Hepatorenal Bypass Research Articles

Modified Ex Vivo Renal Reconstruction to Facilitate Fenestrated-Branched Endovascular Repair of a Thoracoabdominal Aortic Aneurysm.

To report the use of modified ex vivo renal artery (RA) reconstruction in a patient with 2 small right RAs (RRAs) in anticipation of planned fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysm (TAAA). A staged hybrid repair was utilized in a patient with Extent II TAAA involving celiac axis (CA), superior mesenteric artery (SMA), single left RA (LRA), and 2 small (<3 mm) RRAs. The first-stage operation consisted of hepato-renal bypass using modified ex vivo renal reconstruction with single end-to-end anastomosis to both RAs using a saphenous vein graft. A second stage FB-EVAR was performed using patient-specific manufactured stent-graft with 3 fenestrations for the CA, SMA, and LRA 6 weeks later. The patient recovered with no complications. At 4 years, the patient had widely patent hepato-renal bypass and target vessels with normal renal function. The use of adjunctive hybrid procedures may optimize or facilitate FB-EVAR. In this patient, salvage of 2 small RAs was not ideally suited for branch stenting but was possible using modified ex vivo RA reconstruction with preservation of kidney parenchyma and function. This case report illustrates a hybrid approach to overcome one of the most frequent limitations to total endovascular incorporation of renal arteries, eg small diameter, early bifurcation and multiple vessels. The modified ex vivo technique allows meticulous renal artery reconstruction without the deleterious effect of warm ischemia and without the cumbersome reconstruction of ureter and vein that is needed with traditional on table ex vivo auto transplantation. The technique is used in a minority of cases and adds the morbidity of open approach. Case selection is of paramount importance.

Renovascular hypertension: results in adulthood of renal autotransplantation performed in children.

This study describes the long-term results of renal autotransplantation for renovascular hypertension performed in children who are now 21 years of age or older. Sixteen children (4 boys, 12 girls) with a mean age of 11.2 years at the time of the procedure underwent ex-vivo surgery at the university hospital of Saint-Etienne between 1992 and 2008. Acetylsalicylic acid was used for antiplatelet therapy in the postoperative period, without routine anticoagulation. The mean follow-up period was 15years. The clinical course of these patients was retrospectively reviewed in adulthood and the results analyzed. The children were treated with a mean of 2.37 drugs per patient, and the mean preoperative blood pressure of the entire patient population was 151/89mmHg. Mean preoperative creatinine clearance was 80ml/min/1.73 m2. There was no postoperative death. One patient experienced a thrombosis immediately after the surgery, leading to a redo surgery. In this patient diuresis was restarted, but without efficient concentration and filtration, ultimately leading the patient to have a renal transplant after 1year. At the end of the follow-up period, eight of the 16 patients (50%) were cured and the others were improved. At the last follow-up the mean blood pressure was 127/70mmHg, and the mean number of drugs per patient was 0.68. The mean creatinine clearance at last follow-up was 104.3ml/min/1.73 m2. Three patients had secondary procedures, with two undergoing percutaneous angioplasty (at postoperative months 9 and 12, respectively) and one having an hepatorenal bypass at postoperative year 4. Primary patency was 12/16 (75%); primary assisted patency was 15/16 (94%); secondary patency was 16/16 (100%). This study shows that renal autotransplantation has good and stable long-term results and is an effective conservative strategy for treating renovascular hypertension in children, thus avoiding nephrectomy.

Common Hepatic Artery as Inflow in Kidney Transplantation

Kidney transplantation originating from the hepatic artery has not previously been reported. Herein, we report a third kidney transplantation with the common hepatic artery as inflow. A 62-year-old male with chronic renal failure due to polycystic kidney disease was proposed to a third kidney transplantation. CT-scan showed diffuse calcification of the aorto-iliac axis and the splenic artery. The common hepatic artery was the only artery suitable for anastomosis and as such was chosen as the inflow for retransplantation. The operation was performed through a right subcostal laparotomy. A saphenous bypass was interposed between the common hepatic artery and the graft, then the renal vein was anastomosed to the suprarenal inferior vena cava. Duration of warm ischemia was 27 min. Postoperative course was complicated with delayed graft function of 17 days and pulmonary infection. Patient was discharged at day 30. With a follow-up of 40 months, serum creatinine level and eGFR are, respectively, 191 µmol/L and 32 mL/min. Hepato-renal bypass technique can be used in kidney retransplantation when patient anatomy is not compatible with other classical options.

Treatment of renal fibromuscular dysplasia in an adolescent male: A case report

Introduction: Fibromuscular dysplasia (FMD) is a rare vascular disease that causes stenosis in the major arteries such as the renal and carotid arteries. The exact prevalence of FMD in the general population is not known. It is often presented with symptoms of hypertension. Mainly reported in middle-aged females, the diagnosis of FMD is often delayed. There are very few case reports of FMD in males and children in literature. Case Report: We report the case of a 13-year-old asymptomatic boy found to have FMD in the right renal artery (RRA). An angiography revealed high grade stenosis that was corrected by surgery. A hepatorenal bypass using anastomosis of the gastroduodenal artery (GDA) to RRA was deemed appropriate. An angioplasty at the anastomosis six weeks after this procedure corrected an upward trend in postsurgical blood pressure readings and RRA blood velocities. Two years after the surgery, the patient has well-controlled blood pressure, managed with low dose of ACE-inhibitors. Conclusion: Hepatorenal bypass of RRA through anastomosis of GDA was a viable surgical option in this case. The monitoring of blood pressure readings allowed for early detection and correction of any post-surgical stenosis.

Surgical Salvage of Acute Renal Artery Occlusion in the Setting of a Solitary Kidney

Management of acute renal artery occlusion in patients with a solitary kidney has a poorly defined prognosis. Loss of renal function is reported by some when acute warm ischemia reaches 2 hours. We report a unique case of a patient that had a 24-hour onset of anuria and acute renal failure upon arrival to the hospital. Nuclear imaging showed trace uptake of the right kidney, without evidence of excretion. Conventional digital subtraction angiography was performed; however, evidence of nephrogram or distal filling of the renal artery was not demonstrated. Secondary to conflicting studies, a computed tomography of the abdomen and pelvis with intravenous contrast revealed only minimal cortical perfusion despite complete occlusion of the previously grafted right renal artery. Patient was taken for urgent hepatorenal bypass surgery. Intraoperative return of urine output occurred immediately after completion of the bypass. Hemodialysis, which was required preoperatively, was stopped after <30 days of bypass procedure. Over 2 years following successful renal salvage, the patient has maintained a normal glomerular filtration rate and patency of her bypass by duplex follow-up.

A Rare Case of Visceral Arterial Stenoses in Williams–Beuren Syndrome Treated by Complex Revascularization

Williams-Beuren syndrome is a rare neurodevelopmental disorder. We present the case of a 27-year-old patient with Williams-Beuren syndrome and a juxtarenal abdominal aorta coarctation. As arterial hypertension (AHT) was not controlled, bilateral renal artery bypasses were performed at the age of 2 years by means of a hepatorenal bypass and a splenorenal bypass. Twenty years later, the patient presented with abdominal pain, diarrhea, and recurrence of AHT, and severe celiac artery and superior mesenteric artery stenoses were discovered. The distal arterial complications of this syndrome are uncommon. After 5 years of medical treatment, aggravation of the patient's symptoms prompted us to consider possible surgical management. The patient was successfully treated using a complex direct and indirect procedure that consisted of a bypass between the celiac aorta and infrarenal aorta, associated with a celiac artery bypass. Instead of endovascular management, this surgical procedure could be considered effective and long lasting for treating this rare cause of renal AHT.

Hepatorenal bypass using autogenous, free internal iliac artery graft: An attractive alternative to revascularize the right kidney in Takayasu′s disease

Nonspecific aortoarteritis or Takayasu's disease (TD) is a chronic pan endarteritis of unknown origin involving the aorta and its major branches affecting young adults especially women. The disease is more common in eastern Asian countries. Hypertension in these patients generally reflects as renal artery stenosis, which is seen in 28–75% of patients. Surgical revascularization is occasionally needed in patients with failed medical management or endovascular interventions. We report two cases of Takayasu's arteritis in young women where renal revascularization was done using free internal iliac artery hepatorenal bypass graft with excellent control of hypertension in the postoperative period.

Flash pulmonary edema in an orthotopic heart transplant recipient

Flash pulmonary edema (FPE) is a severe renovascular disease that leads to acute recurring pulmonary edema and acute systemic hypertension. Though rarely reported in the literature, its incidence is probably underestimated secondary to misdiagnosis, especially in patients with normal left ventricular function. We report the case of an orthotopic heart transplant recipient who presented with FPE despite having normal left ventricular function and no signs or symptoms of transplant rejection. Discovery of severe bilateral atherosclerotic renal artery stenosis in this patient led to emergency hepatorenal bypass surgery and a favorable postoperative course.

Hepatorenal Bypass Allowing Fenestrated Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysm: A Case Report

A 61-year-old man presented with a 66-mm juxtarenal aortic aneurysm. He was unfit for open repair. The anatomical proximity of his right renal artery (RRA) and his superior mesenteric artery (SMA) precluded fabrication of an endograft allowing perfusion of both vessels. He underwent a hepato-renal bypass to his RRA and subsequent fenestrated endovascular aneurysm repair (EVAR) using an endoprosthesis with fenestrations for the SMA and the left renal artery (LRA), and a scallop for the coeliac trunk. Follow-up imaging showed all visceral vessels to be perfused. The use of this limited hybrid approach allows endovascular treatment of aneurysms that are initially unsuitable for such an approach.

Improvement of renal function in azotaemic hypertensive patients after surgical revascularization.

Between 1974 and 1986, 17 patients (16 men and 1 woman) with renal insufficiency (serum creatinine greater than 1.5 mg/dl, mean 3.75 mg/dl), with a mean age of 51.3 years, underwent surgical renal revascularization. Two of them were on maintenance haemodialysis. All were severely hypertensive in spite of antihypertensive drugs. Atherosclerosis was the cause of renal stenosis in 14 cases and fibromuscular dysplasia in 3. Operative procedures included splenorenal shunt (5), autotransplantation (3), aortorenal bypass (3), hepatorenal bypass (1), bilateral renal endarterectomy (1), renal ostial closure (1) and nephrectomy (3). Mean serum creatinine showed a decrease from 3.76 to 1.65 mg/dl (P less than 0.005). Mean arterial pressure dropped from 161 mmHg to 103 mmHg (P less than 0.001). Systolic and diastolic pressures also showed significant decreases. Two patients died. Four patients required a second operation and the renal function and blood pressure then improved. Renovascular disease must be ruled out in patients with renal insufficiency associated with hypertension, including those patients on haemodialysis. We conclude that renal revascularization surgery is a reliable and efficient form of treatment in selected cases of renal failure of renovascular origin.

Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction

Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve.

Surgical renal artery reconstruction without contrast arteriography: the role of clinical profiling and magnetic resonance angiography

Purpose: Contrast arteriography is the accepted gold standard for diagnosis and treatment planning in patients with atherosclerotic renovascular disease (RVD). In this study, the results of a selective policy of surgical renal artery reconstruction (RAR) with magnetic resonance angiography (MRA) as the sole preoperative imaging modality are reviewed. Methods: From May 1993 to May 1998, 25 patients underwent RAR after clinical evaluation, and aortic/renal MRA performed with a gadolinium-enhanced and 3-dimensional phase contrast technique. Clinical presentations suggested severe RVD in all patients and included poorly controlled hypertension (16 patients), hospitalization for hypertensive crises and/or acute pulmonary edema (13), and deterioration of renal function within one year of operation (15). Thirteen patients had associated aortic pathologic conditions (12 aneurysms, 1 aortoiliac occlusive disease), and eight of these patients also underwent noncontrast computed tomography scans. Significant renal dysfunction (serum creatinine level, ≥2.0 mg/dL) was present in all but 4 patients with 14 of 25 patients having extreme (creatinine level, ≥3.0 mg/dL) dysfunction. Results: Hemodynamically significant RVD in the main renal artery was verified at operation in 37 of 38 reconstructed main renal arteries (24/25 patients). A single accessory renal artery was missed by MRA. RAR was comprehensive (bilateral or unilateral to a single-functioning kidney) in 21 of 25 patients and consisted of hepatorenal bypass graft (3 patients), combined aortic and RAR (13 patients), isolated transaortic endarterectomy (8 patients), and aortorenal bypass graft (1 patient). Early improvement in both hypertension control and/or renal function was noted in 21 of 25 patients without operative deaths or postoperative renal failure. Sustained favorable functional results at follow-up, ranging from 5 months to 4 years, were noted in 19 of 25 patients. Conclusion: MRA is an adequate preoperative imaging modality in selected patients before RAR. This strategy is best applied in circumstances where the clinical presentation suggests hemodynamically significant bilateral RVD and/or in patients at substantial risk of complications from contrast angiography. (J Vasc Surg 1999;29:1012-21.)

Renal Artery Stenosis Complicating Polycystic Kidney Disease

Polycystic kidney disease (PCKD) commonly causes hypertension and leads to chronic renal insufficiency. Correctable renal artery stensosis can coexist with PCKD and contribute to both hypertension and progressive decline in renal function but is often overlooked. To illustrate the diagnostic and therapeutic implications of this unusual combination of pathology, the authors present the case of a 59-year-old woman with severe PCKD who presented with recurrent bouts of malignant hypertension, flash pulmonary edema, and accelerated decline of renal function over a 3-month period. In the course of normal findings from cardiac catheterization, aortography demonstrated severe right renal artery stenosis. Captopril renal scintigraphy confirmed the viability of both kidneys and the physiologic significance of the right renal artery stenosis even in the setting of chronic renal insufficiency. Right renal artery revascularization was achieved by using a hepatorenal bypass with reversed greater saphenous vein. The patient had an immediate improvement in renal function and blood pressure control as evidenced by a decline in creatinine and a reduction of medication requirements, respectively. In 15 months' follow-up, this therapeutic result has been maintained and she has not experienced any further bouts of pulmonary edema. This unusual case emphasizes the need to pursue correctable pathology of the renal arteries despite the presence of chronic renal insufficiency unrelated to vascular occlusive disease in order to preserve renal function and stabilize hypertension. Patients with multiple etiologies of renal dysfunction represent diagnostic and therapeutic challenges that are not insurmountable but require diligence in pursuing repairable lesions when their clinical course deviates from that expected from the uncorrectable pathology.

Unexplained intraoperative hypotension, acute ischemic hepatitis, and pancreatitis associated with aortorenal bypass surgery

A 69-year-old male smoker who had severe atherosclerotic renovascular disease associated with progressive deterioration of kidney function, poorly controlled hypertension, and a 5-cm solid fight renal mass was scheduled for partial nephrectomy and hepatorenal bypass. He had no history of other cardiovascular disease or prior abdominal surgery. The physical examination was unremarkable except for a blood pressure of 170/90 mmHg. Laboratory studies included normal white blood cell count, hematocrit, platelet count, liver function tests, and clotting characteristics. The blood urea nitrogen concentration was 25 mg/dL (normal, 8 to 25 mg/dL); creatinine, 2.2 mg/dL (normal, 0.7 to 1.4 mg/dL); and creatinine clearance, 25 mL/min. Carbon dioxide arteriography was performed 1 month before the surgery and showed bilateral proximal 80% renal artery stenosis. A lateral aortogram showed a mild proximal celiac trunk stenosis with patent splenic, hepatic, and superior mesenteric arteries, and occluded inferior mesenteric artery. The right hepatic artery originated from the superior mesenteric artery and had a 50% to 60% osteal stenosis. The preoperative electrocardiogram and thallium stress test were normal; a carotid duplex ultrasound showed a 40% to 59% stenosis of the fight internal carotid artery. Under general endotracheal anesthesia (induction and endotracheal intubation with 150 mg of propofol and 10 mg of vecuronium, and maintenance with oxygen, nitrous oxide, and isoflurane), a bilateral subcostal incision was made, and a Bookwalter retractor was positioned. At exploration, a decreased pulse was noted in the porta hepatis area; therefore, an aortorenal rather than a hepatorenal bypass was performed. After resection of the kidney mass under cold ischemia (duration, 45 minutes), the anterolateral side of the aorta was clamped, and an aortorenal bypass with a reversed greater saphenous vein graft was performed with warm ischemia time of 25 minutes. The patient received no systemic heparinization and only regional arterial heparin flushes (up to 1,000 U) were used during the revascularization. The operation lasted about 4 hours. During the first 2 hours, the systolic blood pressure was between 100 and ll0 mmHg, and a continuous intravenous dopamine drip (dose, 1 to 3 ~tg/kg/min) was administered. The central venous pressure was 15 to 18 mmHg. During the last 2 hours of the surgery, the systolic blood pressure was maintained between 90 to 100 mmHg (despite relatively low blood loss and light anesthesia with 0.2% to 0.3% isoflurane) with increased fluid administration, and dopamine and epinephrine infusions at 12 ~g/kg/min and 0.03 to 0.07 pg/kg/min, respectively. The estimated blood loss during the entire operation was 1,500 mL, and the patient received 2 U of packed red blood cells. In

Hepatorenal Bypass for Renovascular Hypertension

An alternative source of arterial inflow is sometimes necessary for renal revascularization when aortorenal endarterectomy or bypass are inappropriate due to a diseased aorta. We report the case of a 29-year-old male who underwent hepatorenal bypass for renovascular hypertension and chronic renal insufficiency. Hepatorenal revascularization was performed by interposing reversed saphenous vein between the common hepatic artery and the right renal artery. Postoperatively, both renal and hepatic functions were normal and the hypertension was reduced.

The Contemporary Role of Extra-anatomical Surgical Renal Revascularization in Patients with Atherosclerotic Renal Aretery Disease

We delineate the current role of extra-anatomical revascularization techniques in the treatment of patients with atherosclerotic renal artery stenosis. There are 2 components to this study. In part 1 all abdominal aortograms performed between 1989 and 1993 were reviewed to document the presence of significant abdominal aortic and visceral arterial atherosclerosis in patients with atherosclerotic renal artery stenosis. A total of 254 patients with atherosclerotic renal artery stenosis was identified. Among 44 patients with severe unilateral disease the incidence of significant abdominal aortic atherosclerosis was 75 percent. The incidence of significant (greater than 50 percent) stenosis of the celiac, right common iliac and left common iliac arteries was 52 percent, 32 percent and 27 percent, respectively. In 129 patients with severe atherosclerotic renal artery stenosis bilaterally or in a solitary kidney the incidence of significant abdominal aortic atherosclerosis was 81 percent, and the incidence of significant (greater than 50 percent) stenosis of the celiac, right common iliac and left common iliac arteries was 59 percent, 57 percent and 59 percent, respectively. These data indicate that hepatorenal, splenorenal and iliorenal bypass cannot be performed in many patients with atherosclerotic renal artery stenosis due to significant disease involving the donor vessels for these operations. In part 2, all patients undergoing surgical renal revascularization with an extra-anatomical bypass operation between 1980 and 1992 were reviewed. A total of 175 operations was done in 171 patients, including hepatorenal bypass in 59, splenorenal bypass in 54, iliorenal bypass in 37, thoracic aortorenal bypass in 23, renal autotransplantation in 1 and superior mesentero-renal bypass in 1. There were 5 operative deaths (2.9 percent) and 7 cases of postoperative graft thrombosis (4 percent). All patients with poorly controlled hypertension were cured or improved postoperatively. Among patients with ischemic nephropathy, postoperative renal function improved in 35 percent, remained stable in 47 percent and deteriorated in 18 percent. Extra-anatomical techniques remain an important component of the surgical armamentarium for atherosclerotic renal artery stenosis. Thoracic aortorenal bypass is a useful new approach in patients with significant celiac and iliac occlusive disease.

Extra-anatomic renal revascularization in patients with renal artery stenosis and abdominal aortic occlusion

Thirteen patients with atherosclerotic renal artery stenosis and total abdominal aortic occlusion underwent extra-anatomic surgical renal revascularization without aortic replacement. Renal artery stenosis was present unilaterally (n = 2), bilaterally (n = 7), or in a solitary kidney (n = 4). Surgical renal revascularization was indicated for treatment of severe hypertension in all patients and for preservation of renal function in 10 patients. The level of abdominal aortic occlusion was suprarenal (n = 3), perirenal (n = 2), or infrarenal (n = 8). All patients had extensive collateral vascular supply to the lower extremities with absent (n = 7) or mild (n = 6) claudication. Surgical renal ervascularization was achieved with hepatorenal bypass (n = 6), mesenterorenal bypass (n = 4), or splenorenal bypass (n = 3). None of the patients underwent concomitant aortic replacement. There were no operative deaths. Postoperatively, hypertension was improved in 10 patients, unchanged in 2 patients, and worse in 1 patient. Renal function was improved in 8 patients, stable in 2 patients, and worse in 3 patients. After surgical renal revascularization, no patient required aortic replacement, while 1 patient underwent extra-anatomic revascularization of the lower extremities. We conclude that some patients with renal artery stenosis and abdominal aortic occlusion can be managed by surgical renal revascularization alone without a more extensive and potentially hazardous aortic replacement. In these patients, extra-anatomic techniques can allow safe and successful surgical renal revascularization while avoiding surgery on the diseased aorta.

Unilateral renal artery revascularization can salvage renal function and terminate dialysis in selected patients with uremia

Revascularization of renal arteries to salvage glomerular function in patients with chronic renal failure is performed infrequently. However, during the past 12 months we have encountered three patients over 60 years of age known to have chronic renal failure who were on dialysis for 2 weeks, 3 weeks, and 2 months, respectively. All three patients were hypertensive, requiring between four and five antihypertensive medications. One patient was ventilator dependent in intractable cardiac failure with pulmonary artery systolic pressures ranging from 60 to 70 mm Hg. Standard biplanar arteriography revealed occlusion of the left renal artery with distal reconstitution in two patients and a 99% stenosis of the right renal artery in the remaining patient. The contralateral renal artery was totally occluded in two patients and diffusely stenotic in one. The recipient kidneys measured 8, 10, and 11 cm in length. Kidney function was assessed by renal scintigraphy and creatinine clearance. Two splenorenal bypasses and one hepatorenal bypass with 6 mm polytetrafluoroethylene graft were performed successfully. After surgery, renal function improved in all patients with two of three patients resuming normal function as evidenced by reduction of serum creatinine levels to 0.9 and 1.3 mg/dl. The third patient recovered to have a creatinine level of 3.2 mg/dl. All patients were discharged home within 1 month with a daily urine output greater than 1500 ml. At discharge, each patient required only two antihypertensive medications to control blood pressure. Duplex scanning 3, 6, and 12 months after surgery confirmed patency of all reconstructions. We conclude that unilateral renal artery revascularization in selected patients who are dialysis dependent can be performed safely and avert the necessity for chronic dialysis.

Renovascular Hypertension in Elderly Patients

In elderly patients with uncontrolled hypertension or increasing azotemia caused by renovascular disease, hepatorenal or splenorenal bypass procedures are helpful alternatives. The presence of diffuse atherosclerosis makes aortorenal bypass technically difficult. Surgery of this type can be accomplished with acceptable morbidity and mortality, even in suitably screened elderly patients.

Hepatorenal and Splenorenal Artery Bypass for Salvage of Renal Function

Hepatic and splenic arteries have been used increasingly as inflow sources to avoid aortorenal bypass in patients whose cardiac dysfunction may be exacerbated by aortic clamping and in patients with previous aortic grafting in whom periaortic dissection is more hazardous than incising undisturbed tissue planes. During an 18-month period, eight patients with atherosclerotic renal artery stenosis and azotemia were treated with six hepatorenal and five splenorenal artery bypasses. Serum creatinine improved initially in all patients. Severe hypertension, present in five patients, improved significantly in four (80%). In one-half the gastroduodenal branch of the hepatic artery was suitable for end-to-end anastomosis to the renal artery, obviating the need for an interposition graft. Hepatorenal bypass is a safe, simple procedure that has been associated with few complications, although occasional transient subclinical evidence of hepatic dysfunction has been reported. Splenorenal bypass requires a relatively more hazardous exposure and is associated with a low risk of splenic and pancreatic injury, especially when the spleen and splenic flexure of the colon are mobilized to expose the splenic artery. The risk of splenic injury is substantially reduced when the splenic artery is approached through the retroperitoneum at the base of the transverse mesocolon as described.