Reoperation for complications of renal artery reconstructive surgery undertaken for treatment of renovascular hypertension

Renal autotransplantation for the treatment of renal artery aneurysm

OBJECTIVE

Renal artery aneurysms are a rare condition; however, the rate of diagnosis has been increasing, because of the increasing use of complementary diagnostic methods. The best treatment strategy for RAAs remains controversial. Data on ex-vivo surgery associated with kidney autotransplantation are scarce. As a result, the goal of this study was to describe this technique and to report our results.

METHODS

A retrospective monocentric study was undertaken using the clinical records and images of 35 patients diagnosed with renal artery aneurysm from 01/01/2010 to 31/12/2018. Indications for ex vivo surgery and autotransplantation were complex aneurysms with diameter >20 mm or rapid growth or symptomatic aneurysms or women wishing to become pregnant. Complex aneurysms were defined by anatomical criteria (bifurcation of the renal artery and its primary branches or hilar aneurysms) and/or physiological criteria (when time of warm ischemia in in-situ reconstruction is expected to last more than 45 minutes). The technique of ex-vivo surgery and autotransplantation consists of performing a nephrectomy, renal cooling, treatment of aneurysm in banking and implantation of the kidney in the homolateral iliac fossa.

RESULTS

A total of 35 patients with 56 renal artery aneurysms (26 women, mean age 52.4 years-minimum and maximum 16 and 74 years) were included. Of these, 27 were treated by surgery and 8 were followed clinically. Among those treated surgically, 24 performed ex vivo surgery associated with autotransplantation. Regarding ex vivo surgery, nephrectomy was performed by laparoscopic surgery in 24 of the 27 surgeries, the mean surgical time was 5.3 hours, the median warm ischemia time was 4 minutes and the length of hospital stay was 12.2 days. Mortality was 0% and the kidney patency rate was 93% with a follow up of 47.2 months. Of the 17 patients with hypertension, 6 cured it, 4 improved and 7 maintained hypertension.

CONCLUSION

Kidney autotransplantation appears to be efficient for most complex RAA with the possibility to minimize surgical aggression by performing laparoscopic nephrectomy.

Risk of rupture of an aortorenal vein graft aneurysm after the surgical repair of Takayasu arteritis-induced right renal artery stenosis: A case report and a literature review

INTRODUCTION

Takayasu arteritis (TA) is a chronic and nonspecific inflammatory disease mainly affecting the aorta and its major branches, resulting in the stenosis or occlusion of target arteries. Approximately 50% to 60% of patients with TA likely have renal artery stenosis (RAS), which results in refractory hypertension (HTN) and renal dysfunction. Aortorenal bypass with saphenous vein graft (SVG) is the classical procedure to relieve patients' symptoms. Graft restenosis is the most common complication during long-term follow-up. However, aortorenal vein graft aneurysm (AVGA) is uncommonly reported, and symptomatic or ruptured AVGA that needs reoperation is even rarer. Long-term follow-up results after AVGA reoperation also remain scare. Here, we introduced the long-term result of a symptomatic AVGA under the reoperation of polytetrafluoroethylene (PTFE) graft replacement and provided a literature review of AVGA reoperation after surgical bypass for RAS.

CLINICAL FINDING

An 18-year-old male complained about mild to severe right lumbar pain for 5 days. He underwent right aortorenal bypass with SVG for TA-induced right renal artery stenosis to relieve refractory HTN and renal dysfunction 2 years ago. However, this patient did not proceed with a follow-up after the procedure. Physical examination showed normal vital signs, and an obvious percussion tenderness over the right kidney region was detected. The updated computed tomography angiography (CTA) revealed a right AVGA with a maximum diameter of 26 mm. No restenosis of the proximal and distal anastomoses was detected.

DIAGNOSIS

The patient was diagnosed to have right aortorenal vein graft aneurysm at the risk of rupture and Takayasu arteritis.

INTERVENTIONS

The AVGA was resected with a 6 mm PTFE graft replacement. An end-to-side proximal anastomosis to the orifice of the original anastomosis on the abdominal aorta and an end-to-end distal anastomosis to the distal normal renal artery were made.

OUTCOMES

The patient had an uneventful postoperative clinical course and was discharged from the hospital 5 days after the operation. The 4-year updated CTA revealed no restenosis or aneurysmal degeneration of the prosthetic graft.

CONCLUSION

Symptomatic AVGA that needs reoperation is rare. Prosthetic graft replacement is an effective way to eliminate the risk of potential rupture. A 4-year satisfactory result indicative of a prosthetic graft can be the first choice for aortorenal bypass in RAS without active biological inflammation.

A New Method for Renal Protection During Renal Artery Revascularization

An original method for renal protection during renal artery revasculariza tion is described. Temporary reperfusion of the renal artery (three to five min utes) after critical periods of cross-clamping (thirty minutes), using a balloon T-shunt, permits prolongation of the total time of renal ischemia. A more care ful operative technique is permitted; if necessary, technical errors can be cor rected during the surgical procedure. Accordingly, this method is useful for providing renal protection during resection of thoracoabdominal aneurysms. On the basis of their experimental and clinical results, the authors conclude that this method is safe and suitable for clinical application.

Total endovascular solution for complex visceral aneurysms

Visceral aneurysms are rare in the general population (<2%), and the most serious complication is represented by aneurysm rupture. The use of stent grafts to exclude visceral aneurysms is described in several reports but is reserved for patients with favorable anatomy. We report here on a hepatic artery pseudoaneurysm in a liver transplant patient and a patient with an aneurysmal vein graft degeneration of a renal bypass, both with no suitable proximal neck for standard stent grafting. Both patients were successfully treated with a custom-made aortic endograft with a single fenestration for the hepatic or renal artery, together with a visceral covered stent. Although initial results are promising, long-term follow-up is required to assess durability.

Saphenous vein graft aneurysm with graft-enteric fistula after renal artery bypass

A 65-year-old female presented with upper gastrointestinal hemorrhage thirty years following an aorta-to-right renal artery bypass constructed with saphenous vein. Upper endoscopy demonstrated a duodenal ulcer, and a CAT scan demonstrated aneurysmal degeneration of her renal artery bypass with duodenal impingement. Laparotomy demonstrated erosion of the aneurysm through the posterior wall of the duodenum; extra-anatomic renovascular reconstruction and primary duodenal repair was performed. Although aneurysmal degeneration of intraabdominal saphenous vein grafts is well described and rupture likewise reported, this report represents the first description of an intraabdominal autogenous vein graft aneurysm presenting with gastrointestinal erosion and fistula.

Fibromuscular dysplasia: when is intervention warranted?

Fibromuscular dysplasia is a multifactorial arteriopathy that primarily affects small and medium-sized arteries. It is most common in the renal and internal carotid arteries. Pathological classification is based on the arterial wall layer most significantly involved. The natural history and incidence of asymptomatic disease is unknown. The most common lesions become symptomatic as a high-grade stenosis producing renovascular hypertension or as an embolic source for the cerebral circulation. Treatment is reserved for symptomatic lesions. Most simple lesions are effectively treated by catheter-based intervention. Surgical therapy is warranted for more complex lesions. Both produce durable, long-term results.

Is prosthetic renal artery reconstruction a durable procedure? An analysis of 489 bypass grafts

OBJECTIVE

Renal artery stenosis has been classically addressed with saphenous vein bypass graft or transaortic endarterectomy performed either primarily or in combination with an aortic procedure. In this series, we report the outcome of our 12-year experience with renal artery reconstruction using prosthetic conduit.

METHODS

Patients undergoing renal artery bypass grafting from 1987 to 1999 were identified. Demographics, indications, concurrent operations, complications, and patency were analyzed. Patients underwent postoperative duplex scan with subsequent ultrasound scans at 6-month intervals.

RESULTS

There were 489 procedures performed in 414 patients with indications: high-grade renal artery stenosis in combination with abdominal aortic aneurysm repair or symptomatic aortoiliac occlusive disease (309 [63%]), renovascular hypertension (118 [24%]), and renal salvage (20 [4%]). Indications for the remainder included trauma, renal artery aneurysm, or an infected aortic graft. Inflow was aorta or aortic graft in 95% of patients with the remainder taken from the iliac or visceral vessels. The retroperitoneal approach was used in 97.8%. Nonfatal complications occurred in 11.4% with a 1.4% early and 4.8% late occlusion rate. Renal function worsened in 3.1% of all patients. Secondary patency at 1 and 5 years was 98% and 96%, respectively.

CONCLUSION

Renal artery reconstruction with prosthetic conduit has an acceptable and durable result whether used for primary renal artery reconstruction or concomitant reconstruction with aortic procedures.

Aneurysmal degeneration and late rupture of an aortorenal vein graft: case report, review of the literature, and implications for conduit selection

The saphenous vein is among the most commonly used conduits for renal artery revascularization in adults. Vein grafts are more durable in the renal artery bed than in coronary and peripheral beds, and mechanisms of potential graft failure vary. Coronary vein grafts often fail because of atherosclerotic degeneration, whereas lower extremity grafts fail because of intimal hyperplasia or progression of underlying disease. In contrast, renal vein grafts may dilate over time but seldom fail. This may relate to the distinct hemodynamic environment of the renal bed with low-resistance, high-velocity blood flow. However, frank aneurysmal degeneration of renal vein grafts is rare with only a single report of rupture in the literature. We report an additional case of rupture of a late graft aneurysm and review the literature and our own experience with renal revascularization to underscore the rarity of this serious complication. The saphenous vein for aortorenal bypass grafting continues to be a favorable conduit for renal revascularization. Long-term duplex ultrasound scanning follow-up is recommended to survey the reconstructed artery and perhaps more important, to evaluate progression of subclinical disease in the contralateral renal artery.

MR angiography after renal revascularization: spectrum of expected anatomic results and postintervention complications

The use of magnetic resonance (MR) angiography in screening for renal artery stenosis has been extensively evaluated. However, the MR angiographic findings after renal artery revascularization are not as well characterized. The renal artery and parenchyma can be evaluated after revascularization with a comprehensive MR imaging protocol that includes T1- and T2-weighted spin-echo sequences, three-dimensional (3D) gadolinium-enhanced MR angiography, and 3D phase-contrast MR angiography. Because surgical techniques for revascularization vary, knowledge of the surgical procedure is necessary to ensure inclusion of the pertinent anatomy at 3D gadolinium-enhanced MR angiography and to define appropriate 3D phase-contrast MR angiography volumes. The 3D gadolinium-enhanced MR angiography volume can be manipulated to view relevant vascular anatomy at the optimal obliquity and section thickness. This protocol allows robust, noninvasive evaluation of the expected arterial anatomy after revascularization, including renal artery endarterectomy, aortorenal bypass grafts, and extraanatomic reconstructions. In cases of suspected postrevascularization complications, gadolinium-enhanced MR angiography is useful because of its lack of nephrotoxicity and radiation exposure. Immediate complications of renal revascularization include renal artery thrombosis, renal infarction, and perinephric hemorrhage. Long-term complications include aneurysms of bypass grafts and recurrent stenosis of the renal artery.

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.

Pediatric renovascular hypertension: a thirty-year experience of operative treatment

PURPOSE

This study was undertaken to characterize the changing operative treatment of pediatric renovascular hypertension and subsequent outcomes in a 30-year experience at a single institution.

METHODS

Clinical data were analyzed on 57 pediatric patients, 24 girls and 33 boys, ranging in age from 10 months to 17 years, who underwent operations for renovascular hypertension from 1963 to 1993 at the University of Michigan. Renal artery disease included atypical medial-perimedial dysplasia, often with secondary intimal fibroplasia (88%), and inflammatory mural fibrosis (12%). Abdominal aortic narrowings affected 15 patients. Data were categorized into three chronologic eras (I:1963-1972, II:1973-1980, and III:1981-1993) to allow identification of therapeutic trends.

RESULTS

Primary surgical procedures were undertaken 74 times. Ex vivo reconstruction was necessary once. Primary operations included aortorenal bypass with autogenous vein grafts (n = 26) or internal iliac artery grafts (n = 7); iliorenal bypass with vein grafts (n = 2); renal artery resection beyond the stenosis and reimplantation into the aorta (n = 10), the main renal artery (n = 2), an adjacent segmental renal artery (n = 3), or the superior mesenteric artery (n = 3); renal artery resection and reanastomosis (n = 3); focal renal arterioplasty (n = 2); operative dilation (n = 7); splenorenal bypass (n = 2); and primary nephrectomy (n = 7). Among 23 primary operations performed in era I, 56.5% were aortorenal bypasses with vein grafts, but in era III this form of revascularization represented only 3% of 33 primary operations. No reimplantations were performed in era I, whereas reimplantations accounted for 51.5% of era III procedures. Thirteen patients underwent staged or concomitant aortic reconstructions with thoracoabdominal aortoaortic bypass grafts (n = 5) or patch aortoplasty (n = 8). Fourteen patients underwent a total of 20 secondary operations, including seven secondary nephrectomies. Operative therapy benefited 98% of these children: hypertension was cured in 45 (79%), improved in 11 (19%), and unchanged in one (2%). There were no operative deaths.

CONCLUSIONS

Contemporary surgical management emphasizes direct reimplantation of main renal arteries into the aorta, reimplantation of segmental arteries into adjacent renal arteries, patch aortoplasty for associated abdominal aortic coarctations, and single-stage revascularizations. Pediatric patients with renovascular hypertension clearly benefit from carefully executed operative therapy.

Percutaneous transluminal angioplasty and surgery of the renal artery

The management of patients with renal artery disease has changed in recent years. This has occurred due to the advent of PTA as an effective method of treatment for certain patients, an enhanced appreciation of advanced atherosclerotic renal artery disease as a correctable cause of renal failure, and improved results of surgical revascularisation in both older patients with severe aortic atherosclerosis and younger patients with branch renal artery disease. PTA currently yields excellent results and is the treatment of choice for patients with fibrous dysplasia of the main renal artery and non-ostial atherosclerotic lesions. Most reports in the literature indicate that surgical revascularisation provides more effective therapy for patients with ostial atherosclerotic lesions. Surgical revascularisation also remains the treatment of choice for the majority of patients with branch renal artery disease, a renal artery aneurysm, renal artery occlusion, and recurrent renal artery stenosis after failed PTA or surgery. Excellent clinical results can be achieved with both PTA and surgical revascularisation in properly selected patients.

Renovascular hypertension: predicting surgical cure with exercise renography

Renal artery stenosis with resultant renovascular hypertension has attracted clinical attention because the disease is potentially curable and because numerous diagnostic and therapeutic modalities compete for clinical acceptance. An exercise-mediated disturbance of renal hippurate transport was recently described, and has been implicated as having a role in nephrogenic fixed hypertension. To predict the final course of renovascular hypertension before operation we carried out a prospective study with the goal of verifying the predictive value of exercise hippurate scintigraphy. The study was to test the hypothesis that patients with disturbance of renal hippurate transport (pathologic renogram) induced by exercise would have stabilized hypertension and would continue to be hypertensive after operation. Thirty-one patients with hypertension who had unilateral or bilateral renovascular stenosis documented on angiography were referred to rest and exercise hippurate scintigrams before operation. The results of the examinations at rest served as standard and were compared with the exercise scintigrams. In 19 of the 31 (61%) patients a disturbance of transrenal hippurate transport evolved during exercise, whereas 12 (39%) patients failed to respond to exercise with altered hippurate kinetics. Twenty-six patients went on to renovascular operations; five had percutaneous transluminal angioplasty. Revascularization results differed markedly when the blood pressure response of patients with positive results on exercise (abnormal) and patients with negative results on exercise (normal) were compared. Ten of 12 patients with hypertension who had normal exercise renograms were cured. In comparison, blood pressure values were little influenced by therapy in patients with an abnormal response, where 17 of 19 patients continued to have hypertensive disease after therapy.(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)

Management of pediatric visceral arterial and aortic coarctation

Two unusual pediatric vascular problems have been managed surgically. The first patient is a five-and-a half-year old girl who presented with renal artery stenosis and aneurysm and renovascular hypertension. This was treated by excision of the aneurysm and reimplantation of the right renal artery. The second patient is a two-year old girl with atresia of the abdominal aorta, superior mesenteric artery (SMA) and both renal arteries. She was treated by PTFE patch graft angioplasty of the aorta, SMA reimplantation and bilateral aorto-renal autogenous saphenous vein bypass.