Renal Artery Surgery: The Struggle for Technical Advances and Durable Outcomes

Abstract

A large number of recent RCTs have cast an ominous shadow on indications for surgical intervention on renal artery stenosis (RAS).The latest ESC/ESVS 2017 guidelines remind us that medical therapy remains the best option for RAS and that surgery should be considered only in highly selected cases such as symptomatic RAS associated with complex anatomy, failed endovascular procedure, or during open aortic surgery. 1 The main goal of renal artery surgery in patients with RAS is to treat resistant hypertension. In patients with renal artery aneurysm (RAA), renal artery surgery aims to either protect from rupture or to treat concomitant hypertension.In their study, Steuer et al. 2 have clearly highlighted that renal artery surgery is indeed feasible and maintainable. They reported a postoperative mortality rate of 4.3% for atheromatous RAS patients, which is consistent with previous reports from the 1990s. 3,4 However, with a median follow up of 10 years, the results on hypertension have been given at one year only, limiting the value of the report. If after three years, the effect on hypertension has disappeared, the message on the durability of RAS surgery loses some of its interest. As a reminder, with a median follow up of 43 months, CORAL failed to identify any benefit of renal artery intervention compared to best medical treatment. 5 So, there is little to be expected from a study reporting clinical data at one year after surgery of which the benefit is to yield a more lasting result than percutaneous angioplasty. Of note, it was somewhat surprising that a higher rate of cure of hypertension was obtained in atherosclerotic renal artery stenosis than in patients with fibromuscular dysplasia (FMD), for which numerous articles have shown a long lasting cure of hypertension, as high as 58%, 6 or 50% in a series of children from Chavent et al. 7 with a mean follow up of 15 years.Among the most challenging aspects of reporting the results of a retrospective study or a registry is that different pathologies and techniques are amalgamated into a necessarily heterogeneous group. In this report, we do not know which anatomical criteria determine the choice between the different reported techniques. Although it is stated that only one aneurysm was treated by ex vivo repair, it is not known which technique was used. Nor is it known why a hypogastric arterial graft was not the preferred material used in the six RAAs located in the branches of the renal artery?Furthermore, for saccular and short necked RAA, laparoscopic neurosurgical clip placement procedures which reduce surgical aggressiveness have not been discussed in this series. 8 Similarly, in cases of ex vivo repair with renal auto transplantation, not a word on laparoscopy for kidney extraction which has been shown to be an interesting alternative. 9In summary, even though surgery for RAA has improved over the last 10 years, the authors do not report the many specific techniques now routinely used in dedicated centres to improve quality and safety, for example on tab...

Surgical treatment of renovascular hypertension

“…This result was in agreement with Dupey and Ricco (2019) (6 ) who dedicated that surgical revascularization can provide immediate improvement in kidney function and normalizing the blood pressure in RAS patients. They stated that the main goal of renal artery surgery in patients with RAS is to treat resistant hypertension.…”

“…Steuer et al 2019. 18) and Balk et al 2007. (19) mentioned that the indications and surgical procedures for surgical repair of renal artery stenosis similar to the indications in the present study…”

“…Renovascular hypertention is suspected when hypertension develops suddenly in patients under 30or over 55years of age or abruptly worsens in any patient. (6) No single test for renovascular hypertention is definitive. Imaging studies which are used for diagnosis include Intravenous urography, renal arteriography.…”

“…(12) Surgical procedures may include aortorenal bypass grafting, endarterectomy, or occasionally extra anatomic repair using anastomosis to the hepatic or splenic arteries. (1,4,6) Fibromuscular dysplasia predominantly affects young women with normal kidney function, so renal artery revascularization in fibromuscular dysplasia is expected to be relatively successful. (13)(14)(15) AIM OF THE WORK The aim of this work was to evaluate the indications of surgical treatment of renovascular hypertension.…”