Extraanatomic Renal Revascularization: Surgical and Anatomic Variations

Abstract

A thoracic-aorta-left renal artery bypass with polytetrafluoroethylene (PTFE) and three gastroduodenal right renal artery bypasses were constructed in four patients in whom loss of renal function and the potential for dialysis were imminent. These extraanatomic bypasses showed durable patency with preservation of renal function. Gastroduodenal- renal bypass requires an appreciation of the anatomic relationship of the right renal artery to the right renal vein. Anatomic studies were performed in 80 human cadavers to assess the anatomic relationships of the right renal artery with respect to the right renal vein. In 50% of the cadavers studied, the right renal artery was superior to the right renal vein. It was located inferior to the right renal vein in 17.5% and directly posterior in 32.5%.

Extraanatomic bypasses may be required for treatment of renal hypertension or parenchymal salvage. Gastroduodenal-renal and thoracorenal reconstructions are unusual variants of extraanatomic bypasses, and though uncommonly required, may be extremely useful methods to employ for renal revascularization.

Get full access to this article

View all access options for this article.

References

Ransay LE , Waller PC : Blood pressure response to percutaneous transluminal angioplasty for renovascular hypertension. An overview of published series. Brit Med J 300:569-572, 1990.

Novick AC : Percutaneous Transluminal Angioplasty and Surgery of the Renal Artery. Eur J Vasc Surg 8:1-9, 1994.

Sos TA : Angioplasty for the treatment of azotemia and renovascular hypertension in atherosclerotic renal artery disease. Circulation 83(suppl 1):I-162-I-166, 1991 .

Dean RH , Keyser JE , Dupont WD , et al: Aortic and renal vascular disease: Factors affecting the value of combined procedures. Ann Surg 200:336-343, 1984.

Wylie EJ , Stoney RJ , Ehrenfeld WK : Manual of Vascular Surgery. New York: Springer-Verlag, pp 233-257, 1980.

Cambria RP , Brewster DC , L'Italien GJ , et al: The durability of different reconstructive techniques for atherosclerotic renal artery disease. J Vasc Surg 20:76-85, 1994.

Libertino JA , Bosco PJ , Ying CY , et al: Renal revascularization to preserve and restore renal function. J Urol 147:1485-1487, 1992.

Novick AC , Ziegelbaum M. , Vidt DG , et al: Trends in surgical revascularization for renal artery disease . JAMA 257:498-501, 1987.

Brewster DC , Darling RC : Splenorenal arterial anastomosis for renovascular hypertension. Ann Surg 189:353-358, 1979.

10.

Reilly JM , Rubin BG , Thompson RW , et al: Long-term effectiveness of extraanatomic renal artery revascularization . Surgery 116:784-791, 1994.

11.

Novick AC , Stewart R. , Hodge EE , et al: Use of the thoracic aorta for renal arterial reconstruction . J Vasc Surg 189:353-358, 1994.

12.

Ascer E. , Gennaro M. , Rogers D. : Unilateral renal artery revascularization can salvage renal function and terminate dialysis in selected patients with uremia. J Vasc Surg 18:1012-1018, 1993.

13.

Chibaro EA , Libertino JA , Novick AC : Use of the hepatic circulation for renal revascularization. Ann Surg 199:406-411, 1984.

14.

Ertuck E. , Novick AC , Vidt DG , et al: Secondary renal revascularization for recurrent renal artery stenosis. Cleveland Clinic J Med 56:427-431, 1989.

15.

Gill IS , Novick AC , Hodge EE : Extraanatomic renal revascularization in patients with renal artery stenosis and abdominal aortic occlusion. Urology 42:630-634, 1993.

16.

Libertino JA , Zinman L. , Breslin DJ , et al: Hepatorenal artery bypass in the management of revascular hypertension. J Urol 115:369-372, 1976.

17.

Libertino JA , Lagneau P. : A new method of revascularization of the right renal artery by the gastroduodenal artery. Surg Gynecol Obstet 156:221-223, 1983.

18.

Mestres CA , Campistol JM , Ninot S. , et al: Improvement of renal function in azotaemic hypertensive patients after surgical revascularization. Br J Surg 75:578-580, 1988.

19.

Moncure AC , Brewster DC , Darling RC , et al: Use of the splenic and hepatic arteries for renal revascularization . J Vasc Surg 32:154-159, 1986.

20.

Moncure AC , Brewster DC , Darling RC , et al: Use of the gastroduodenal artery in right renal artery revascularization . J Vasc Surg 8:154-159, 1988.

21.

Novick AC , Palleschi J. , Straffon RA , et al: Experimental and clinical hepatorenal bypass as a means of revascularization of the right renal artery. Surg Gynecol Obstet 148:557-561, 1979.

22.

Novick AC , Pohl MA , Schreiber M. , et al: Revascularization for preservation of renal function in patients with atherosclerotic renovascular disease. J Urol 129:907-912, 1983.

23.

Novick AC , McElroy J. : Renal revascularization by end-to-end anastomosis of the hepatic and renal arteries. J Urol 134:1089-1093, 1985 .

24.

Perler BA : Emergency gastroduodenal-renal artery bypass: An extraanatomic approach for salvage of the solitary kidney. Am Surg 53:679-681, 1987.

25.

Rigdon EE , Durham JR , Massop DW , et al: Hepatorenal and splenorenal artery bypass for salvage of renal function. Ann Vasc Surg 5:133-137, 1991.

26.

Turini D. , Barbanti G. , Beneforti P. , et al: Revascularization of the right ischemic kidney by gastroduodenal artery. Eur J Urol 16:69-71, 1989.

27.

Pickering TG , Devereux RB , James DG , et al: Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: Treatment by angioplasty or surgical revascularization. Lancet 2:551-552, 1988.

28.

Messina LM , Zelenock GB , Yao KA , et al: Renal revascularization for recurrent pulmonary edema in patients with poorly controlled hypertension and renal insufficiency: A distinct subgroup of patients with arteriosclerotic renal artery occlusive disease. J Vasc Surg 15:73-80, 1992.