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

Femoral artery transposition is a safe and durable option for the treatment of popliteal artery aneurysms

OBJECTIVE

A suitable ipsilateral great saphenous vein (GSV) autograft is widely considered the best material for arterial reconstruction of a popliteal artery aneurysm (PAA). There are, however, cases in which such a GSV is absent, diseased, or of too small diameter for this use. Alternatives to GSV are synthetic conduits, but with a reduced long-term patency, in particular for infragenicular bypass; other venous autografts of marginal use; and stent grafts still in the first stages of their evaluation. However, a sufficiently long segment of the ipsilateral superficial femoral artery (SFA) is often preserved in patients with a PAA. Such a segment may be used as an autograft for popliteal reconstruction. Moreover, the morphometric characteristics of the SFA often optimally match those of the distal native popliteal bifurcation. SFA autografts (SFAAs) have therefore become our choice when the ipsilateral GSV is not suitable. We herein present the long-term results of SFAA for the treatment of PAA in the absence of a suitable GSV.

METHODS

Within this single-center study, all cases during the last 26 years were retrospectively reviewed. Demographics, risk factors, comorbidities, morphometrics of the PAA, and preoperative and follow-up data were intentionally sought.

RESULTS

From 1997 to 2017, there were 67 PAAs treated with an SFAA. The mean age of the patients was 67.67 ± 12 years, and 98% were male. Symptoms included intermittent claudication in 25% (17), critical limb ischemia in 7% (5), and acute ischemia in 10% (7) of the patients; 51% (34) of the patients were asymptomatic. The mean aneurysm diameter of the treated PAA was 29 ± 11 mm (12-61 mm). The mean operative time was 254.8 ± 65.6 minutes (140-480 minutes), with a mean cross-clamp time of 64.5 ± 39 minutes (19-240 minutes). The median length of stay was 9 ± 6.4 days (5-42 days). There were no early amputations or deaths in the series. During a mean follow-up of 47.91 ± 48.23 months, there were 2 anastomotic stenoses, 11 thromboses, 1 infection, and 1 aneurysmal degeneration of the graft; 6 patients died of unrelated causes. The 1-, 3-, 5-, and 10-year primary and secondary patency rates were 93% and 96%, 85% and 90%, 78% and 87%, and 56% and 87%, respectively.

CONCLUSIONS

These data suggest that SFAA use to treat PAA is a safe and durable option. A prospective and comparative work is necessary to confirm these results and to determine the interest of this technique as a first-line strategy.

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.

[Results of surgical treatment for renal artery dysplasia]

PURPOSES

To retrospectively assess functional results of surgical treatment for renal artery dysplasia.

PATIENTS AND METHOD

From January 1992 to December 2001, 11 symptomatic patients including 9 women (mean age 47 years, range 23-67), underwent surgery for renal artery dysplasia. Three patients presented with normalized hypertension, three others presented with isolated systolic hypertension, and the five remaining presented with grade II or III hypertension. Angiograms showed evidence of dysplasia of 16 renal arteries. Six arteries showed stenosis (37.5%), four aneurysms (25%), four both (25%), and two arteries showed wall irregularities (12.5%). Endovascular revascularizations were performed in five patients (45%) during the treatment of six renal arteries (37.5%). All endovascular procedures were angioplasties without any stent placement. Six patients (55%) underwent conventional procedures (in situ or ex-situ surgery) for the treatment of seven renal arteries (44%).

RESULTS

In the short term, the treatment had a significant decrease on the systolic arterial pressure (p=0.019) and in the number of drugs used (p=0.009), but was not significant in the diastolic arterial pressure (p=0.084). The benefits persisted after two years of follow-up (PAS, p=0.023, PAD, p=0.047, drugs p=0.03). Benefits persisted in all of the six patients who had had hypertension for less than five years. There was 60% functional failure in the treatment of the five patients with a more than five years history of hypertension.

CONCLUSION

This study confirms the short and long term's beneficial results of the surgical treatment of symptomatic renal artery dysplasia. Rapid care of those patients should optimize the functional results.

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.

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.

Artery grafts in microsurgery

Artery grafts appear to have no significant advantages over vein grafts in experimental models. Research in preservation of artery grafts continues, and holds possibilities of creating stored grafts that can be used clinically. Clinical use of artery grafts in microsurgery is limited to anecdotal use of arteries harvested from damaged body parts in emergencies and use of branched grafts from the subscapular system in elective arterial reconstruction. These clinical uses have never been analyzed, and their reliability and advantages remain undefined.

Repair of an aneurysm of the left main coronary artery

Coronary artery aneurysms are rare, especially in the left main coronary artery. Coronary artery aneurysms may rupture or cause myocardial infarction. There are only a few reports of coronary artery aneurysms of the left main coronary artery treated surgically. We report a case in which an arterial graft from the internal iliac (hypogastric) artery was used for the reconstruction of a congenital coronary artery aneurysm of the left main coronary artery. After a follow-up of 5 years, the patient is well and in good condition.

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.

Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study

PURPOSE

The purpose of this prospective randomized study was to compare percutaneous transluminal renal angioplasty (PTRA) and operation as initial therapy with regard to technical results, primary and secondary patency, and effects on blood pressure and renal function in patients with atherosclerotic unilateral renal artery stenosis.

METHODS

Fifty-eight patients who did not have diabetes, who were less than 70 years of age, and who had severe hypertension and significant stenosis were randomized to receive PTRA or operation. Angiography was performed 10 days, 1 year, and 2 years after treatment to verify patency, and blood pressure and renal function were simultaneously evaluated.

RESULTS

Technically, PTRA was successful in 83% and operation in 97% of patients. The primary patency rate after 24 months was 75% in the PTRA group and 96% in the operative group in technically successful cases. The secondary patency rate in the PTRA group was 90% and in the surgical group 97%. To achieve these results four patients in the PTRA group required operation, and one patient in the surgical group required PTRA. Hypertension was cured or improved after additional treatment in 90% of the patients after PTRA and 86% after operation. The corresponding figures for improved or unchanged renal function were 83% and 72%, respectively. After additional treatment, effects on blood pressure and renal function did not differ. Seventeen percent of the patients treated with PTRA required surgical intervention.

CONCLUSIONS

PTRA is recommended as first choice of therapy for atherosclerotic renal artery stenosis causing renovascular hypertension if combined with intensive follow-up and aggressive reintervention.

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

Over a 16-year period (1973-1989), 63 renal autotransplants were performed in 59 patients for fibro-muscular dysplasia (FMD) with renal artery stenoses (42 kidneys) or aneurysms (21 kidneys). About two-thirds of the autotransplants were performed before percutaneous transluminal angioplasty (PTA) was established for clinical use. However, vascular disease at a site or type not suitable for PTA was present in 57 (90%) of the kidneys. Hypertension was the leading symptom in 56 patients, including four in whom renal autotransplantation was performed as an emergency for acute renal artery occlusion or malignant hypertension. Blood pressure returned to normal or improved in 51 (91%) and remained unchanged in five patients (9%) following autotransplantation. Three patients with renal artery aneurysm in whom haematuria and loin pain were the indications for treatment, became asymptomatic following surgical intervention. Bilateral renal autotransplantation was performed synchronously in one and sequentially in three patients. There were no operative deaths, but two kidneys were lost postoperatively in two 2-year-old children owing to renal vascular thrombosis. In the follow-up period (mean 4.3 years), one additional kidney was lost at 3 months owing to progressive FMD. Blood pressure and renal function remained stable in all other patients. Based on the excellent results achieved in this series, it is concluded that extracorporeal vascular repair and renal autotransplantation is a safe procedure for the patient as well as the kidney affected by FMD. The procedure is advocated as an alternative to in situ reconstruction in patients with renal artery disease not accessible to PTA, such as aneurysms and complex branch renal artery stenoses.