Recovery of Renal Function after 3 Months of Dialysis in a Patient with Atherosclerotic Renovascular Disease Following Aortoiliac Bypass and Left Renal Artery Reimplantation

Abstract

A 67-year-old Caucasian man was admitted in September 2001 because of dyspnœa and oliguria. He had a history of smoking, hypertension, and hyperlipemia. On admission, the blood pressure was 160/110 mmHg, there were inspiratory crackles at both lung fields, peripheral œdema, and a bilateral murmur in the periumbilical region. Laboratory investigations showed a normocytic anemia (Hb 8.6 g/dl, MCV 92 fl), with a serum creatinine of 397 mmol/l. The chest X-ray showed cardiomegaly, parahilar pulmonary œdema and a left pleural effusion. An echocardiogram showed severe impairment of systolic function. Abdominal ultrasonography showed a small right kidney (polo-polar length: 5.8 cm; left kidney: 8.6 cm) and an aortic aneurysm (length 6.2 cm, transverse diameter 4.8 cm) involving both common iliac arteries. The right common iliac artery had maximum longitudinal and transversal diameters of 4 and 4.7 cm, respectively. Doppler ultrasonography revealed significantly reduced blood flow to the left kidney (with resistance index of 0.53) and absence of flow to the right kidney. MR angiography (Fig. 1(a)) showed a significant stenosis of the left renal artery (Fig. 1(b)). The clinical course was characterised by progressive renal failure and difficulty in maintaining cardiac output despite the use of diuretics, nitrates and dopaminergic drugs. Angiography was performed to explore the possibility of percutaneous angioplasty (PTA). It showed complete occlusion of the left main renal artery, and a sub-occlusive stenosis of a left accessory renal artery (probably corresponding to the patent vessel on MR). PTA was unsuccessful. Hemodialysis was started, with rapid improvement of cardiopulmonary function. The serum creatinine stabilised around 700 mmol/l, with minimal urine output. In December 2001, an echocardiogram showed improvement of systolic function. Neither angina nor ischemic ECG changes were recorded during dypiridamole echo-stress. Because of the improvement in cardiac function, and the characteristics of the aortoiliac aneurysm, surgical correction by aortoiliac bypass was planned, including reimplantation of the left renal artery. The procedure was successfully performed in January 2002. Immediately after surgery, the patient recovered a good urine output. On day one, dialysis was performed because of hyperkalemia. Over the next few days the serum creatinine progressively fell to 486 mmol/l. MR angiography showed adequate flow in the reimplanted artery (Fig. 2). Fourteen months later, the serum creatinine was 500 mmol/l, and the patient no longer required hemodialysis. Eur J Vasc Endovasc Surg 28, 562–564 (2004) doi: 10.1016/j.ejvs.2004.05.006, available online at http://www.sciencedirect.com on