ADVANCED RENOVASCULAR HYPERTENSION AND RENAL-INSUFFICIENCY - TRENDS IN MEDICAL COMORBIDITY AND SURGICAL APPROACH FROM 1970 TO 1993

Purpose: The primary aims of this study were to delineate trends in me dical comorbidity and surgical approach in patients with renal atheros clerosis and azotemia. Methods: We reviewed 1643 patients undergoing r enovascular surgery between 1970 and 1993. We focused on those with th e most advanced kidney disease (serum creatinine > 2 mg/dl) (n = 402). Attention was focused specifically on trends in sex, age, medical ris k factors, surgical technique (bypass vs endarterectomy), and outcome including eventual need for long-term dialysis, Results:Prom 1970 to 1 980, 652 patients underwent renovascular surgery, with 98 (15%) having a serum creatinine > 2 mg/dl. From 1980 to 1993, the percentage of pa tients with renal insufficiency increased to 31% (304 of 991) (p < 0.0 01). Gender distribution did not change, but median age rose from 63.5 years in the first decade to 68.0 in the past 13 years. A remarkable increase in all serious medical risk factors also occurred (first vs s econd decade). Another significant trend was a shift toward bilateral simultaneous transaortic endarterectomy (18% from 1980 to 1985 vs 53% from 1986 to 1993;p < 0.01), which simplified and achieved complete re nal revascularization, especially in patients having multiple renal ar tery stenoses and those needing aortic grafting for occlusive or aneur ysmal disease (56% from 1970 to 1980 vs 75% from 1980 to 1993). Patien ts at low risk (0 to 1 comorbid medical conditions) had a 30-day morta lity rate of 5.6% compared with patients at high risk (2 to 3 comorbid conditions) (15.5%) (P = 0.016). The eventual need for long-term dial ysis remained low (9%) for patients with a preoperative serum creatini ne of 2 to 2.9 mg/dl compared with those with a serum creatinine great er than 3 mg/dl (35%, p < 0.01). Conclusions: In the past 20 years, th ere has been a remarkable increase in the medical comorbidity and exte nt of aortic disease in patients undergoing surgical revascularization for advanced renovascular hypertension and renal insufficiency. Howev er, the surgical approach can be simplified and expedited by bilateral transaortic endarterectomy, and the risk of Late dialysis can be redu ced significantly by operating before the serum creatinine exceeds 3 m g/dl.