Late Results of Reconstructive Surgery for Renovascular Disease

Abstract

In order to determine the late results of reconstructive surgery for renovascular disease, a review was made of a series of 505 consecutive patients who underwent operation over a 20-year period. There were 257 males (50.9%) with an age range of 3-80 years. Renal artery bypass grafts were used in 75.4% (471/625) and thromboendarterectomy and/or patch angioplasty in 15.0% (94/625) of reconstructions. Associated vascular procedures were performed in 38.0% (186/489) of patients. Operative mortality (30-day) was 1.8% (9/489) overall, and 4.8% (9/186) with associated procedures but there was no operative mortality in 303 consecutive isolated renal artery reconstructions. The blood pressure was normal or improved in 65% of patients at a mean follow-up interval of 49.3 months, range 1-240 months. The best response rate was obtained in younger patients with isolated renal lesions. Linear regression analysis showed age at operation to be the most important determinant of blood pressure response (p < 0.003) with the presence or absence of diffuse atherosclerosis as another but less powerful determinant of responsiveness (p < 0.07). Crude 15-year survival was 70% (340/489). The overall five- and ten-year actuarial survival probabilities were 80 and 62% respectively. The most common causes of death were myocardial infarction, stroke, and cancer. Cox regression analysis for variables influencing survival indicated that age at operation (p < 0.001), sex (p < 0.01) and the presence or absence of fibromuscular disease (p < 0.002) were the major determinants of late survival with persistent severe hypertension exerting an important but lesser influence. The results of this study indicate that about two-thirds of patients will experience long-term relief of hypertension after operation and that the best long-term survival and blood pressure relief will be obtained in patients less than 50 years of age. Because hypertension in females is better tolerated, younger, male patients appear to have the most to gain from successful renovascular reconstruction.

Surgery, Transluminal Dilatation and Medical Therapy in the Management of Renovascular Hypertension

“…Postoperative outcome of the present retrospective analysis is comparable with results reported in other studies [2][3][4]. A similar relative high incidence of primary nephrectomy has also been described in the cooperative study of renovascular hypertension [2], This incidence becomes markedly lower when results from single spe cialized centers are analyzed [3,15], Our results also indicate that the criteria originally used to select patients for surgery were at least in part abandoned on the introduction of percutaneous translu minal dilatation (PTD).…”

“…A similar relative high incidence of primary nephrectomy has also been described in the cooperative study of renovascular hypertension [2], This incidence becomes markedly lower when results from single spe cialized centers are analyzed [3,15], Our results also indicate that the criteria originally used to select patients for surgery were at least in part abandoned on the introduction of percutaneous translu minal dilatation (PTD). This explains why dilated pa tients had a slightly impaired kidney function, were older and showed a much smaller blood pressure elevation and a longer history of hypertension than operated cases.…”

“…Since then, various therapeutic approaches to reno vascular hypertension have been tried, the most impor tant being reconstructive or ablative surgery, antihyper tensive drugs including converting enzyme inhibitors and percutaneous transluminal dilatation (PTD). There are numerous studies on the results of these therapeutic procedures reporting an improved and cured incidence of renovascular hypertension in 60-95% of surgically treated patients [2][3][4] and in 35-90% in dilated patients [5][6][7][8]. Medical therapy with conventional antihyperten sive drugs seems to be successful in controlling hyperten sion in about 50% of the cases [9], whereas under the converting enzyme inhibitor, captopril, sufficient blood pressure control was observed in as many as 80% of the cases [10,11], Up to now, direct comparisons between the described therapeutic regimes have been lacking.…”

Fibromuscular Dysplasia: State of the Science and Critical Unanswered Questions

“…19,20,[226][227][228][229][230][231][232][233][234][235][236][237][238][239] It is important that the primary revascularization procedure be successful because nephrectomy is common with reoperation.…”

Percutaneous Renal Angioplasty

“…Complications of the procedure are reported in 6-10% of cases, most spontaneously resolving but with occasional cases of renal artery occlusion (Schwarten et al 1980, Martin et al 1981, Colapinto et al 1982, Tegtmeyer et al 1983). The reported results of surgery for renal vascular hypertension are remarkably similar, but the surgical mortality rate of 2-6% reflects'the inevitable hazards of major surgery in older'patients with vascular disease (Foster et al 1975, Lankford et al 1979, Lawrie et al 1980. Renal transplant artery stenosis occurs in 5-25% of patients (Lacombe 1975).…”