Simultaneous aortic replacement and renal artery revascularization: The influence of preoperative renal function on early risk and late outcome

• Published in: Journal of vascular surgery 2001-12, Vol.34 (6), p.1041-1049
• Main Authors: Tsoukas, Athanassios I., Hertzer, Norman R., Mascha, Edward J., O'Hara, Patrick J., Krajewski, Leonard P., Beven, Edwin G.
• Format: Article
• Language: English
• Subjects: Aged; Angiography; Aortic Aneurysm - complications; Aortic Aneurysm - mortality; Aortic Aneurysm - surgery; Aortic Diseases - complications; Aortic Diseases - surgery; Arterial Occlusive Diseases - complications; Arterial Occlusive Diseases - mortality; Arterial Occlusive Diseases - surgery; Biological and medical sciences; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - instrumentation; Blood Vessel Prosthesis Implantation - methods; Blood Vessel Prosthesis Implantation - mortality; Creatinine - blood; Endarterectomy - adverse effects; Endarterectomy - instrumentation; Endarterectomy - methods; Endarterectomy - mortality; Female; Glomerular Filtration Rate; Hospital Mortality; Humans; Male; Medical sciences; Middle Aged; Predictive Value of Tests; Preoperative Care; Proportional Hazards Models; Renal Artery Obstruction - blood; Renal Artery Obstruction - complications; Renal Artery Obstruction - diagnosis; Renal Artery Obstruction - mortality; Renal Artery Obstruction - surgery; Retrospective Studies; Risk Factors; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Survival Analysis; Treatment Outcome; Ultrasonography, Doppler, Duplex; Vascular Patency; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1067/mva.2001.118584

Purpose: We documented the postoperative complication rate and the late results of simultaneous infrarenal aortic replacement and renal artery (RA) revascularization at the Cleveland Clinic and correlated these findings with the preoperative serum creatinine level (SCr) and other baseline risk factors. Methods: A retrospective review of hospital charts and outpatient records was supplemented with a telephone canvass and the invitation to return for a complimentary RA duplex scan, when a scan had not been done within the previous year. Data were collected for 73 consecutive patients (mean age, 69 years) who underwent aortic procedures that were combined with the repair of RA stenosis from 1989 to 1997 (mean follow-up, 44 months). The preoperative SCr was 2 mg/dL or lower in 45 patients (group R1; median, 1.5 mg/dL) and was higher than 2 mg/dL in the remaining 28 patients (group R2; median, 2.6 mg/dL). Results: Forty-seven of the patients in this series had aortic aneurysms, 15 patients had aortoiliac occlusive disease, and 11 patients had both types of lesions. Bilateral RA revascularization was necessary for seven patients in group R1 (15%) and for eight patients in group R2 (29%). Group R2 contained more patients with medically resistant hypertension (57%) than group R1 (29%, P =.019). Although there was no statistically significant difference between the 30-day mortality rates (group R1, 2.2%; group R2, 11%), the related in-hospital mortality rate for 15 bilateral RA revascularizations (13%) was nearly twice that of 58 unilateral revascularizations (6.9%). Patients in group R2 were at a higher risk for postoperative dialysis than those in group R1 (36% vs 6.7%, P =.008), and patients in group R2 had longer lengths of stay in the hospital (median, 14 days vs 9 days; P =.004). By means of Kaplan-Meier analysis, the 5-year survival rate was lower for patients in group R2 (53%; 95% CI, 33%-73%) than for patients in group R1 (85%; 95% CI, 74%-96%; log rank P =.005). Despite all other liabilities in group R2 patients, however, their resistant hypertension was cured or improved in 88% of cases and their SCr appeared to decline with time. Conclusion: The early postoperative risk of simultaneous aortic/RA procedures appears to be highest in patients who have an elevated SCr, bilateral RA stenosis or occlusion, and a comparatively low long-term survival rate. In this particular group, the adjunctive use of endovascular techniques might conceivably reduce the magni