Surgery after failed percutaneous renal artery angioplasty

Purpose: This retrospective review describes the surgical management of 51 patients after failed percutaneous renal artery angioplasty (F-PTRA). Methods: From January 1987 through June 1998, 51 consecutive patients under went surgical repair of either atherosclerotic (32 patients) or fibromuscul ar dysplastic (FMD; 19 patients) renovascular vascular disease after F-PTRA . These patients form the basis of this report. Surgical repair was perform ed for hypertension (29 patients with atherosclerosis: mean blood pressure, 205 +/- 34/110 +/- 23 mm Hg; 18 patients with. FMD: mean blood pressure, 1 94 +/- 24/118 +/- 18 mm Hg) or ischemic nephropathy (20 patients with ather osclerosis: mean serum creatinine level, 2.0 +/- 0.8 mg/dL; three patients with EMD: mean serum creatinine level, 2.0 +/- 1.1 mg/dL). Emergency operat ion was required in four patients for acute renal artery thrombosis tone pa tient with atherosclerosis, one patient with FMD), renal artery rupture ton e patient with atherosclerosis), or infected pseudoaneurysm tone patient wi th atherosclerosis). Operative management, blood pressure and renal functio n response to operation, and dialysis-free survival rate were examined and compared with 487 patients (441 patients with atherosclerosis, 46 patients with FMD) treated by operation alone. Results: Among the patients with atherosclerotic renovascular disease, ther e were three postoperative deaths (9.4%) after repair for F-PTRA. Secondary operative repair was associated with emergent repair or nephrectomy in 16% of cases, while more extensive renal artery exposure and more complex oper ative management was required in 50% of patients with atherosclerosis and 6 5% of patients with FMD repaired electively. Among the 28 operative survivo rs with hypertension and atherosclerotic renovascular disease, blood pressu re benefit after F-PTRA was significantly lower when compared with patients with atherosclerosis who underwent treatment with operation only (57% vs 8 9%; P <.001). However, blood pressure benefit in the 19 patients with FMD d id not differ (89% vs 96%). Among the 28 patients with atherosclerosis, pre operative estimated glomerular filtration rate (EGFR) as compared with post operative EGFR was significantly increased (47.4 +/- 4.2 mL/min/1.73m(2) vs 56.6 +/- 5.1 mL/min/1.73m(2) P =.002). However, EGFR prior to PTRA. was no t significantly different from postoperative EGFR (51.6 +/- 3.4 mL/min/l.73 m(2) vs 56.6 +/- 4.9 mL/min/1.73m(2); P =.121). As compared with patients w ith atherosclerosis who underwent treatment with operation alone, there was no difference in the dialysis-free survival rate. Conclusion: Operative repair after F-PTRA was altered in 59% of the patient s with atherosclerosis and in 68% of patients with FMD. Blood pressure bene fit for patients with FMD was unchanged after F-PTRA. However, the blood pr essure benefit was significantly decreased among patients with atherosclero sis. Decreased EGPR after F-PTRA was recovered with operative renal artery repair. However, postoperative EGFR as compared with EGFR prior to PTRA was unchanged. Blood pressure and renal function response after F-PTRA. for at herosclerotic renovascular disease warrants further study.