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.
Chaikof, EL; Smith, RB; Salam, AA; Dodson, TF; Lumsden, AB; Chapman, R; Kosinski, AS
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