Laparoscopic aortorenal bypass

Background and Purpose: Open surgical renovascular repair, although produci ng excellent results, confers significant operative morbidity, As a result, less morbid procedures such as percutaneous balloon angioplasty and stenti ng have gained increasing acceptance. Laparoscopic techniques have not prev iously been applied to renal revascularization. The aim of this study was t o demonstrate the technical feasibility and the long-term clinical and path ologic outcomes of laparoscopic aorto-left renal artery bypass in a chronic porcine model, Materials and Methods: Eight animals were used in the study, All laparoscop ic suturing and knot-tying were performed intracorporeally using free-hand techniques. The following operative steps were employed: (1) aortic dissect ion and cross-clamping; (2) transection and refashioning of the left renal artery ostium; (3) in-situ renal hypothermia; (4) end-to-side aorto-left re nal artery anastomosis; and (5) aortic unclamping, In situ renal hypothermi a was achieved laparoscopically by infusion of ice-cold heparinized saline into the renal artery through a balloon catheter, Results: All eight pigs underwent laparoscopic aortorenal bypass successful ly, The median surgical time was 110 minutes, and the aortic cross-clamping time was 45.5 minutes. The median anastomotic time was 40 minutes, and the renal warm ischemia time was 9 minutes, The median estimated blood loss wa s 30 mL. An intraoperative complication of suture breakage leading to anast omotic hemorrhage occurred in one animal; the problem was corrected laparos copically. Postoperatively, one animal died from pneumonia, The remaining s even animals experienced no postoperative complications and were euthanized , one each at postoperative day 0 and 1 and week 1, 2, 3, 4, and 6, The med ian preoperative and postoperative (at euthanasia) serum creatinine values (1.15 mg/dL v 1.2 mg/dL; P = 0.39) were similar, However, compared with pre operative peripheral renin activity (0.25 mu g/L per hour), the postoperati ve peripheral renin activity was elevated (0.9 mu g/L per hour; P = 0.047), Autopsy revealed a grossly normal left kidney, with Doppler confirmation o f flow in the repaired renal artery in all seven animals. Ex vivo angiograp hy confirmed a patent anastomosis, On histopathology examination, the early left renal parenchymal specimens revealed transient, mild acute tubular ne crosis that resolved over sequential specimens without significant long-ter m sequelae, Histologic analysis of the aorto-left renal artery anastomotic site revealed gradual endothelialization with time, Conclusions: Laparoscopic aortorenal artery revascularization is technicall y feasible. Our chronic animal model has demonstrated durable success over a 6-week follow-up. This study represents the initial report in the literat ure.