Contemporary outcomes for branch renal artery repair

Abstract

BackgroundThe purpose of this study was to provide an updated description of demographics, technical details, and clinical outcomes of 101 consecutive branch renal artery repairs in 98 patients using cold perfusion. MethodsA single-institution, retrospective analysis branch renal artery reconstructions was performed between 1987 and 2019. ResultsPatients were predominantly Caucasian (80.6%) women (74.5%) with a mean age of 46.8 ± 15.3 years. The mean preoperative systolic and diastolic blood pressures were 170.4 ± 33.0 mm Hg and 99.2 ± 19.9 mm Hg, respectively, requiring a mean of 1.6 ± 1.1 antihypertensive medications. The estimated glomerular filtration rate was 84.0 ± 25.3 mL/min. Most patients (90.2%) were not diabetic and never smokers (68%). Treated pathology included aneurysm (87.4%) and stenosis (23.3%) with histology demonstrating fibromuscular dysplasia (44.4%), dissection (5.1%), and degenerative not otherwise specified (50.5%). The right renal arteries were most frequently treated (44.2%), with a mean of 3.1 ± 1.5 branches involved. Reconstruction was accomplished using bypass in 90.3% of cases using aortic inflow in 92.7% and a saphenous vein conduit in 92%. Branch vessels served as outflow in 96.9% and syndactylization of branches was used to decrease the number of distal anastomoses in 45.3% of repairs. The mean number of distal anastomoses was 1.5 ± 0.9. Postoperatively, the mean systolic blood pressure improved to 137.9 ± 20.8 mm Hg (mean decrease of 30.5 ± 32.8 mm Hg; P < .0001) and the mean diastolic blood pressure improved to 78.4 ± 12.7 mm Hg (mean decrease of 20.1 ± 20.7 mm Hg; P < .0001) with patients requiring a mean of 1.4 ± 1.0 antihypertensive medications (mean decrease of 0.2 ±1.0 medications; P = .048). The postoperative estimated glomerular filtration rate was 89.1 mL/min (mean increase of 4.1 mL/min; P = .08). The mean length of stay was 9.0 ± 5.8 days and 96.1% of patients were discharged home. The mortality rate was 1% (one patient with liver failure) and the major morbidity rate was 15%. There were five infectious complications (pneumonia, Clostridium difficile, and wound infection) and five patients required return to the operating room (one for nephrectomy, one for bleeding, two for thrombosis, and one for second trimester pregnancy loss requiring dilation and curettage and splenectomy). One patient required temporary dialysis owing to graft thrombosis. Two patients developed arrhythmias. No patients suffered a myocardial infarction, stroke, or limb loss. After 30 days, follow-up data were available for 82 bypasses. At this time, three reconstructions were no longer patent. Intervention was required to retain patency for five bypasses. After 1 year, patency data were available for 61 bypasses and five were no longer patent. Of the five grafts with loss of patency, two underwent intervention in attempt to maintain patency, which subsequently failed. ConclusionsRepair of renal artery pathology involving the branches can be performed with short- and long-term technical success and significant prospect of decreasing an elevated blood pressure. The operations required to fully address the presenting pathology are often quite complex involving multiple distal anastomoses and consolidation of small secondary branches. The procedure carries a small but significant risk of major morbidity and mortality.