Paul W. Sanger, M.D., Harry K. Daugherty, M.D., Francis Robicsek, M.D., and Vincenzo Gallucci, M.D.

Transcription

1 THE ANNALS OF THORACIC SURGERY Journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association VOLUME 3 NUMBER 3 MARCH 1967 Aorticqrenal Disease A Surgical Entity Paul W. Sanger, M.D., Harry K. Daugherty, M.D., Francis Robicsek, M.D., and Vincenzo Gallucci, M.D. I t is generally agreed [5-81 that hypertension caused by renovascular disease should be treated surgically. Similarly, symptomatic occlusive lesions of the abdominal aorta as well as aneurysms of the abdominal aorta are indications for surgery. There are also reports in literature [Z, 41 indicating the feasibility of simultaneous repair of both renal and aortic lesions if they both contribute to the patient s ailment. The situation, however, is quite different if the two types of vascular lesions-renal and aortic-occur together but one does not rnanifest itself in any clinical disturbance. Under such conditions the leave it alone policy usually prevails. Renal arteries unfortunately are often grafted to heavily arteriosclerotic but open abdominal aortas. Similarly, segments of aorta occluded or aneurysmatically dilated are frequently resected but renal arterial strictures are left untouched. From the Department of Cardiovascular and Thoracic Surgery, Charlotte Memorial Hospital, Charlotte, N.C. This work was supported by grants by the John A. Hartford Medical Research Foundation and by National Institutes of Health Grant No. HE Presented at the Thirteenth Annual Meeting of the Southern Thoracic Surgical Association. Asheville, N.C., Nov. 3-5, 1966.

2 SANGER, DAUGHERTY, ROBICSEK, AND GALLUCCI In the past we have pursued the policy outlined above. In several instances, however, the failure of an otherwise successful operation was traced clearly to the fact that while operating on a symptomatic vascular lesion, the presence of an associated but symptomless lesion was disregarded. CASE REPORTS CASE 1 This patient was a 61-year-old business executive who was admitted to the hospital because of pain in the low back area and both lower extremities. There was a weak femoral pulse on the right side, and there were no palpable pulses over the left leg. Blood pressure was 160/90 mm. Hg, blood urea nitrogen 15 mg. Lumbar aortography (Fig. 1) revealed the distal abdominal aorta to be irregular and narrowed. The right iliac artery was narrowed at its origin, and the left iliac artery was completely occluded. The right renal artery appeared to be normal and there was a satisfactory excretory urogram on the right side, but no vascular filling or excretion of dye could be demonstrated on the left side. There was a filling defect in the aorta measuring 3 X 1 cm. just where the left renal artery should have originated. This, however, was interpreted as an artifact due to the needle injection. The patient s abdominal aorta was explored. The portion below the renal arteries was heavily arteriosclerotic, the right iliac artery was open but severely calcified, and the left iliac artery was completely occluded. The aorta and both iliac arteries were resected and replaced with a bifurcated vascular prosthesis. The patient tolerated the surgery well: however, following the operation he failed to excrete any urine. He expired seven days following the operation in spite of extensive supportive therapy including hemodialysis. At the autopsy a large organized thrombus was found above the line of the anastomosis, completely occluding the orifice of the left renal artery. The location of this thrombus was identical with the filling defect demonstrated on the aortogram. Apparently around this older thrombus there was a recent clot formation which had not obstructed the aortic flow but had extended into the lumen of the left renal artery. FIG. 1. Translumbar needle aortogram of Case 1. Note the filling defect of the aorta (arrows) and the faint filling of the left renal artery. 196 THE ANNALS OF THORACIC SURGERY

3 Aorticorenal Disease A FIG. 2. Lumbar aortogram (A) and autopsy specimen (B) of Case 2. The aortography shows stricture of the left common iliac artery, complete occlusion of the right iliac artery, severe arteriosclerotic changes in the lower abdominal aorta, and irregularity and narrowing of the renal arteries (arrows). Autopsy specimen shows that the graft is well positioned and that the renal arteries are completely obstructed by arteriosclerotic plaques and superimposed thrombosis. CASE 2 This patient was a 58-year-old housewife complaining of pain in both lower extremities for the previous two years. The femoral pulse was barely palpable on the left and absent on the right. Blood pressure was 150/90 mm. Hg, and blood urea nitrogen was 20 mg. Lumbar aortography (Fig. 2A) showed that the lower abdominal aorta was irregular and its lumen narrowed, the left iliac artery was severely strictured, and the right common iliac artery was occluded. There were two renal arteries on the left and one on the right. The origin of all these renal vessels appeared to be irregular and narrow. At operation her lower abdominal aorta and both iliac arteries were resected and replaced with a graft. The renal arteries were not explored. The patient made an uneventful recovery. Good femoral and pedal pulses were felt at the time of her discharge. She was doing well until five months following the operation, when, because of throbbing headaches, she was readmitted. At the time of her admission she was somnolent, her blood pressure was 210/130 mm. Hg, her blood urea nitrogen was 180 mg., and her urine output was only 80 cc. during the first 24 hours. Lumbar aortography showed unimpeded flow of contrast material through the bifurcated graft, but there was no filling of the renal arteries. Surgery (renal artery exploration) was recommended, but it was rejected by the patient. She died two days later in uremia. Autopsy (Fig. 2B) showed the aortic graft well positioned and open, but the aorta above the graft as well as the orifice of the renal arteries were severely arteriosclerotic. There was extensive, apparently recent thrombus formation in the renal arteries which completely obstructed the lumen already narrowed by arteriosclerotic plaques. B CASE 3 The third patient was a 36-year-old housewife who was admitted to the hospital with severe headaches, blurred vision, and a blood pressure of VOL. 3, NO. 3, MARCH,

4 SANGER, DAUGHERTY, ROBICSEK, AND GALLUCCI A B C FIG. 3. Case 3, successive aortograms. The first aortogram (A) shows moderate arteriosclerotic changes in the lower abdominal aorta and severe stricture (arrow) of the (only) left renal artery. The picture taken two years following the procedure (B) shows progressive changes in the lower abdominal aorta and no flow through the renal graft. The picture taken four years after the second operation (C) shows progressive narrowing of the abdominal aorta and iliac arteries and the aorticorenal graft to be open with excellent flow to the left kidney. mni. Hg. The patient s right kidney had been removed ten years previously because of pyelonephritis. Catheter aortography (Fig. 3A) showed the lumen of the lower abdominal aorta to be irregular and moderately narrowed. There was a severe stricture just distal to the origin of the (only) left renal artery. On the following day the patient was operated upon, and the stricture of the left renal artery was bypassed with a crimped Dacron vascular prosthesis anastomosed end-to-side to the aorta and to the left renal artery. There was an immediate and dramatic improvement in the patient s condition. She was discharged on the tenth postoperative day with a blood pressure of 120/80. The patient did well for two years, and then she was readmitted as an emergency in a semiconscious state. The blood pressure was measured as 260/160, and the blood urea nitrogen was 180 mg. Lumbar aortography (Fig. 3B) showed no circulation through the vascular prosthesis. There was a trickle of dye passing from the aorta into the left renal artery through the original stricture. The changes in the abdominal aorta (already observed on the previous aortogram) appeared to be more distinct and were apparently due to progressive arteriosclerotic plaque formation. The patient was reoperated upon as an emergency. The lower abdominal aorta was severely calcified and narrowed. A large arteriosclerotic plaque was found to be nearly completely obstructing the aortic orifice of the Dacron prosthesis which was found to be filled with clots. A segment o the aorta was removed and replaced with a Dacron prosthesis, and a side-arm of this prosthesis was anastomosed end-to-end to the distal end of the divided left renal artery (Fig. 4). Again the patient showed an immediate and favorable response to surgery. The blood pressure as well as the blood urea nitrogen dropped to normal values. Aortography four years after the second operation (see Fig. 3C) showed further narrowing of the abdominal aorta and iliac arteries, but the grafted aortic segment maintained its original caliber, and there was good flow to the grafted renal artery. 198 THE ANNALS OF THORACIC SURGERY

5 Aorticorenal Disease A FIG. 4. Case 3. Schema of the operative procedures: (A) first operation, (B) second operation. B DISCUSSION Cases like the above encouraged us to reevaluate our procedures. Consequently we made the operation for aorticorenal disease more extensive. The more radical approach was used in 25 consecutive cases during the past two years; our experience is summarized in Table 1. According to the indication for surgery, the patients were divided in two major groups, as described below. 1. Patients who were operated upon because of hypertension due to arteriosclerotic rend artery stenosis. In our experience, arteriosclerotic stricture of the renal arteries was accompanied by severe changes of a similar nature in the aortic wall. If disturbed by surgery, clots easily form on the irregular aortic intima and may obstruct the relatively small lumen of the renal graft. To avoid this potential source of failure, whenever the extent of the renal arterial stenosis necessitated grafting, a segment of the neighboring abdominal aorta was also replaced by a Dacron prosthesis. The renal graft was connected as a sidearm to this prosthesis. In doing this, the renal graft originated from a virgin area, and the often difficult and always uncertain aorticorenal graft anastomosis was replaced by an entirely new aortic graft-renal graft. This method was used on 12 patients, all of whom suffered from systemic hypertension thought to be due to renal arterial stenosis. One patient died on the fifth postoperative day from an acute myocardial infarction. The recovery of the others was without mishap, and the operative results were classified according to the improvement of their hypertension. There was a significant drop in the blood pressure in 7 patients. The renal function showed no further deterioration in the postoperative period in any of the patients; therefore, it seems that VOL. 3, NO. 3, MARCH, 1967 igg

6 SANGER, DAUGHERTY, ROBICSEK, AND GALLUCCI TABLE 1. CLINICAL EXPERIENCE, Aorta Renal Degree Artery of Aneurysm Stricture Aortic Graft Arterio- Stric- Case Age sclerosis Small Large ture Unilat. Bilat. Straight Bifur. Operated because of hypertension a Operated because of intermittent claudication Operated because of aortic aneurysm THE ANNALS OF THORACLC SURGERY

7 A ort icorena I Disease SURGERY FOR AORTICORENAL DISEASE Renal Artery Ne- Blood Pressure Graft (mm. Hg) Claudication Endarte- phrec- Unilat. Bilat. rectomy tomy Before After Before After Results 2 10/ /80 230/ /90 240/ / / / /90 190/ / / / / / /95 200/ /80 120/80 140/80 200/ / /80 130/90 200/ /90 150/90 150/90 140/ /95 160/ /80 170/ /80 170/ /70 160/90 170/90 180/90 200/90 190/ /90 170/90 140/80 220/ /80 160/80 160/80 150/90 130/90 Fair Died fifth postop. day, myocardial infarction Unchanged Unchanged Unchanged Died sixth postop. day, myocardial infarction VOL. 3, NO. 3, MARCH,

8 SANGER, DAUGHERTY, ROBICSEK, AND GALLUCCI some of the patients classified as unchanged may have been saved from the shutdown of their renal blood supply. 2. Patients who were operated upon because of arteriosclerotic lesions of the aorta but who also had renal arterial stenosis. The patients in this group were operated upon either because of symptomatic occlusive aorticoiliac arteriosclerosis or because of aneurysms of the abdominal aorta. Blood pressure of most of these patients was elevated (11 out of l3), but only 5 of them had severe diastolic values over 100 mm. Hg. The aim of operation primarily was to relieve the aortic anomaly, stricture, or aneurysm. As an added benefit there was a significant decrease in their hypertension. This decrease, however, was proportionally less than in the group of patients on whom the operation was performed primarily for renovascular hypertension. We believe the possibility of conserving kidney function even in the patients who did not have severe hypertension, or whose hypertension did not improve significantly, made the effort of the additional anastomosis worthwhile. One patient was lost in this group-a 63-year-old man who was operated on for a large abdominal aneurysm and whose left renal arterial stricture was corrected at the same time. He expired on the fifth postoperative day because of an acute myocardial infarction. CONCLUSIONS Experience in cardiac surgery has shown that a previously silent valvular lesion may become manifest following repair of another diseased valve and thus threaten the outcome of an otherwise successful operation. There seems to be an analogy between this observation and the events which often occur following surgery on the abdominal aorta and its branches. We had the unrewarding experience of treating only the symptomatic lesion when renal artery stricture and arteriosclerotic disease of the abdominal aorta occurred together. In several cases, the clinically unsignificant vascular condition which was not corrected became a serious problem postoperatively. After such experience, it became our policy to repair, if possible, all major abnormalities of the aorta and its branches. To pursue this philosophy, one has to have accurate information on the entire abdominal arterial system. We do not agree with those [l] who believe that sufficient information can be gained by noting that a femoral pulse is absent or by feeling the pulsation of an abdominal aneurysm, and who say that contrast injection studies do not yield enough information to justify the expense, risk and morbidity which it imposes. We have performed more than 800 abdominal aortographies by the direct translumbar needle puncture technique and by retrograde catheterization through the femoral artery. 202 THE ANNALS OF THORACIC SURGERY

9 Aorticorenal Disease So far we have been fortunate not to have lost a life or limb. In our opinion, contrast injection studies of the entire abdominal arterial system with serial arteriography is a necessity for planning operation on the abdominal aorta and its branches. We depart from this only in cases of extreme emergency, such as a ruptured abdominal aneurysm [9]. SUMMARY Experience with the surgical management of combined arteriosclerotic disease of the abdominal aorta and renal arteries is presented. In several instances the failure of an otherwise successful operation was traced to the fact that while operation was done on a symptomatic vascular lesion, the presence of an associated symptomless lesion was disregarded. It is the authors opinion that in most cases when replacement of the renal artery is indicated, a segment of the neighboring abdominal aorta should also be replaced by a vascular prosthesis. The renal graft thus originates from a clean area instead of the usually severely arteriosclerotic aorta. A plea is also made to repair silent renal arterial strictures to prevent postoperative renal insufficiency and preserve renal function whenever operations are done on a diseased abdominal aorta. REFERENCES 1. Cannon, J. A., Van de Water, J., and Barker, W. F. Experience with the surgical management of 100 consecutive cases of abdominal aortic aneurysm. Amer. J. Surg. 106:128, De Bakey, M. E., Morris, G. C., Morgen, R. O., Crawford, E. S., and Cooley, D. A. Lesions of the renal artery: Surgical technic and results. Arner. J. Surg. 107:84, MacVaugh, H., 111, and Roberts, B. Results of resection of abdominal aneurysms. Surg. Gynec. Obstet. 113: 17, Morris, G. C., De Bakey, M. E., Cooley, D. A., and Crawford, E. S. Surgical treatment of renal hypertension. Ann. Surg. 15 1: 854, Morris, G. C., Jr., De Bakey, M. E., Cooley, D. A., and Crawford, E. S. Experience with 200 renal artery reconstructive procedures for hypertension or renal failure. Circulation 27:346, Poutasse, E. F., and Dustan, H. P. Arteriosclerosis and renal hypertension. J.A.M.A. 165:1521, Robicsek, F., Citron, D. S., Sanger, P. W., Taylor, F. H., and Hawes, C. T. The development of malignant hypertension following nephrectomy. North Carolina Med. J. 22:607, Robicsek, F., Citron, D. S., Taylor, F. H., and Sanger, P. W. The treatment of malignant hypertension due to ischemia of the solitary functioning kidney. Angiology 14:377, Sanger, P. W., Robicsek, F., Taylor, F. H., and Thomas, M. J. Ruptured aneurysms of the abdominal aorta. North Carolina Med. J. 25:122, VOL. 3, NO. 3, MARCH,