Renal and intestinal artery occlusive disease

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.

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.