Chronic renal artery occlusion: Nephrectomy versus revascularization

Purpose: The surgical management of chronic atherosclerotic renal artery oc clusion (RAOCC) was studied. Methods: From January 1987 through December 1996, 397 consecutive patients were treated for atherosclerotic renal artery disease. Ninety-five hyperten sive patients (mean blood pressure, 204 +/- 31/106 +/- 20 mm Hg; mean medic ations, 3.0 +/- 1.1 drugs) were treated for 100 RA-OCCs. Eighty-four (88%) patients had renal dysfunction, defined by serum creatinine levels greater than or equal to 1.3 mg/dL, (mean serum creatinine level, 2.8 +/- 2.0 mg/dL ). Demographic characteristics, operative morbidity and mortality blood pre ssure/renal function response, and postoperative decline in renal function were examined and compared with that of 302 patients treated for renal arte ry stenosis (RAS). Results: After operation, there were 5 perioperative deaths (5.2%), 2 (2.8% ) after revascularization and 3 (12%) after nephrectomy (P=.11), compared w ith 12 (4.0%) perioperative deaths in the RAS group (P=.59). After controll ing for important covariates, estimated survival and blood pressure benefit s did not differ between RA-OCC patients treated by nephrectomy or revascul arization (P=.13; 87% vs 92%, P=.54), Excretory renal function was consider ed improved in 49% of 79 RA-OCC patients with renal dysfunction, including 9 patients removed from dialysis-dependence. Among patients treated for uni lateral disease, revascularization for RA-OCC was associated with significa nt improvement in renal function (P <.01); however, nephrectomy alone did n ot increase renal function significantly Improved renal function after oper ation was associated with a significant and independent increase in surviva l (P <.01) and dial)sis-free survival (P <.01) among patients treated for R A-OCC. In addition, blood pressure benefit, renal function response, and es timated survival did not differ significantly after reconstruction for RA-O CC or RAS. Conclusion: Among hypertensive patients treated for RA-OCC, equivalent bene ficial blood pressure response was observed after both revascularization an d nephrectomy. In patients who underwent bilateral renal artery revasculari zation, the change in excretory renal function attributable to repair of RA -OCC cannot be defined. In patients treated for unilateral disease, however , improvement in function was observed only after revascularization. Moreov er, improved renal function demonstrated a significant and independent asso ciation with improved survival. This experience supports renal revasculariz ation in preference to nephrectomy for RA-OCC in select hypertensive patien ts when a normal distal artery is demonstrated at operation.