drug was prescribed. Two patients were lost to follow-up; the other 9 were assessed with angiography at a mean of 8.8 years after the operation. All grafts were found to be in excellent condition, with no evidence of dilatation, kinking, twisting, anastomotic fibroplasia, or wall irregularities.

CONCLUSION

On the basis of this experience, the external iliac artery is confirmed as a substitute for the renal artery, and the excellent long-term results would seem to make it particularly useful in young patients with long life expectancy, such as those with renal artery fibrodysplasia.

Intentional internal iliac artery occlusion to facilitate endovascular repair of aortoiliac aneurysms

PURPOSE

The safety of intentional occlusion of patent internal iliac arteries (IIAs) to facilitate the endovascular repair of aortoiliac artery aneurysms (abdominal aortic aneurysms [AAAs] and iliac aneurysms [IAs]) was evaluated.

METHODS

We analyzed the techniques and clinical sequelae of selective occlusion of one or both IIAs in 103 patients and correlated these findings with the results of preoperative angiograms to identify vascular anatomy that may predict postoperative pelvic ischemia. To quantify the clinical presentation of pelvic ischemia, we developed these criteria: class 0, no symptoms; class I, nonlimiting claudication with exercise; class II, new onset impotence, with or without moderate to severe buttock pain, leading to physical limitation with exercise; class III, buttock rest pain, colonic ischemia, or both. IIA occlusion was achieved in 100% of the patients by means of either catheter-directed embolization or orificial coverage with a stent-graft. No patient in this study had angiographic evidence of significant visceral occlusive disease before the procedure. Sixty-four patients had isolated AAAs, 23 patients had AAAs and IAs, and 16 patients had isolated IAs. Ninety-two patients had one IIA selectively occluded, and 11 patients had both IIAs selectively occluded.

RESULTS

After IIA occlusion, 12 patients were categorized in class I, 9 patients were categorized in class II, and 1 patient was categorized in class III, for a total of 22 patients (21%) with pelvic ischemia. Sixteen (17%) of 92 patients had unilateral IIA occlusions, and six (17%) of 11 patients had bilateral IIA occlusions. Five patients in class I improved and had no symptoms within 1 year, and one patient in class II was downgraded to class I because of improved symptoms. Two unique preoperative angiographic findings were identified in the remaining 16 patients (16%) with chronic pelvic claudication: (1) stenosis of the remaining IIA origin (> 70%) with nonopacification of more than three of the six IIA branches (63%); and (2) small caliber, diseased or absent medial and lateral femoral circumflex arteries ipsilateral to the side of the IIA occlusion (25%). One patient with class III ischemia died of cardiovascular collapse associated with colon infarction caused by either acute ischemia or particulate embolization.

CONCLUSION

The incidence of pelvic ischemia after IIA occlusion is 20% immediately after endovascular aortoiliac aneurysm repair. A total of 25% of patients had no symptoms within 1 year. Two preoperative radiologic findings may help identify patients who are at risk for pelvic ischemia: stenosis of the patent IIA and disease deep femoral ascending branches ipsilateral to the occluded IIA. The risk of colon ischemia appears to be small after selective IIA occlusion to facilitate endovascular AAA repair.

Obtaining a superficial femoral artery graft in adolescents and children with the deep femoral artery transposition

A new technique to obtain a segment of the superficial femoral artery as an arterial conduit in young patients while an unobstructed peripheral blood flow is maintained by superficial femoral artery-deep femoral artery transposition is illustrated with two clinical examples. The explanted arterial autograft requires no replacement by another graft and provides a conduit of up to 10 cm in length. Excellent results were achieved in both patients at 1 year. This technique is recommended instead of saphenous vein conduits in very young patients because of the risk for late vein degeneration.

Long-term outcome with surgical treatment of renovascular hypertension

PURPOSE

The purpose of this study was to prospectively study certain surgical approaches to renal artery stenosis and the long-term outcomes.

METHODS

One hundred thirty-six children were evaluated for severe hypertension, 53 had renovascular lesions. The approach to diagnosis, the role of balloon angioplasty, comparison of reimplantation with bypass grafting, the role of vein grafts and the incidence of graft aneurysm formation, the possible protective effect of vein graft mesh wraps, and approaches to treatment of associated aortic and visceral artery narrowing were all studied prospectively and the long-term results evaluated.

RESULTS

Fibromuscular hyperplasia (FMH) was the main etiology (45 of 53 patients), with 17 of these having midaortic involvement as well. Sex distribution was equal; average age was 9 years. Malignant hypertension was the rule, and three had renal failure. Twenty-three of the 45 had bilateral vessel involvement. Fifty of the 53 patients underwent operation. Aortography was the most definitive approach to diagnosis and planning therapy. Balloon angioplasty was used in eight patients, but this only worked long term in branch vessel locations or at graft anastomoses. A variety of surgical approaches were used depending on the pathology encountered. Thirty-eight patients underwent revascularization, seven underwent primary nephrectomy, five underwent primary partial nephrectomy, and 12 had aortoaortic bypass performed. Seventy percent were cured, 26% improved; and 4% did not respond to treatment with up to 16 years of follow-up. There was no mortality.

David M. Hume memorial lecture. Surgical treatment of renovascular hypertension

BACKGROUND

Renal artery occlusive disease is the most common form of surgically correctable hypertension. Considerable scientific advances have improved our understanding of the pathophysiologic sequellae of a renal artery stenosis, the means of documenting the functional importance of such lesions, and the role of alternative surgical approaches in treating this disease. This work assesses the historical basis for the surgical treatment of renovascular hypertension.

DATA SOURCES

A review of the American literature on the subject of renovascular hypertension was undertaken, with particular attention to early work emanating from the University of California, San Francisco, the University of Michigan, and Vanderbilt University. These three institutions had considerable influence on the evolving techniques of operative intervention for renovascular hypertension.

CONCLUSIONS

The contemporary surgical management of renal artery stenotic disease causing secondary hypertension includes recognition of the heterogeneic character renal artery diseases, documentation of the functional significance of the stenoses, and performance of a properly chosen operation. Surgical therapy benefits 85% to 95% of properly selected patients having renovascular hypertension.

Iatrogenic external iliac artery disruption during open pelvic lymph node dissection: successful repair with hypogastric artery transposition

We report the first case of a wide, iatrogenic, proximal disruption of the right external iliac artery, occurring during staging open lymph node dissection for prostate cancer, which was repaired by hypogastric artery transposition. The hypogastric artery was mobilized and rotated anteriorly, and sutured to the distal segment of the external iliac artery. This is a feasible, innovative and safe technique which permits, by a single anastomosis, the secure reconstruction of a vascular axis to the leg when other procedures are not accessible.

The case for renal revascularization

This report reviews renovascular disease, hypertension and renal parenchymal dysfunction. The primary lesions responsible are discussed as well as the strategies for restoring normal renal perfusion. The natural history studies document progressive impairment of renal perfusion and the consequence of renal dysfunction. Renal revascularization interrupts this pathway by relieving or lessening hypertension and preserving renal function which are the therapeutic options.

Midaortic syndrome and hypertension in childhood

Midaortic syndrome is a form of fibromuscular hyperplasia that involves the abdominal aorta including the renal and visceral branches. Symptomatology depends on the degree and location of vessel narrowing. This report updates the authors' experience and details 17 operative cases, the largest reported series. Seventeen of the 45 patients who have been operated on for severe renovascular hypertension have had this syndrome. Ages have ranged from 5 months to 15 years (average, 9.7 years). Signs and symptoms have included various manifestations of malignant hypertension, congestive heart failure, oliguric renal failure, and claudication. Intestinal angina has not been noted despite celiac and/or superior mesenteric arterial involvement. Although balloon angioplasty was performed in two patients, lasting results were not achieved. One primary nephrectomy was performed. The other 16 patients had vascular reconstructions including aortoaortic bypass grafting (n = 12), with bilateral renal artery bypasses (n = 9) or unilateral renal bypass (n = 3) or bilateral renal bypass alone (n = 4). The majority had associated visceral artery narrowing, but excellent collaterals have been present so no visceral reconstructions have been required. All renal artery bypasses have been with reinforced saphenous vein.

RESULTS

In the average follow-up period of 48 months, 12 of the 17 patients have been cured of hypertension, and the other five have improved. Claudication, congestive failure, and renal failure have been alleviated. Thus far, reinforcement of the saphenous vein grafts has prevented aneurysmal degeneration and graft loss.

CONCLUSION

These results indicate that aggressive single-stage reconstruction is the best approach for these children.

Complex branch renovascular disease: management options and late results

PURPOSE

The purpose of this report is to review management options and late results of complex renovascular disease managed over the last 22 years.

METHODS

Complex branch renal artery disease in 84 kidneys was repaired during 75 operations performed in 68 consecutive patients. There were 61 females (90%) and 7 males (10%) whose predominant pathologic diagnosis was fibromuscular dysplasia manifesting as either renovascular hypertension or aneurysmal degeneration. These patients underwent 15 in situ, 52 ex vivo, and 8 combined reconstructions. In situ repair primarily with use of the bifurcated internal iliac artery autograft was used for primary lesions of the proximal renal artery bifurcation (two branches). Ex vivo repairs, primarily with use of the multibranch internal iliac autograft and hypothermic perfusion preservation, were used for all other patterns of distal renal artery branch disease and reoperative problems.

RESULTS

Renovascular reconstruction was successful in salvaging 83 of 84 kidneys (98.8%) in 67 of 68 patients. There were no operative deaths. Two reconstructions thrombosed in the early postoperative period. One was due to severe aortic disease, the other to branch artery dissection after a failed balloon angioplasty. Both patients continued to have hypertension. Before hospital discharge 65 patients had 81 renal revascularizations proven patent by arteriography. Their renal function was assessed and blood pressure was determined in a follow-up extending to 20 years (mean 7.5 years, median 7.9 years). Late arteriograms were obtained in 30 patients (46%) an average of 52 months after operation (range 6 months to 18 years). They demonstrate stable renal artery repair with no evidence of late graft failure in each. Hypertension was cured or improved in 51 of 53 patients (96%) with a proven patent reconstruction. Aneurysms were successfully repaired in 11 patients. Renal function was improved in four patients with ex vivo repairs, unchanged in 59 patients (15 in situ, 44 ex vivo), and persistently worse in only three patients, all of whom had in situ repairs.

CONCLUSION

The branched arterial autograft allows the restoration of normal renal arterial anatomy and function when inserted to replace complex distal renovascular disease. This provides a durable repair, essential for younger patients affected by this pattern of disease who anticipate a normal life span after renovascular repair. Successful long-term correction of diastolic hypertension and aneurysmal disease was accomplished without significant morbidity.

The durability of different reconstructive techniques for atherosclerotic renal artery disease

PURPOSE

Among various surgical techniques for renal artery reconstruction (RAR), anatomic aortorenal bypass has been the preferred standard. Yet concern regarding origin of the bypass from a diseased aorta and desire to avoid a major aortic operation in these patients who are often at poor risk has led to increasing use of extraanatomic bypass grafting, particularly hepatorenal and splenorenal bypass. This study was conducted to compare the safety and long-term performance of these different techniques of renal artery reconstruction.

METHODS

We reviewed a 15-year (1976 to 1991) experience with 323 surgical RAR performed in 285 patients with atherosclerotic renovascular disease. Long-term patency and survival rates were analyzed by life-table methods. Variables potentially affecting early failure of the RAR and perioperative and late mortality rates were examined by Cox proportional hazards models.

RESULTS

Diffuse atherosclerosis characterized the patients' clinical profile. Clinically evident coronary artery disease was present in 54% of patients, and some degree of renal insufficiency was present in 60%. Ninety-five percent of patients had hypertension with poor control of hypertension seen in 50%. Aortic disease necessitated combined aortic grafting and RAR in 43% of the study group. Various techniques of RAR were used as follows: endarterectomy or patch angioplasty, 8.5%; extraanatomic bypass grafting, 37% (hepatorenal, 62; splenorenal, 52; iliorenal, 7); and aortorenal bypass grafting, 54% (native aorta, 34; combined aortic graft and RAR, 140). Early failure of the RAR occurred in 5% of cases, and the operative mortality rate for the entire cohort was 5.6%. Median follow-up duration was 9.4 years. A comparison of early and late patency for the major types of RAR revealed equivalent (p = 0.44) performance of aortorenal and extraanatomic bypass grafting. Perioperative complications occurred more frequently (p < 0.02) in patients undergoing combined operations. The cumulative 5-year survival rate for all patients was 75%.

CONCLUSIONS

Because extraanatomic bypass grafting can provide long-term results equivalent to aortorenal bypass grafting, the choice among techniques for RAR in patients with diffuse atherosclerosis should be based on both technical and operative safety considerations, rather than adherence to aortorenal bypass grafting as an inherently superior technique.

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.

The mid-aortic dysplastic syndrome. Surgical considerations with a 2 to 18 year follow-up and selective histopathological study

Mild-aortic dysplastic syndrome is usually presented with advanced hypertension in young individuals in association with either weak or absent femoral pulses, due to diffuse narrowing of the aorta in its mid thoraco-abdominal course. There is frequent involvement of visceral arterial branches such as renal and superior mesenteric arteries. Although the disease has been popularised by the appealing name of "abdominal coarctation", the term mid-aortic dysplastic syndrome is more appropriate. In spite of the fact that the syndrome was described almost three decades ago, its exact aetiology remains obscure and pathogenesis speculative. Surgical revascularisation remains the only therapeutic remedy, in dealing with this particular group of young hypertensive patients. The clinical presentation, angiographic assessment and long-term outcome, following reconstruction in 11 patients (mean age 24.4 years) with mid-aortic dysplastic syndrome were evaluated, in an effort to determine the effectiveness of surgery. Late follow-up, slightly exceeding 16 years (mean 5.6 years) has shown normal and relief from hypertension in practically all individuals. Furthermore, in order to elucidate at least some aspects of histopathology, studies were undertaken upon specimens from the aortic wall and the renal, carotid, lumbar and brachial arteries. The results suggested predominantly dysplastic features in the media, intima and particularly along the course of internal lamina. Aortography, using different projections, revealed variable patterns of high mid-aortic stenosis with or without associated renal artery disease. All patients were hypertensive (mean blood pressure 170 mmHg) and co-exist renal artery disease, unilateral in three and bilateral in three cases, was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of renal artery reconstruction with autogenous artery in patients with renovascular hypertension

Renal artery reconstruction for the treatment of renovascular hypertension is preferably performed with an autologous graft when a graft is required. Although satisfactory results with vein grafts have been reported, stenosis and dilatation are not infrequent complications which have been observed only occasionally in arterial grafts. We have analysed our long-term results obtained with autogenous arterial grafts for renal artery reconstruction to determine the functional and anatomical results with regard to these complications. The data from 57 survivors operated on from 1959 through 1983 were analysed. All patients were hypertensive and the average systolic and diastolic blood pressure was 173/109 mmHg (mean number of 2.2 drugs). The renal artery stenosis was caused by arteriosclerosis and fibrodysplasia in 24 and 33 patients, respectively. In situ repair was performed in 30 patients (arterial bypass: 17 patients; splenorenal bypass: 13 patients). Extracorporeal repair of fibrodysplastic branch lesions was performed in 27 patients using branched hypogastric artery grafts (mean number of 2.4 branch anastomoses per kidney). Results were evaluated in the short (mean 8.3 months) and long term (mean 7.5 years) and the blood pressure response classified as either beneficial (cured/improved) or failed. Anatomical results were evaluated by angiography in the short-term in 87% of the patients and the long-term in 70%. A beneficial blood pressure response was obtained in 77% and 86% of patients in the short and long-term, respectively. The average blood pressure level after an interval of several years (long term) was 144/87 mmHg (mean number of 0.9 antihypertensive drugs). After in situ reconstruction, 2 and 1 anatomical failures were observed in the short and long-term, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Renovascular reconstruction: factors affecting long-term prognosis in 919 patients followed up to 31 years

During the 31-year period from May 3, 1955, to May 12, 1986, renovascular reconstructions were performed on 919 patients. The mean age of the 529 men was 54 +/- 0.58 (SE) years and, of the 390 women, 48 +/- 0.7 years. Mean preoperative diastolic blood pressure was 110 +/- 0.6 mm Hg. The most common causes of renal artery stenosis were atherosclerosis in 647 patients, fibromuscular disease in 161 patients, and renal artery aneurysm in 51 patients. In the remaining 60 patients, other causes were present, including kinks and fibrous bands. The most common surgical procedures were Dacron bypass graft (780 arteries) and endarterectomy with or without a patch graft (329 arteries). Four hundred sixty-nine patients had associated operations, the most common of which were abdominal aortic aneurysmectomy in 231 and aortoiliofemoral reconstruction in 141 patients. The perioperative mortality rate was 5.5% (51 of 919 overall); for renal procedures alone, it was 1.7% (8 of 450) and for combined surgical procedures, 9.2% (43 of 469). The overall graft patency rate at a follow-up of 18.8 +/- 1.9 months was 88.6% (381 of 430) and at a second follow-up of 50 +/- 4.3 months, 86.7% (111 of 128). Analysis of long-term blood pressure response and factors affecting late survival indicated that patients with preoperative diastolic pressures of greater than 100 mm Hg and renal artery stenosis of greater than 70% had the best blood pressure responses and that male sex, increasing age, bilateral renal stenosis, and associated vascular operations lowered the survival rate whereas fibromuscular disease enhanced the duration of survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Renovascular hypertension in children. Surgical repair with special reference to the use of reinforced vein grafts

Surgical correction of renovascular hypertension in children is especially challenging because there is high incidence of bilateral renal artery lesions and stenosis of the abdominal aorta. Seventeen patients with severe hypertension, whose ages ranged from 2 to 16 years (mean 10.2 years), had surgical repair of these lesions from 1974 to 1987. Twenty-nine renal artery lesions were repaired. Twelve (71%) were bilateral, five (29%) were unilateral, and eight patients (47%) had abdominal aortic lesions (midaortic stenosis). Twenty-eight saphenous vein grafts and one splenorenal graft were used to bypass the renal artery lesions. The midaortic lesions were bypassed with Dacron grafts from the superceliac aorta to the aortic bifurcation. No operative deaths occurred. Nineteen of the 28 vein grafts were reinforced with a 6 mm diameter tubular Dacron mesh to prevent aneurysmal degeneration seen in three of nine unsupported vein grafts. Follow-up arteriograms were available in 15 patients up to 11 years after operation (mean 5.0 years). There has been no aneurysmal dilatation in the 19 mesh-supported grafts. The ratio of vein graft diameter to the diameter of the native aorta was 1.25 +/- 0.38 (+/- standard deviation) in unsupported grafts and 0.65 +/- 0.09 in mesh-supported grafts, representing a 92% increased diameter in the unsupported grafts. Three vein grafts (10.3%) required percutaneous transluminal angioplasty for late postoperative vein graft stenoses, but no stenotic lesions have developed at the aortic suture lines. One graft occluded 7 years postoperatively after replacement of an aneurysmal vein graft, and one early postoperative graft occlusion occurred, for a graft failure rate of 7%. Seventy-six percent of patients (13 of 17) are normotensive without medication, and 24% (4 of 17) are considered improved with hypertension controlled with a lower dose of medication. Our results attest to the safety and efficacy of this complicated surgery. Saphenous veins, supported by external Dacron mesh, appear to be a suitable graft material for renal reconstruction in this population.

Surgical correction of renovascular hypertension

The role of surgical revascularization in the management of patients with renal artery disease has changed in recent years. This has occurred owing to the advent of transluminal angioplasty as an effective method of treatment for certain patients, improved results of surgical revascularization in older patients with atherosclerosis, an enhanced appreciation of advanced atherosclerotic renal artery disease as a correctable cause of renal failure, and the development of more effective surgical techniques for patients with severe aortic atherosclerosis and branch renal artery disease. Surgical revascularization is at present the treatment of choice for patients with branch renal artery disease, ostial atherosclerotic renal artery disease, a renal artery aneurysm, and patients in whom renal angioplasty has been unsuccessful. Excellent clinical results continue to be achieved with surgical revascularization in properly selected patients.

Aortorenal arterial autografts: the last two decades

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 disease-free 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.

Arterial fibromuscular dysplasia

Fibromuscular dysplasia is a nonatherosclerotic, noninflammatory vascular disease that involves primarily the renal and internal carotid arteries and less often the vertebral, iliac, subclavian, and visceral arteries. Although its pathogenesis is not completely understood, humoral, mechanical, and genetic factors as well as mural ischemia may play a role. The natural history is relatively benign, with progression occurring in only a minority of the patients. Typical clinical manifestations are renovascular hypertension, stroke, subarachnoid hemorrhage, abdominal angina, or claudication of the legs or arms. In patients with symptoms, percutaneous transluminal angioplasty has emerged as the treatment of choice in most involved vascular beds.

Evolving strategies for the repair of complex renovascular lesions

Fifty-five patients with 59 complex renovascular lesions required two or more branch artery anastomoses during aortorenal grafting. Forty-five reconstructions involving 112 branches were facilitated using hypothermic ex vivo perfusion preservation, whereas 14 involving 28 branches were repaired in situ. Ex vivo repair was used whenever the kidney was considered unreconstructable by in situ techniques. Fibromuscular dysplasia predominated and the branched internal iliac artery was used for renal artery substitution. There were no deaths and only one kidney (ex vivo) was lost. Branch vessel occlusion occurred in two of 140 anastomoses (1.4%). Ninety-eight per cent (51/52) of the heparinized patients had cure or improvement at mean follow-up of 5 years. No late graft dysfunction occurred in postoperative angiographic follow-up. The branched internal iliac artery is uniquely suited and remains the preference of the authors for the replacement of the diseased renal artery and its branches. The in situ repair is ideally suited for lesions limited to the renal artery bifurcation. Ex vivo repair is reserved for complex or reoperative distal arterial lesions. Unique characteristics in the group include: bilateral lesions (25%), solitary kidney (22%), reoperative lesions (16%), children (9%), and coexisting significant aortic disease (7%). In situ and ex vivo repair meet all the challenges of complex renovascular disease. The strategies outlined will achieve outstanding long-term total and segmental renal salvage in the treatment of hypertension or aneurysmal disease. When ex vivo repair is required, it can be accomplished with only one additional simple maneuver, the reanastomosis of the renal vein.

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

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

Treatment of renovascular hypertension by unilateral nephrectomy. A follow-up study in patients above 60 years of age

The long term results of surgical intervention in 26 elderly patients with renovascular hypertension are presented. All patients were above 60 years of age at the day of operation. The majority of the patients had atherosclerotic renovascular disease with only one case of fibromuscular dysplasia. Several patients had severe extrarenal atherosclerotic disease. The diagnosis of renovascular hypertension was based upon the results of isotope renography, renal arteriography and renal vein catheterization. All patients underwent unilateral nephrectomy. Notably, no deaths or complications occurred in relation to surgery. At the follow-up study, blood pressure was lowered and the requirement for antihypertensive drugs reduced in 86% of the patients. We conclude that unilateral nephrectomy in elderly high risk patients with renovascular hypertension is a safe and efficient procedure.

Role of balloon dilatation in the treatment of renovascular hypertension

Renal angioplasty is now well established as a treatment for renovascular hypertension. In patients with fibromuscular dysplasia, the technique is usually technically successful, and the therapeutic effect on blood pressure is as good as with surgical revascularization. In patients with atheroma, the success rate is lower, mainly because of technical problems associated with inability to pass the catheter across the stenosis. In patients in whom this can be done, the results are similar to those of surgery. In our experience, the rate of restenosis is acceptably low, and in most patients, improvement has been maintained over two years. Selection of suitable patients is based on screening from the clinical history and examination, combined with renin-sodium profiling. Renal vein renin measurements have been found reliably to predict the therapeutic outcome of angioplasty, and the incremental method of Vaughan has been preferable to use of the ratio between the two renal veins. In patients with high renin-sodium profiles or in those with normal profiles and a clinical suspicion of renovascular hypertension, renal vein renin values would be determined next, usually with digital intravenous angioplasty. A single test dose of captopril may also be useful as a screening test. If these procedures do indicate the presence of renovascular hypertension, the patient is admitted to the hospital, and arteriography and angioplasty are performed at the same session.

Percutaneous transluminal angioplasty. The radiologist's contribution to the treatment of vascular disease

Percutaneous transluminal angioplasty is a nonsurgical treatment for vascular disease. It is relatively safe and economical and may be an alternative, or an adjunct, to surgery, or may be helpful where no surgical alternative exists. Percutaneous transluminal angioplasty is applicable to nearly every system, except the carotid bifurcation plaque.

Percutaneous transluminal renal angioplasty in renovascular hypertension due to atheroma or fibromuscular dysplasia

We attempted percutaneous transluminal renal angioplasty in 89 patients with hypertension and renal-artery stenosis (including 51 with atheromatous and 31 with fibromuscular stenoses) who were then followed for an average of 16 months (range, 4 to 40). Angioplasty was technically successful in 87 per cent of the fibromuscular stenoses and in 57 per cent of the unilateral atheromatous stenoses but in only 10 per cent of the bilateral atheromatous stenoses. After successful angioplasty, blood pressure was reduced to normal or improved in 93 per cent of the patients with fibromuscular dysplasia and in 84 per cent of the patients with atheromatous disease. Angiographic follow-up at an average of 21.8 months in 15 patients showed persistent relief of the stenoses and a 12 per cent average increase in kidney size. Renal angioplasty is effective for long-term control of hypertension in patients with renal-artery stenosis due to fibromuscular dysplasia or unilateral non-ostial atheroma.

Renovascular hypertension: surgical treatment

Renovascular occlusive disease is a common form of surgically remediable secondary hypertension. Operative options include: Bypass grafts, ex vivo reconstructions, endarterectomy, and transluminal dilation. Primary nephrectomy is undertaken only for irreparably diseased ischemic kidneys. Excellent results of surgical treatment reflect accurate identification of operative candidates and performance of appropriate operative procedures. Surgical benefits are more likely in pediatric patients and adults with fibrodysplastic or focal arteriosclerotic renovascular disease than in patients with clinically overt generalized arteriosclerosis. A review of 1631 renovascular hypertensive patients treated operatively documented a salutary outcome in 85-90% of patients.