Bilateral Renal Revascularization Research Articles

The Influence of Suprarenal Aortic Cross-clamping on Perioperative and Follow-up Results of Open Repair of Abdominal Aortic Aneurysm

The objective was to retrospectively assess the perioperative and long-term outcomes in patients operated on with open repair of abdominal aortic aneurysm (AAA) with or without suprarenal aortic cross-clamping in a single-center experience. From January 2008 to December 2018, 1608 consecutive open and endovascular interventions for AAA were performed. Data concerning these interventions were prospectively recorded; a retrospective analysis of the database was performed and 540 elective open interventions for unruptured AAA were found, in 73 cases with suprarenal aortic cross-clamping (group 1) and in 467 cases with infrarenal aortic cross-clamping (group 2). The two groups were compared in terms of clinical, anatomic, and surgical characteristics and perioperative (<30 days) outcomes with χ2 test; follow-up results were compared with Kaplan-Meier curves and log-rank test. There were no differences between the two groups in terms of demographics, risk factors, and comorbidities, except for a higher percentage of female patients in group 1 than in group 2 (16.2% and 9.1%, respectively; P = .05). Mean preoperative estimated glomerular filtration rate was similar in the two groups as well. Most patients in both groups had a bifurcated aortobi-iliac graft; in group 1, 22 patients had a unilateral or bilateral renal revascularization, whereas in 51 cases, the ostium of one or both renal arteries was included in the proximal anastomosis. The mean time of renal ischemia in group 1 was 16 ± 12 minutes. Patients in group 1 had a longer time of intensive care unit stay than patients in group 2, but the overall length of stay was similar. Perioperative mortality rates were 4.1% in group 1 and 2.7% in group 2 (P = .5); nonfatal major complications occurred in 14 patients in group 1 (19%) and in 69 patients in group 2 (14.5%; P = .3). Follow-up was available in 512 patients (95%), with a median duration of 48 months (range, 1-144 months). Estimated 7-year survival rates were 51.5% in group 1 and 76.5% in group 2 (P < .001; log-rank, 15.3), whereas the corresponding figures in terms of freedom from AAA-related complications were 63.5% and 85.5% (P = .002; log-rank, 9.5). Moreover, patients in group 1 were more likely than patients in group 2 to undergo a reintervention at 7-year follow-up. In patients with complex AAA requiring suprarenal aortic cross-clamping, a significant increase of long term mortality, AAA-related complications, and reintervention was found in comparison with patients undergoing infrarenal aortic clamping.

Outcome of Concomitant Renal Artery Reconstructions in Patients with Aortic Aneurysm and Occlusive Disease

The question remains as to whether patients presenting with aortoiliac occlusive disease (AIOD) or abdominal aortic aneurysms (AAAs) have similar outcomes when concomitant renal artery reconstructions are performed. In this study, we analyzed our experience with simultaneous aortic and renal reconstructions using a retroperitoneal approach. Over a 5-year period, all patients with either AAAs > 5 cm or symptomatic AIOD who were found to have high-grade renal artery stenosis and who underwent aortic reconstructions with concomitant renal revascularization were analyzed through our vascular surgery registry. Morbidity and mortality were quantitatively evaluated. Data were analyzed using the chi-square test. A total of 1,133 patients with AAA (n = 832) and AIOD (n = 301) underwent aortic reconstructions. Two hundred thirty-one patients had 283 concomitant renal revascularizations, including bypass, reimplantation, and endarterectomy, for high-grade (> 70%) renal artery stenosis via a left retroperitoneal approach. The mortality rate of AAA repair with and without renal revascularization was 2.3% (4/178) and 1.5% (10/654), respectively, and that of aortobifemoral bypass for AIOD with and without renal revascularization was 5.7% (3/53) and 2.8% (7/248), respectively. Of the 7 deaths in patients requiring aortic and renal reconstructions, 4 occurred in patients with bilateral renal revascularization. Transient renal insufficiency, ischemic colitis, and cardiopulmonary failure occurred in 5.6%, 2.2%, and 9.6% of patients with AAA repair and in 5.7%, 0%, and 9.4% of patients with AIOD. Two patients developed acute occlusion of their renal bypasses; one was successfully revised, whereas the other led to a nephrectomy. In patients with AAAs, AIOD, and high-grade renal artery stenosis, simultaneous aortic and renal reconstructions can be performed through a retroperitoneal approach with a limited and acceptable mortality. With concomitant renal and aortic procedures, patients with AIOD have a higher mortality when compared with those with AAAs, although this difference is not statistically significant.

Bilateral Extraanatomic Renal Revascularization Utilizing the Celiac Artery as an Inflow

A case of poorly controlled renovascular hypertension and worsening renal insufficiency in a patient with prior aortic aneurysm replacement and a hepatic artery stenosis was treated with bilateral extraanatomic renal revascularization utilizing the celiac artery as an inflow. Three years following revascularization, her blood pressure is well controlled and her renal function is stable. Renal revascularization using the celiac trunk as an inflow source has not been previously reported. This case demonstrates that the celiac artery can be used for bilateral renal artery revascularization if the hepatic or splenic arteries are found to be inadequate as an inflow source.

Chronic renal artery occlusion: Nephrectomy versus revascularization

Purpose: The surgical management of chronic atherosclerotic renal artery occlusion (RA-OCC) was studied. Methods: From January 1987 through December 1996, 397 consecutive patients were treated for atherosclerotic renal artery disease. Ninety-five hypertensive patients (mean blood pressure, 204 ± 31/106 ± 20 mm Hg; mean medications, 3.0 ± 1.1 drugs) were treated for 100 RA-OCCs. Eighty-four (88%) patients had renal dysfunction, defined by serum creatinine levels ≥1.3 mg/dL (mean serum creatinine level, 2.8 ± 2.0 mg/dL). Demographic characteristics, operative morbidity and mortality, blood pressure/renal function response, and postoperative decline in renal function were examined and compared with that of 302 patients treated for renal artery stenosis (RAS). Results: After operation, there were 5 perioperative deaths (5.2%), 2 (2.8%) after revascularization and 3 (12%) after nephrectomy ( P = .11), compared with 12 (4.0%) perioperative deaths in the RAS group ( P = .59). After controlling for important covariates, estimated survival and blood pressure benefits did not differ between RA-OCC patients treated by nephrectomy or revascularization ( P = .13; 87% vs 92%, P = .54). Excretory renal function was considered improved in 49% of 79 RA-OCC patients with renal dysfunction, including 9 patients removed from dialysis-dependence. Among patients treated for unilateral disease, revascularization for RA-OCC was associated with significant improvement in renal function ( P < .01); however, nephrectomy alone did not increase renal function significantly. Improved renal function after operation was associated with a significant and independent increase in survival ( P < .01) and dialysis-free survival ( P < .01) among patients treated for RA-OCC. In addition, blood pressure benefit, renal function response, and estimated survival did not differ significantly after reconstruction for RA-OCC or RAS. Conclusion: Among hypertensive patients treated for RA-OCC, equivalent beneficial blood pressure response was observed after both revascularization and nephrectomy. In patients who underwent bilateral renal artery revascularization, the change in excretory renal function attributable to repair of RA-OCC cannot be defined. In patients treated for unilateral disease, however, improvement in function was observed only after revascularization. Moreover, improved renal function demonstrated a significant and independent association with improved survival. This experience supports renal revascularization in preference to nephrectomy for RA-OCC in select hypertensive patients when a normal distal artery is demonstrated at operation. (J Vasc Surg 1999;29:140-9.)

Successful delayed bilateral renal revascularization during active phase of Takayasu's arteritis

Successful bilateral renal revascularization was performed 24 days after the development of angiotensin converting enzyme-inhibitor–induced bilateral renal artery thrombosis and anuric acute renal failure in a patient with Takayasu's arteritis. Excellent results were obtained after an unusually long ischemic time for a patient with active-phase disease. The outcome suggests that aggressive surgical revascularization can benefit patients with renal failure caused by renal arterial occlusion during the active phase of Takayasu's arteritis. (J Vasc Surg 1998;27:552-4.)

Access to the Right Renal Artery from the Left Retroperitoneal Approach

One of the perceived limitations of the left retroperitoneal approach to the aorta is inadequate access to the right renal artery. Many consider the need for a concomitant right renal artery revascularization a contraindication to performing an aortic reconstruction through the left retroperitoneum. Exposure of the right renal artery can be difficult due to the posterior course of the artery behind the vena cava. However, when the aorta is transected, the right renal artery can be easily approached with anterior and cephalad displacement of the aortic root. Over the past 3 years, 52 patients have had right or bilateral renal artery revascularization via the left retroperitoneal approach; of these procedures, 37 were performed with concomitant aortic procedures. In total, 34 patients had bilateral and 18 had unilateral revascularizations. Five patients had a transaortic endarterectomy performed, and 36 were bypassed with 6-mm expanded polytetrafluoroethylene side limbs from the aortic graft. Indications for revascularization were: 39 for suprarenal aortic bypass, seven for renal salvage and six for primary renovascular hypertension. All reconstructions have remained patent and all have been followed by serial duplex and renal flow scans (follow-up for 1–42 months). The operative mortality rate was 5.8% (3/52). There were no major cardiorespiratory complications in this group. Adequate exposure to the proximal right renal artery can be obtained through the left retroperitoneal approach to the aorta, and successful revascularization of one of both renal arteries can be technically performed with acceptable mortality and morbidity.

Access to the right renal artery from the left retroperitoneal approach

One ofthe perceived limitations of the left retroperitoneal approach to the aorta is inadequate access to the right renal artery. Many consider the need for a concomitant right renal artery revascularization a contraindication to performing an aortic reconstruction through the left retroperitoneum. Exposure of the right renal artery can be difficult due to the posterior course of the artery behind the vena cava. However, when the aorta is transected, the right renal artery can be easily approached with anterior and cephalad displacement of the aortic root. Over the past 3 years, 52 patients have had right or bilateral renal artery revascularization via the left retroperitoneal approach; of these procedures, 37 were performed with concomitant aortic procedures. In total, 34 patients had bilateral and 18 had unilateral revascularizations. Five patients had a transaortic endarterectomy performed, and 36 were bypassed with 6-mm expanded polytetrafluoroethylene side limbs from the aortic graft. Indications for revascularization were: 39 for suprarenal aortic bypass, seven for renal salvage and six for primary renovascular hypertension. All reconstructions have remained patent and all have been followed by serial duplex and renal flow scans (follow-up for 1-42 months). The operative mortality rate was 5.8% ( 3 52 ). There were no major cardiorespiratory complications in this group. Adequate exposure to the proximal right renal artery can be obtained through the left retroperitoneal approach to the aorta, and successful revascularization of one of both renal arteries can be technically performed with acceptable mortality and morbidity. Copyright © 1996 The International Society for Cardiovascular Surgery.

Empirical reconstruction of the renal artery: long-term outcome.

Unequivocal indications for renal artery reconstruction remain the presence of significant underlying renal insufficiency or severe hypertension. Thus surgical intervention for renal artery stenosis in the absence of this clinical picture may well be considered empirical and, as a consequence, treatment recommendations are ill-defined. Our experience with reconstruction of the minimally symptomatic or asymptomatic renal artery lesion in association with primary aortic repair over a 10-year period was reviewed. Thirty-two patients who had atherosclerotic renal artery stenosis > or = 70% underwent prophylactic renal revascularization between 1982 and 1992. The patients' median age was 63 years (range, 44 to 79 years); 23 (72%) were men and nine (28%) were women. All had preoperative serum creatinine levels < or = 1.7 mg/dl (1.29 +/- 0.24 mg/dl) and were receiving either no antihypertensive medication (22%) or only a single agent (78%). Aortoiliac occlusive disease was present in 38% of this population, and aortic aneurysmal disease either alone or in combination with occlusive disease was found in 62%. Operative management included unilateral renal artery repair in 21 patients (66%) and bilateral renal revascularization in the remaining 11 (34%). The median decrease in postoperative serum creatinine level (> or = 7 days after operation) was 0.81 +/- 0.05% (mean postoperative serum creatinine level 1.27 +/- 0.07 mg/dl). The 30-day operative mortality rate was 3.1% (1 of 32). Late follow-up was available for 96% of patients (30 of 31; median, 64 months). Kaplan-Meier life table analysis revealed a 5-year probability of survival of 90.2% (95% confidence interval, 0.802 to 1.00). Stability of renal function was assessed by modeling the change in serum creatinine level over time with the intraclass correlation model. A serum creatinine level (mg/dl) = 1.3348 + 0.0011 x time (months) demonstrated minimal deterioration of excretory function during the observation period. Furthermore, the blood pressure of the majority of patients (75%) remained normal either with a single agent or without medication. Recurrent stenosis in one patient required treatment by percutaneous transluminal angioplasty. Adjunctive repair of the renal artery may be an appropriate option in selected patients who undergo simultaneous aortic surgery, even in the absence of severe hypertension or renal insufficiency. Surgical intervention can be accomplished with acceptable perioperative morbidity rates, and stability of renal function is sustainable in the majority of patients.

Outcomes after major vascular surgery: the patients' perspective.

Surgical outcomes are traditionally defined by rates of morbidity and mortality, as well as the success with which operative objectives are met. Although quality of life after surgery has been sporadically mentioned in the literature since the turn of the century, far greater emphasis has been placed on traditional outcome measures. As the population ages and technological advances permit high-risk interventions in selected elderly patients, the assessment of outcomes with respect to quality of life has become increasingly relevant. To assess quality of life and surgical outcome, 15 patients undergoing simultaneous bilateral renal revascularization at Yale-New Haven Hospital were retrospectively studied. Fifteen charts were reviewed for data on length of hospital stay, number of days in the intensive care unit, operative morbidity, and short- and long-term results. The SF-36, a previously validated health status questionnaire, was used to survey the 11 long-term survivors. Telephone surveys were conducted by a vascular nurse. Of the 11 long-term survivors, nine patients rated their health as good to excellent (eight rated it the same or better than before surgery), eight had no or minimal physical disability, and 10 remained as involved socially as previously. The SF-36 appears to be an effective instrument for assessing postoperative quality of life. It was concluded that this group of patients was satisfied with the outcome of surgery, suggesting that major vascular surgical interventions could be undertaken in selected elderly patients without significant adverse impact on quality of life.

Successful Pregnancy after Bilateral Extracorporeal Renal Revascularization and Autotransplantation

Successful Pregnancy after Bilateral Extracorporeal Renal Revascularization and Autotransplantation

Retroperitoneal approach for bilateral renal and visceral artery revascularization

Revascularization for renal and visceral arterial occlusive disease has traditionally been performed via a transperitoneal approach. Exposing these arteries transperitoneally is often difficult, however, and may require extensive medial visceral rotation. An alternative is a left retroperitoneal approach for renal and visceral arterial revascularization, including procedures involving the right renal artery. Over the past 7 years, a total of 186 such procedures have been performed using this approach. Of 30 that involved primarily the celiac and mesenteric arteries, 20 were completed with a bypass graft and 10 with transaortic endarterectomy. Of 156 procedures performed for renal arterial occlusive disease or aneurysmal disease extending above the renal arteries, 32 were treated with transluminal endarterectomy, 21 were treated with bilateral bypasses, and 72 were treated with unilateral bypass. Concomitant aortic endarterectomy or graft replacement was performed in 110 of this group. Operative mortality was 3.3%. Reconstructions were followed-up (for 1 to 76 months) with serial duplex and renal flow ultrasonography scans. One thrombosis developed in a renal artery bypass. We conclude that the left retroperitoneal approach may conveniently be used to reconstruct the celiac artery, superior mesenteric artery, and both renal arteries. These reconstructions may be performed with either an endarterectomy or bypass technique. In particular, the need to revascularize the right renal artery should not be regarded as a contraindication to using a left retroperitoneal approach.

Simultaneous bilateral renal revascularization: Predeicting and assessing outcome in high-risk patients: Richard J. Gusberg, MD, Kimberly O. Lacey, RN, Harlan Krumholz, MD, Bauer E. Sumpio, MD, PhD, and George H. Meier, MD, Yale University School of Medicine, New Haven, Conn.

Simultaneous bilateral renal revascularization: Predeicting and assessing outcome in high-risk patients: Richard J. Gusberg, MD, Kimberly O. Lacey, RN, Harlan Krumholz, MD, Bauer E. Sumpio, MD, PhD, and George H. Meier, MD, Yale University School of Medicine, New Haven, Conn.

Combined coronary artery bypass grafting and bilateral renal revascularization for unstable angina and impending renal failure

The purpose of our article is to describe a patient with severe hypertension and moderate renal insufficiency, unstable angina, and a 6 cm abdominal aortic aneurysm. A previous aortogram had demonstrated severe bilateral renal artery stenoses. Cardiac catheterization demonstrated severe coronary disease. After cardiac catheterization acute renal failure and pulmonary edema requiring dialysis developed in the patient. In addition, evidence of impending myocardial necrosis developed. Because of the critical nature of the myocardial and renal ischemia it was necessary to perform combined myocardial and renal revascularization rather than staged procedures. At the time of coronary artery bypass grafting, a vein graft was anastomosed to the right coronary artery vein graft and tunneled through the diaphragm into the abdomen to revascularize both renal arteries. After surgery renal function gradually improved, and no further dialysis was required. The abdominal aortic aneurysm was repaired at a subsequent operation. At 2-year follow-up all grafts remained patent. The serum creatinine is 1.2 mg/dl. Although most patients with combined coronary artery disease and renal artery disease can be treated with staged operations, our procedure may be of value in patients in whom staged procedure are not feasible and in whom the infrarenal aorta is severely diseased or aneurysmal.

Isolated Bilateral Renal Artery Thrombosis

Bilateral renal artery thrombosis with anuria following blunt abdominal trauma is distinctly unusual. We report a 16-year-old female in whom emergency revascularization with a primary reimplantation on the right and a hypogastric artery interposition graft on the left was performed following angiographic documentation of bilateral renal artery occlusion. Excellent renal function was demonstrated bilaterally at 7 weeks. Bilateral renal revascularization is feasible in the acute setting and can yield excellent results.

Isolated Bilateral Renal Artery Thrombosis

Bilateral renal artery thrombosis with anuria following blunt abdominal trauma is distinctly unusual. We report a 16-year-old female in whom emergency revascularization with a primary reimplantation on the right and a hypogastric artery interposition graft on the left was performed following angiographic documentation of bilateral renal artery occlusion. Excellent renal function was demonstrated bilaterally at 7 weeks. Bilateral renal revascularization is feasible in the acute setting and can yield excellent results.

Management of renovascular hypertension in the elderly population

This article summarizes our experience with the operative management of renovascular hypertension in a contemporary population of elderly patients. During a recent 18-month period 35 of 74 patients (47%) undergoing an operation for renovascular hypertension at our center were in their seventh (21 patients) or eighth (14 patients) decade of life (mean age, 68 years). There were 17 men and 18 women with blood pressures ranging from 176/90 mm Hg to 280/215 mm Hg (mean, 213/121 mm Hg). Twenty-seven patients (77%) had renal insufficiency (serum creatinine greater than or equal to 1.3 mg/dl). Nineteen patients had severe insufficiency (serum creatinine greater than or equal to 2.0 mg/dl), with five of these patients being dependent on dialysis. Thirty-three of 35 patients (94%) had evidence of organ-specific atherosclerotic damage as manifested by cardiac disease (72%), cerebrovascular disease (37%), or renal insufficiency (77%). Operative management consisted of unilateral revascularization in 17 patients (includes three contralateral nephrectomies), bilateral renal revascularization in 17 patients, and primary nephrectomy in one. Simultaneous aortic replacement was performed in nine patients. There were two operative deaths (5.7%) and two postoperative graft thromboses (4%). Hypertension was cured (three) or improved (27) in 30 of the 33 survivors (91%). Renal function was improved in six and worsened in two patients with severe non-dialysis-dependent renal insufficiency. Three of five patients who were dependent on dialysis before surgery were removed from dialysis after renal revascularization. On follow-up (mean, 10.3 months) we found that five patients had died. This article emphasizes the complexity of atherosclerosis in the current population presenting for operative management of renovascular hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of renovascular hypertension in the elderly population

This article summarizes our experience with the operative management of renovascular hypertension in a contemporary population of elderly patients. During a recent 18-month period 35 of 74 patients (47%) undergoing an operation for renovascular hypertension at our center were in their seventh (21 patients) or eighth (14 patients) decade of life (mean age, 68 years). There were 17 men and 18 women with blood pressures ranging from 176/90 mm Hg to 280/215 mm Hg (mean, 213/121 mm Hg). Twenty-seven patients (77%) had renal insufficiency (serum creatinine ≥1.3 mg/dl). Nineteen patients had severe insufficiency (serum creatinine ≥2.0 mg/dl), with five of these patients being dependent on dialysis. Thirty-three of 35 patients (94%) had evidence of organ-specific atherosclerotic damage as manifested by cardiac disease (72%), cerebrovascular disease (37%), or renal insufficiency (77%). Operative management consisted of unilateral revascularization in 17 patients (includes three contralateral nephrectomies), bilateral renal revascularization in 17 patients, and primary nephrectomy in one. Simultaneous aortic replacement was performed in nine patients. There were two operative deaths (5.7%) and two postoperative graft thromboses (4%). Hypertension was cured (three) or improved (27) in 30 of the 33 survivors (91%). Renal function was improved in six and worsened in two patients with severe non-dialysis-dependent renal insufficiency. Three of five patients who were dependent on dialysis before surgery were removed from dialysis after renal revascularization. On follow-up (mean, 10.3 months) we found that five patients had died. This article emphasizes the complexity of atherosclerosis in the current population presenting for operative management of renovascular hypertension. Despite the complexity of disease in this elderly population, our experience suggests that operative management is beneficial and can be accomplished with acceptable albeit increased risk in properly selected elderly patients.

Simultaneous Aortic Reconstruction and Bilateral Renal Revascularization: Is This a Safe and Effective Procedure?

Between 1982 and 1987, 32 patients with severe aortorenal atherosclerosis had simultaneous aortic and bilateral renal revascularization. All patients were hypertensive. Eighteen patients (56%) had renal insufficiency with a mean serum creatinine (SC) of 2.8 mg/dl. Nine patients had an aortic aneurysm; the remaining 23 patients had aortoiliac occlusive disease of varying severity. Aortic reconstruction was done with either a straight (six patients) or bifurcated (26 patients) Dacron graft. Renal revascularization was accomplished with either bypass (60 arteries) or transaortic endarterectomy (four arteries). One patient died of pulmonary embolism (operative mortality rate 3%). Beneficial blood pressure response was achieved in 28 of 31 survivors, (90%). Among the 18 patients with renal insufficiency, mean SC was 2.80 +/- 1.18 mg/dl preoperatively and 1.65 +/- 0.48 mg/dl postoperatively (p less than 0.001). Among eight patients with severe renal dysfunction before surgery (SC greater than 3 mg/dl), mean SC was 3.90 +/- 0.85 mg/dl before and 1.79 +/- 0.69 mg/dl after operation (p less than 0.001). In follow-up extending to 58 months (mean 27.6 months), five late deaths occurred; cumulative survival was 94% at 2 years and 60% at 4 years. There were no instances of worsening hypertension; one patient had deteriorating renal function. These results indicate that severe aortorenal atherosclerosis can be managed with simultaneous aortic reconstruction and bilateral renal revascularization at low operative risk. In addition, there can be high expectation of significant and persisting benefit in both hypertension and renal dysfunction after operation.

Simultaneous aortic reconstruction and bilateral renal revascularization: Is this a safe and effective procedure?

Between 1982 and 1987, 32 patients with severe aortorenal atherosclerosis had simultaneous aortic and bilateral renal revascularization. All patients were hypertensive. Eighteen patients (56%) had renal insufficiency with a mean serum creatinine (SC) of 2.8 mg/dl. Nine patients had an aortic aneurysm; the remaining 23 patients had aortoiliac occlusive disease of varying severity. Aortic reconstruction was done with either a straight (six patients) or bifurcated (26 patients) Dacron graft. Renal revascularization was accomplished with either bypass (60 arteries) or transaortic endarterectomy (four arteries). One patient died of pulmonary embolism (operative mortality rate 3%). Beneficial blood pressure response was achieved in 28 of 31 survivors, (90%). Among the 18 patients with renal insufficiency, mean SC was 2.80 ± 1.18 mg/dl preoperatively and 1.65 ± 0.48 mg/dl postoperatively (p < 0.001). Among eight patients with severe renal dysfunction before surgery (SC greater than 3 mg/dl), mean SC was 3.90 ± 0.85 mg/dl before and 1.79 ± 0.69 mg/dl after operation (p < 0.001). In follow-up extending to 58 months (mean 27.6 months), five late deaths occurred; cumulative survival was 94% at 2 years and 60% at 4 years. There were no instances of worsening hypertension; one patient had deteriorating renal function. These results indicate that severe aortorenal atherosclerosis can be managed with simultaneous aortic reconstruction and bilateral renal revascularization at low operative risk. In addition, there can be high expectation of significant and persisting benefit in both hypertension and renal dysfunction after operation.

Simultaneous aortic reconstruction and bilateral renal revascularization. Is this a safe and effective procedure?

Between 1982 and 1987, 32 patients with severe aortorenal atherosclerosis had simultaneous aortic and bilateral renal revascularization. All patients were hypertensive. Eighteen patients (56%) had renal insufficiency with a mean serum creatinine (SC) of 2.8 mg/dl. Nine patients had an aortic aneurysm; the remaining 23 patients had aortoiliac occlusive disease of varying severity. Aortic reconstruction was done with either a straight (six patients) or bifurcated (26 patients) Dacron graft. Renal revascularization was accomplished with either bypass (60 arteries) or transaortic endarterectomy (four arteries). One patient died of pulmonary embolism (operative mortality rate 3%). Beneficial blood pressure response was achieved in 28 of 31 survivors, (90%). Among the 18 patients with renal insufficiency, mean SC was 2.80 +/- 1.18 mg/dl preoperatively and 1.65 +/- 0.48 mg/dl postoperatively (p less than 0.001). Among eight patients with severe renal dysfunction before surgery (SC greater than 3 mg/dl), mean SC was 3.90 +/- 0.85 mg/dl before and 1.79 +/- 0.69 mg/dl after operation (p less than 0.001). In follow-up extending to 58 months (mean 27.6 months), five late deaths occurred; cumulative survival was 94% at 2 years and 60% at 4 years. There were no instances of worsening hypertension; one patient had deteriorating renal function. These results indicate that severe aortorenal atherosclerosis can be managed with simultaneous aortic reconstruction and bilateral renal revascularization at low operative risk. In addition, there can be high expectation of significant and persisting benefit in both hypertension and renal dysfunction after operation.