Use of the splenic and hepatic artery for renal revascularization in patients with atherosclerotic renal artery disease

Treatment of distal splenic artery aneurysm by laparoscopic aneurysmectomy with end-to-end anastomosis: A case report

RATIONALE

Splenic artery aneurysm (SAA) is the most common visceral artery aneurysm, while most SAAs are treated by endovascular or open procedures.

PATIENT CONCERNS

Here we present a case of SAA treated by laparoscopic aneurysmectomy with end-to-end anastomosis.

DIAGNOSES

A 40-year-old woman was incidentally found to have an asymptomatic distal SAA. CT scan revealed the SAA to be located at the hilum of the spleen, with a maximal diameter of 2.7 cm.

INTERVENTIONS

To prevent sudden rupture, the patient received laparoscopic aneurysmectomy. During the operation, end-to-end anastomosis was also performed since a tortuous proximal splenic artery prevented delivery of the stent graft.

OUTCOMES

The patient was ambulated 12 hours after surgery and discharged 5 days later. Postoperative recovery was smooth without hemorrhage, infarction, infection, or splenic artery thrombosis. At 10-month follow-up,no hemorrhage, aneurysm recurrence, spleen infarction, splenic artery stenosis, or thrombosis had occurred.

LESSONS

Patients with distal SAA can be treated by laparoscopic aneurysmectomy with end-to-end anastomosis to preserve the spleen. The laparoscopic procedure is safe and feasible in the selected patients.

Endovascular Exclusion of Saphenous Vein Graft Aneurysms Complicating Abdominal Aortic Aneurysm Repair

A 64-year-old man was referred for vascular evaluation before renal transplantation for ischemic nephropathy. In the past he had undergone bilateral renal artery revascularizations using saphenous vein. At the time of transplant evaluation, he was found to have bilateral aneurysms of the saphenous veins used to bypass his renal artery stenoses. He underwent successful endovascular exclusion of the aneurysms with 2 endovascular AneuRx extension cuffs. This case highlights both the versatility of endovascular treatments as well as the importance of a comprehensive vascular examination.

Open repair, endovascular repair, and conservative management of true splenic artery aneurysms

OBJECTIVE

True splenic artery aneurysms (SAAs) are a rare but potentially fatal pathology. For many years, open repair (OPEN) and conservative management (CONS) were the treatments of choice, but throughout the last decade endovascular repair (EV) has become increasingly used. The purpose of the present study was to perform a systematic review and meta-analysis evaluating the outcomes of the three major treatment modalities (OPEN, EV, and CONS) for the management of SAAs.

METHODS

A systematic review of all studies describing the outcomes of SAAs treated with OPEN, EV, or CONS was performed using seven large medical databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to ensure a high-quality review. All articles were subject to critical appraisal for relevance, validity, and availability of data regarding characteristics and outcomes. All data were systematically pooled, and meta-analyses were performed on several outcomes, including early and late mortality, complications, and number of reinterventions.

RESULTS

Original data of 1321 patients with true SAAs were identified in 47 articles. OPEN contained 511 patients (38.7%) in 31 articles, followed by 425 patients (32.2%) in CONS in 16 articles and 385 patients (29.1%) in EV in 33 articles. The CONS group had fewer symptomatic patients (9.5% vs 28.7% in OPEN and 28.8% in EV; P < .001) and fewer ruptured aneurysms (0.2% vs 18.4% in OPEN and 8.8% in EV; P < .001), but no significant differences were found in existing comorbidities. CONS patients were usually older and had smaller-sized aneurysms than patients in the OPEN and EV groups. The only identified difference in baseline characteristics between OPEN and EV was the number of ruptured aneurysms (18.4% vs 8.8%; P < .001). OPEN had a higher 30-day mortality than EV (5.1% vs 0.6%; P < .001), whereas minor complications occurred in a larger number of the EV patients. EV required more reinterventions per year (3.2%) compared with OPEN (0.5%) and CONS (1.2%; P < .001). The late mortality rate was higher in patients treated with CONS (4.9% vs 2.1% in OPEN and 1.4% in EV; P = .04).

CONCLUSIONS

EV of SAA has better short-term results compared with OPEN, including significantly lower perioperative mortality. OPEN is associated with fewer late complications and fewer reinterventions during follow-up. Patients treated with CONS showed a higher late mortality rate. Ruptured SAAs are predictors of a significantly higher perioperative mortality compared with nonruptured SAAs in the OPEN and EV groups.

A New Extra-anatomical Bypass for Atypical Aortic Coarctation with Porcelain Aorta: Reno-iliac Arterial Bypass

We report a case of atypical aortic coarctation with severe calcification of the proximal aorta treated by a new extra-anatomical bypass. This 58-year-old woman with coarctation of the infrarenal aorta had thick circular calcifications of the thoracic aorta and stenosis of the subclavian arteries. To control the progressive claudication, we performed a bypass with an externally supported PTFE graft 6mm in diameter between the right renal artery and the right common iliac artery. Postoperative ankle pressure rose to 84 mmHg (right) and 89 mmHg (left) from zero, and she could walk without pain. Renal function was preserved. Using the proximal anastomosis from the non-diseased aortic branch to avoid the calcified aorta, reno-iliac arterial bypass is a useful alternative for control of ischemic lower limbs.

[Orthotopic renal transplant: our experience]

Orthotopic renal transplant (ORT) is useful in cases of severe atherosclerosis, heterotopic bilateral transplant, unsuitable pelvic vessels and in aortic thrombosis, but it is not available in all the institutions and it is only realized of exceptional form.

AIM

To review the indication, surgical technique and outcome of the ORT at our hospital.

MATERIAL AND METHODS

The studied included five cases between January 1990 and December 2005. We analyzed several variables: demographic characteristics, characteristics of the donor, ischemia times, evolution of renal function and morbi-mortality associated.

RESULTS

Left ORT was performed in three men and two women. Mean patient age was 52+/-5 years, all the patients received kidneys from cadaveric donors. Mean creatinine and urea one month postoperative were 2.2+/-0.72 mg/dl and 103+/-17.2 mg/dl and at 6 months postoperative were 1.8+/-0.59 mg/dl and 78+/-14 mg/dl respectively. Immediately all patients received prophylaxis with low molecular weight heparin but it was indicated antiaggregation to two patients when they left the hospital, anticoagulation to two patients and to one of them was decided to anticoagulation nor antiagregation for history of bled digestive. A patient died for bleeding episode at level of the renal graft six months after the transplant, she was in treatment with dicumarinics, they were indicated by venous deep thrombosis in right leg. The survival a year is 80 % of the graft and the patient. Only two patients returned to hospital later, one of them for presenting an episode of diverticulitis and the other one for renal obstructive failure that needed laying of catheter pig-tail. Four patients presented stenosis of renal native vassels detected in control magnetic nuclear resonance, not symptomatic. There are two patients who take more than three years transplanted with renal stable function (creatinina 1.3 mg/dl and 1.4 mg/dl respectively).

CONCLUSION

ORT is an excellent option in patients with co-morbidity increased for atherosclerosis and that cannot be placed in the iliac fossaes.

Long-Term Follow-up of Renal Artery Stenting in an Australian Population

BACKGROUND

Renal artery stenosis comprises both atherosclerotic renovascular disease and fibromuscular dysplasia, and may be associated with refractory hypertension, acute 'flash' pulmonary oedema and renal failure. The long-term clinical effects of renal artery stenting remain unclear.

AIM

To assess the procedural and long-term safety and efficacy of renal artery stenting and its effect on blood pressure, antihypertensive medication usage and serum creatinine.

METHODS

All patients referred for renal artery stenting at our institution between September 1997 and December 2003 were entered into a prospectively collected database. Systolic and diastolic blood pressure, number of antihypertensive medications, serum creatinine and estimated glomerular filtration rate (eGFR) were recorded. Patients were followed-up at least six months post-procedure.

RESULTS

Eighty-nine patients underwent renal arteriography, with 110 stents deployed in 102 lesions. The procedural success rate was 99% with no procedural mortality. There were two cases of peri-procedural haemorrhage and one of sepsis. One patient developed renal and peripheral atheroemboli.

FOLLOW-UP

Mean follow-up was 28 months (range 6 months-7 years). Eight patients were lost to follow-up. There were nine deaths with a mean time to death of 20.7 months (range 12 months-3 years). There was a highly statistically significant fall in systolic blood pressure (BP) from 161.7+/-29.5 mmHg pre-procedure to 138.7+/-17.9 mmHg at long-term follow-up post-procedure (p<0.0001). The clinical restenosis rate was 6.2%. Renal function and eGFR remained stable and there was a borderline significant decrease in the number of antihypertensive medications used (p=0.05).

CONCLUSION

Renal artery stenting is safe and appears effective for the treatment of clinically significant renal artery stenosis.

Iliorenal Bypass: Indications and Outcomes following 41 Reconstructions

Iliorenal bypass is a nonanatomic means of renal revascularization usually performed in high-risk patients. Its efficacy was assessed in this review of 35 patients (17 males and 18 females, two children and 33 adults) ranging in age 8-84 years, who were subjected to 41 iliorenal bypasses at the University of Michigan Hospital during 1975-2003. Renal artery lesions included arteriosclerosis (n = 20), developmental narrowing (n = 10), arterial fibrodysplasia (n = 3), penetrating trauma (n = 1), and aortorenal dissection associated with Marfan disease (n = 1). All patients had hypertension attributed to their renal artery disease. Twenty patients exhibited renal insufficiency (serum creatinine >1.8 mg/dL). Primary reasons for selecting an iliorenal reconstruction over a more conventional open revascularization included advanced aortic arteriosclerosis (n = 9); prior aortoaortic, aortoiliac, or aortofemoral reconstruction (n = 7); a small aortic aneurysm not justifying aortic surgery (n = 6); prior aortorenal surgery (n = 6); congenital abdominal aortic coarctation (n = 4); a hostile retroperitoneum (n = 2); or compromised cardiac status (n = 1). Eleven patients had prior ipsilateral renal artery interventions. Iliorenal bypasses were to the right kidney (n = 20), the left kidney (n = 9), and bilateral (n = 12). Conduits were saphenous veins (n = 29), synthetic prostheses (n = 11), or direct renal artery-iliac artery reimplantation (n = 1). Initial bypass patency was 93%. Follow-up averaged 7.5 years. Three early and six late graft complications resulted in eight secondary operations. The mean preoperative and postoperative serum creatinine of all 35 patients did not vary (1.9 vs. 1.8 mg/dL), although on an individual basis renal function improved in eight, remained stable in 21, and deteriorated in six patients. The series' mean preoperative blood pressure of 180/97 mm Hg decreased postoperatively to 140/78 mm Hg (P < 0.001). Hypertension was cured in three patients, improved in 27, and became worse in four. Antihypertensive medication numbers decreased postoperatively, from a median of three to two (P < 0.0001). Surgical mortality was limited to one patient succumbing from perioperative intestinal infarction. Iliorenal bypass is an effective means of renal revascularization in patients not amenable to more conventional open or transluminal procedures.

Endovascular treatment of renal artery stenosis

Significant changes have occurred in the treatment of renal artery disease over the past few years. Although excellent clinical results can be obtained with surgery, percutaneous transluminal renal angioplasty has proved similarly efficacious and is now the treatment of choice for nonostial atherosclerotic stenoses and fibromuscular dysplasia. The introduction of stents has become a valuable adjunctive therapy for postangioplasty restenosis and dissection.

Response to angiotensin inhibition in rats with sustained renovascular hypertension correlates with response to removing renal artery stenosis

PURPOSE

Sustained (late-phase) renovascular hypertension is associated with lower plasma renin activity than is the early phase. It is not clear to what extent this reduced plasma renin activity reflects diminished influence of the renin-angiotensin system. It also is not clear whether this change in the character of the disease influences the effectiveness of surgical removal of the renal artery stenosis in reversing hypertension. Using an animal model of sustained (> or =10 weeks after renal artery clipping) two-kidney, one-clip renovascular hypertension, we hypothesized that the magnitude of the depressor response to selective angiotensin II receptor blockade with losartan would reflect the influence of the renin-angiotensin system on hypertension and enable us to predict the depressor response to subsequent surgical removal of the clip.

METHODS

The left renal arteries of 20 male Sprague-Dawley rats weighing 150 to 200 gm were fitted with a silver clip (0.23 mm internal diameter). Systolic blood pressure was measured by means of tail-cuff plethysmography for 10 weeks. Rats were then given losartan orally (30 mg/kg a day) for 1 week while blood pressure was monitored. After an additional week to allow recovery, 13 rats underwent surgical unclipping, and seven underwent sham repair. Blood pressure again was monitored over the final week.

RESULTS

All two-kidney one-clip rats had hypertension 10 weeks after clipping (mean systolic blood pressure 206 +/- 10 mm Hg). Losartan decreased systolic blood pressure by 36 +/- 6 mm Hg. The response was variable, ranging from 3 to 66 mm Hg, and overall blood pressure did not normalize (170 +/- 8 mm Hg). Subsequent surgical unclipping decreased systolic blood pressure by 46 +/- 9 mm Hg. Again the response was variable, ranging from 10 to 99 mm Hg, although overall blood pressure did not normalize (164 +/- 7 mm Hg). The decrease in blood pressure after unclipping showed a high correlation with the blood pressure decrease after losartan administration (r = 0.861, p < 0.001). Resting plasma renin activity (before intervention) was 16 +/- 4 ng angiotensin I per milliliter per hour and was not predictive of the response to either losartan or surgical unclipping. The rats subjected to sham operations had no statistically significant changes in blood pressure. Histologic evaluation showed patent renal arteries without appreciable stenosis or intimal hyperplasia after removal of the clips.

CONCLUSIONS

In sustained two-kidney, one-clip renovascular hypertension, the depressor response to angiotensin II receptor blockade is attenuated, suggesting that late-phase hypertension becomes increasingly angiotensin II-independent. In our model, the extent to which sustained renovascular hypertension becomes refractory to 7 days of angiotensin II blockade is highly predictive of the ultimate outcome of surgical repair of renal artery stenosis.