Fibro-muscular renal artery disease treated by extracorporeal vascular reconstruction and renal autotransplantation: short- and long-term results

Renal Autotransplantation for Uncontrolled Hypertension in Nonatherosclerotic Renal Artery Stenosis-2 Case Reports and a Brief Review of the Literature

Fibromuscular dysplasia is the most common cause of renovascular hypertension in young adults under 40 years old. It is potentially amenable to renal artery angioplasty, which frequently normalizes blood pressure. However, limited options exist if angioplasty is not technically possible, or restenosis occurs. Here, we describe 2 patients who presented with hypertension secondary to renal artery stenosis. In the first case, a young adult with hypertension secondary to renal artery stenosis (fibromuscular dysplasia), developed restenosis 11 weeks after an initially successful renal artery angioplasty. In the second case, a patient with neurofibromatosis type 1 was diagnosed with hypertension secondary to renal artery stenosis. Angioplasty was not possible due to multiple branch occlusions. Both individuals went on to have successful renal autotransplantations, which ultimately cured their hypertension. In this article, we review the background, indications, and blood pressure outcomes in relation to renal autotransplantation in nonatherosclerotic renal artery stenosis.

Indications for and results of renal autotransplantation

PURPOSE OF REVIEW

To understand the indications and outcomes of renal autotransplantation, and when to consider this unique procedure for patients.

RECENT FINDINGS

Renal autotransplantation confers acceptably low rates of graft failure and prevents need for long-term dialysis. Renal autotransplantation remains an important management strategy in very select patients for complex renovascular disease, ureteral stricture disease, ureteral trauma, upper urinary tract urothelial carcinoma, renal cell carcinoma, and Loin-Pain Hematuria Syndrome. With advancements in minimally invasive procedures, the application of renal autotransplantation for refractory stone disease is rare but exists. Robot-assisted laparoscopic renal autotransplantation demonstrates reproducible graft success and complication rates with improved perioperative outcomes (ex. hospital length of stay) - though comparative studies are lacking. Patients would benefit from a multidisciplinary approach from renal transplant surgeons, vascular surgeons, urologists, nephrologists, dieticians, pain management providers, social workers, and psychiatrists.

SUMMARY

In experienced hands, renal autotransplantation is a reasonable treatment approach for complex and refractory renal vascular disease, Loin-Pain Hematuria Syndrome, ureteral strictures and trauma, upper urinary tract malignancy, and stone disease in highly select patients.

Robotic assisted kidney auto-transplantation as a safe alternative for treatment of nutcracker syndrome and loin pain haematuria syndrome: A case series report

BACKGROUND

Describe the outcomes and safety of robotic-assisted kidney auto-transplantation (RAKAT) in the treatment of nutcracker syndrome (NCS) and loin pain haematuria syndrome (LPHS).

METHODS

This retrospective study included 32 cases of NCS and LPHS seen during December 2016 to June 2021.

RESULTS

Three (9%) patients had LPHS and 29 (91%) NCS. All were non-Hispanic whites, and 31 (97%) women. The mean age was 32 years (SD = 10) and the BMI 22.8 (SD = 5). The RAKAT was completed in all patients, 63% had a total improvement of pain. According to the Clavien-Dindo classification, 47% presented with type 1, and 9% with type 3 complications with a mean follow-up of 10.9 months. The incidence of acute kidney injury in post-procedure was 28%. No one required blood transfusions, and there were no deaths during the follow-up.

CONCLUSION

RAKAT was a feasible procedure with a similar complication rate to those reported for other surgical techniques.

Outcome following renal autotransplantation in renal artery stenosis

Introduction

With significant advances in the area of interventional radiology, angioplasty and stenting have become preferred first-line treatment in patients with significant renal artery stenosis. However, not all patients have favorable anatomy to undergo minimally invasive treatments, and reconstruction of the renal artery is an option. In select cases, either improved renal function or maintenance of existing function and sometimes resolution of hypertension can follow surgical treatment.

Material and Methods

This was a prospective observational study conducted from August 2010 to June 2016. Patients <45 years of age with uncontrolled hypertension secondary to renovascular hypertension (RVH) and refractory to medical management and renal arterial disease unfavorable for percutaneous intervention were included in the study. All patients were evaluated thoroughly using computed tomography angiography and diethylenetriaminepentaacetic acid renal scan. Patients underwent autotransplantation either into the right or left iliac fossa. Some kidneys required bench reconstruction of the renal artery and/or its branches before being implanted into either iliac fossa.

Results

Nine patients were included in the study. The mean age was 27 years. Seven were males and two were females. Five patients had bilateral renal artery stenosis. After autotransplantation, initially five patients became free of antihypertensive medicines, but on the follow-up, two patients showed rising trend of blood pressure. The evaluation revealed narrowing at anastomosis site in both patients with salvageable kidney function in one patient. Angioplasty with stenting was done in this patient while the second patient underwent secondary nephrectomy. At 2 years of follow-up, four patients required no antihypertensive medicines.

Conclusion

Autotransplantation can be a successful treatment of severe RVH and should be considered in patients with renal arterial disease unfavorable for percutaneous intervention.

Kidney transplantation in infantile myofibromatosis and fibromuscular dysplasia: a case report

Introduction

We report what we believe to be the first case of a child affected by two rare vascular diseases complicated by kidney failure and successfully treated by kidney transplantation.

Case presentation

A 3-year-old Caucasian girl with fibromuscular dysplasia and infantile myofibromatosis presented with arterial hypertension and renal failure. She received a deceased donor kidney transplantation distal to an iliac graft. The technical peculiarities of this transplantation are described, as well as her favorable long-term outcome.

Conclusion

Kidney transplantation may be considered in a patient with vascular diseases and a history of iliac surgery.

Renal autotransplant in patients with complex hilar renal artery aneurysms

Renal artery aneurysms are uncommon, with an incidence of 0.01% in the general population. The improvement of radiologic techniques and the increased incidence of abdominal imaging for various indications has resulted in increased detection of asymptomatic renal artery aneurysms. Hilar renal artery aneurysms are a subtype of the disease and constitute management challenges. Here, we report 3 patients with hilar renal artery aneurysms treated with renal autotransplant and review the literature.

Branch renal artery repair with cold perfusion protection

PURPOSE

This retrospective review describes the use and clinical outcome of cold perfusion protection during branch renal artery (RA) repair in 77 consecutive patients.

METHODS

From July 1987 through November 2006, 874 patients had open operative RA repair to 1312 kidneys. Seventy-seven patients (62 women, 15 men; mean age, 44 +/- 17 years) had branch RA reconstruction using ex vivo or in situ cold perfusion protection for 78 kidneys. Demographic data and surgical technique were examined. Blood pressure response and renal function were estimated. Patency of repair was determined by angiography and renal duplex ultrasound (RDUS) imaging. Primary RA patency was estimated by life-table methods.

RESULTS

Seventy-eight RAs were repaired using ex vivo (49 kidneys) or in situ (29 kidneys) cold perfusion protection. Bilateral RA repair was performed in eight patients, with 13 repairs to solitary kidneys. RA disease included aneurysm (RAA) in 50, fibromuscular dysplasia (FMD) in 37, atherosclerosis in 5, and arteritis in 2; 16 patients had both FMD and RAA. Hypertension was present in 93.5% (mean blood pressure, 184 +/- 35/107 +/- 19 mm Hg; mean of 1.9 +/- 1.1 drugs). RA repair included bypass using saphenous vein in 69, hypogastric artery in 3, polytetrafluoroethylene (PTFE) in 2, composite vein/PTFE in 2, cephalic vein in 1, or aneurysmorrhaphy in 1. The eight bilateral RA repairs were staged. One patient required bilateral cold perfusion protection. One planned nephrectomy was performed at the time of contralateral ex vivo reconstruction. No primary nephrectomies were required for intended reconstruction. Each RA reconstruction required branch dissection and reconstruction (mean of 2.8 +/- 1.6 branches were repaired). Mean cold ischemia time was 125 +/- 40 minutes. Each kidney was reconstructed in an orthotopic fashion. Five early failures of repair required three nephrectomies and one operative revision. Based on postoperative angiography or RDUS, or both, primary patency of RA repair at 12 months was 85% +/- 5%; assisted primary patency was 93% +/- 4%. Among patients with preoperative hypertension, 15% were cured, 65% were improved, and 20% were considered failed. Early renal function was improved in 35%, unchanged in 48%, and worse in 17%. Four patients had perioperative acute tubular necrosis. No patient progressed to dialysis-dependence.

CONCLUSION

Both ex vivo and in situ cold perfusion protection extend the safe renal ischemia time for complex branch RA repair and avoid the need for nephrectomy.

Long-term results after surgical reconstruction for renal artery fibromuscular dysplasia

OBJECTIVES

To study the initial and long-term results of surgery for renal artery fibromuscular dysplasia (RFMD).

PATIENTS AND METHODS

All patients undergoing renal artery reconstruction (RAR) performed for RFMD between January 1980 and December 1997, were studied. The preprocedural and postprocedural clinical records of 101 patients (80 women, 21 men; mean age at surgery 43 years) were retrospectively reviewed. All surviving patients were invited for clinical reexamination and colour-coded duplex-ultrasound of the renal arteries (RA).

RESULTS

Initial technical success was achieved in 83 of 93 patients (89%), in whom postoperative angiography (90) or renal scintigraphy (three) were performed for assessment of RAR. Early occlusion (four) or stenosis (one) demanded reoperation in five patients (5%). The 30-day mortality and morbidity were 2% and 12% for the entire group. Primary patency rate was 74% at 5 years. Fifteen patients had to be reoperated for restenosis after a mean time of 33 months, resulting in a secondary patency rate of 85% after 5 years. In 61 patients with patent RAR at the time of re-examination, arterial hypertension was cured only in 22 (36%) and improvement in 19 (31%).

CONCLUSION

Vascular surgery for RFMD yields good long-term results as to kidney perfusion and function. Surveillance of RAR-patency by means of ultrasound examination is mandatory in case of recurrence of arterial hypertension or deterioration. Rates of cure of hypertension are disappointing.

Reconstruction for renal artery aneurysm and its effect on hypertension

OBJECTIVES

many renal artery aneurysms (RAA) are diagnosed incidentally in the course of investigations for hypertension and their management is controversial.

AIM

to review the results of renal artery reconstruction for RAA.

METHODS

between January 1978 and December 1998 111 RAR were performed in 81 kidneys in 71 patients.

RESULTS

fifty-nine patients were hypertensive, three had a creatinine >2.0 mg/dl and one was on dialysis. The principal underlying pathology was fibromuscular dysplasia (39) and atherosclerosis (17). The mean RAA diameter was 2.2 (range 1-15) cm overall and 3.5 (range 2-10) cm in four patients who presented with rupture. Fifty-one patients had renal artery stenosis. Autogenous material was used in 105 RAR. There was no 30-day mortality and the morbidity rate was 16%. The 5-year cumulative patency rate was 69%. Hypertension was cured in 25% and improved in 39%.

CONCLUSIONS

RAR tested for RAA treats hypertension and reduces the risk of rupture and distal embolisation.

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.