COMPLEX BRANCH RENOVASCULAR DISEASE - MANAGEMENT OPTIONS AND LATE RESULTS

Purpose: The purpose of this report is to review management options an d late results of complex renovascular disease managed over the last 2 2 years. Methods: Complex branch renal artery disease in 84 kidneys wa s repaired during 75 operations performed in 68 consecutive patients. There were 61 females (90%) and 7 males (10%) whose predominant pathol ogic diagnosis was fibromuscular dysplasia manifesting as either renov ascular hypertension or aneurysmal degeneration. These patients underw ent 15 in situ, 52 ex vivo, and 8 combined reconstructions. In situ re pair primarily with use of the bifurcated internal iliac artery autogr aft was used for primary lesions of the proximal renal artery bifurcat ion (two branches). Ex vivo repairs, primarily with use of the multibr anch internal iliac autograft and hypothermic perfusion preservation, were used for all other patterns of distal renal artery branch disease and reoperative problems. Results: Renovascular reconstruction was su ccessful in salvaging 83 of 84 kidneys (98.8%) in 67 of 68 patients. T here were no operative deaths. Two reconstructions thrombosed in the e arly postoperative period One was due to severe aortic disease, the ot her to branch artery dissection after a failed balloon angioplasty. Bo th patients continued to have hypertension. Before hospital discharge 65 patients had 81 renal revascularizations proven patent by arteriogr aphy. Their renal function was assessed and blood pressure was determi ned in a follow-up extending to 20 years (mean 7.5 years, median 7.9 y ears). Late arteriograms were obtained in 30 patients (46%) an average of 52 months after operation (range 6 months to 18 years). They demon strate stable renal artery repair with no evidence of late graft failu re in each. Hypertension was cured or improved in 51 of 53 patients (9 6%) with a proven patent reconstruction. Aneurysms were successfully r epaired in 11 patients. Renal function was improved in four patients w ith ex vivo repairs, unchanged in 59 patients (15 in situ, 44 ex vivo) , and persistently worse in only three patients, all of whom had in si tu repairs. Conclusion: The branched arterial autograft allows the res toration of normal renal arterial anatomy and function when inserted t o replace complex distal renovascular disease. This provides a durable repair, essential for younger patients affected by this pattern of di sease who anticipate a normal life span after renovascular repair. Suc cessful long-term correction of diastolic hypertension and aneurysmal disease was accomplished without significant morbidity.