Use of the splenic and hepatic arteries for renal revascularization

Abstract

During a 16-year period at the Massachusetts General Hospital 77 patients underwent 79 procedures (29 hepatorenal bypasses, 50 splenorenal arterial anastomoses) for treatment ofrenovascular hypertension, renal preservation, or both. The procedure was chosen primarily to avoid a diseased or scarred aorta in 41, to allow a staged approach to bilateral renal artery stenoses or multiple vascular lesions in 17, as a "lesser operation" for five poor-risk patients, for complex problems including trauma, mycotic aneurysm, aortic dissection, thoracoabdominal aneurysm, and renal artery aneurysm in five, and as the procedure of choice in 11 patients. The perioperative mortality rate was 6% for the 77 patients studied. No hepatic dysfunction was seen. Deterioration of renal fimction occurred on three occasions but only in patients with bilateral simultaneous repair. Cure or improvement of hypertension was achieved in 52 of 63 patients and renal fimction preserved or improved in 67 of 77 patients. Long-term functional results remain good during follow-up periods up to 14 years. Our experience indicates that use of the hepatic or splenic artery may provide a safe and largely successful alternative for renal revascularization in selected circumstances.

Operative mortality for renal artery bypass in the United States: Results from the National Inpatient Sample

“…Several studies have documented a lower risk of operative mortality for hepatorenal and splenorenal bypasses, making this an attractive surgical option in some patients. 2,29,30 Percutaneous RA stenting offers the obvious advantages a lower risk of morbidity and mortality and more rapid return to full functional status compared with surgery. Unfortunately, percutaneous renal revascularization has also yielded less favorable outcomes for blood pressure and renal function.…”

Surgical Revascularization of Atherosclerotic Renovascular Disease: State of the Art

“…6 We do not believe that these procedures demonstrate durability equivalent to direct aortorenal reconstructions, but they are useful in a highly select subgroup of high-risk patients.7…”

“…The length of arteriotomy is at least three times the diameter of the artery to prevent recurrent anastomotic stenosis. For the anastomosis, 6 length, the renal artery can be transected and reimplanted into the aorta at a slightly lower level. The renal artery must be spatulated and a portion of the aortic wall removed as in renal artery bypass.5 During combined aortic replacement in adults, the renal artery-to-graft anastomosis is usually done first after the proximal aortic anastomosis, followed by distal aortic reconstruction.…”

“…6 The lesser omentum is incised to expose the hepatic artery both proximal and distal to the gastroduodenal artery. Next, the descending duodenum is mobilized by the Kocher maneuver, the inferior vena cava and the right renal vein are identified, and the right renal Perspectives in Vascular Surgery and Endovascular Therapy Volume 16, Number 4, 2004 artery is exposed either immediately cephalad or caudad to the renal vein.…”

Posterolateral exposure for renal artery reconstruction

“…this approach' does not require use of the infrarenal aorta or iliac arteries as donor sites for grafts. 15 The$C arteries are frequently severely involved with atherosclerosis, particularly in patients undergoing operations for renal salvage. Biplane arteriography is necessary preoperatively to exclude atherosclerosis or fibromuscular disease of the celiac axis before deciding on splenorenal anastomosis.…”