Renal artery reconstruction for the preservation of renal function

• Published in: Journal of vascular surgery Vol. 24; no. 3; pp. 371 - 382
• Main Authors: Cambria, Richard P., Brewster, David C., L'Italien, Gilbert J., Gertler, Jonathan P., Abbott, William M., LaMuraglia, Glenn M., Moncure, Ashby C., Vignati, John, Bazari, Hasan, Fang, Leslie T., Atamian, Susan
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01-09-1996
• Subjects: Adult; Aged; Aged, 80 and over; Arteriosclerosis - mortality; Arteriosclerosis - physiopathology; Arteriosclerosis - surgery; Coronary Disease - complications; Creatinine - blood; Female; Follow-Up Studies; Humans; Hypertension, Renovascular - etiology; Kidney - physiopathology; Life Tables; Logistic Models; Male; Middle Aged; Postoperative Complications; Renal Artery - surgery; Renal Artery Obstruction - mortality; Renal Artery Obstruction - physiopathology; Renal Artery Obstruction - surgery; Retrospective Studies; Risk Factors; Survival Rate; Treatment Outcome; Vascular Surgical Procedures - methods; Vascular Surgical Procedures - mortality
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/S0741-5214(96)70193-3

Purpose: We reviewed a 13-year experience with an emphasis on long-term survival and renal function response when renal artery reconstruction (RAR) was performed primarily for the preservation or restoration of renal function in patients who had atherosclerotic renovascular disease.
Methods: From January 1, 1980, to June 30, 1993, 139 patients underwent RAR for renal function salvage and were retrospectively reviewed. Inclusion criteria were either preoperative serum creatinine level >2.0 mg/dl (67% of patients) or RAR to the entire functioning renal mass irrespective of baseline renal function. Patient survival was calculated by life-table methods. Cox regression analysis was used to determine relative risk (RR) estimates for the late outcomes of continued deterioration of renal function and late survival after RAR. A logistic regression model was used to evaluate variables associated with perioperative complications.
Results: Clinical characteristics of the cohort were notable for advanced cardiac (history of congestive heart failure, 27%; angina, 22%; previous myocardial infarction, 19%) and renal disease (serum creatinine level <2.0 mg/dl, 33%; 2.0 mg/dl to 3.0 mg/dl, 40%, >3.0 mg/dl, 27%). Cardiac disease was the principle cause of early (6 of 11 operative deaths) and late death. Operative management consisted of aortorenal bypass in 47%, extraanatomic bypass in 45%, and endarterectomy in 8%; 45% of patients required combined aortic and RAR. The operative mortality rate was 8%; significant perioperative renal dysfunction occurred in 10%. Major operative morbidity was associated with increasing azotemia (RR = 2.1;
p = 0.001; 95% confidence interval [CI], 1.3 to 4.7 for each 1.0 mg/dl increase in baseline creatinine level). Of those patients who had a baseline creatinine level ≥2.0 mg/dl, 54% had ≥20% reduction in creatinine level after RAR. Late follow-up data were available for 87% of operative survivors at a mean duration of 4 years (range, 6 weeks to 12.6 years). Actuarial survival at 5 years was 52% ± 5%. Continued deterioration in renal function occurred in 24% of patients who survived operation, and eventual dialysis was required in 15%. Deterioration of renal function after RAR was associated with increasing levels of preoperative creatinine (RR = 1.6; 95% CI, 1.2 to 1.8;
p = 0.001 for each 1.0 mg/dl increment in baseline creatinine level), and inversely related to early postoperative improvement in creatinine level (RR = 0.41; 95% CI, 0.2 to 0.9;
p = 0.04).
Conclusions: Intervention before major deterioration in renal function and an aggressive posture toward the frequently associated coronary artery disease are necessary to improve long-term results when RAR is performed for renal function salvage. (J Vasc Surg 1996;24:371-82.)