The durability of different reconstructive techniques for atherosclerotic renal artery disease

Among various surgical techniques for renal artery reconstruction (RAR), anatomic aortorenal bypass has been the preferred standard. Yet concern regarding origin of the bypass from a diseased aorta and desire to avoid a major aortic operation in these patients who are often at poor risk has led to increasing use of extraanatomic bypass grafting, particularly hepatorenal and splenorenal bypass. This study was conducted to compare the safety and long-term performance of these different techniques of renal artery reconstruction.

We reviewed a 15-year (1976 to 1991) experience with 323 surgical RAR performed in 285 patients with atherosclerotic renovascular disease. Long-term patency and survival rates were analyzed by life-table methods. Variables potentially affecting early failure of the RAR and perioperative and late mortality rates were examined by Cox proportional hazards models.

Diffuse atherosclerosis characterized the patients' clinical profile. Clinically evident coronary artery disease was present in 54% of patients, and some degree of renal insufficiency was present in 60%. Ninety-five percent of patients had hypertension with poor control of hypertension seen in 50%. Aortic disease necessitated combined aortic grafting and RAR in 43% of the study group. Various techniques of RAR were used as follows: endarterectomy or patch angioplasty, 8.5%; extraanatomic bypass grafting, 37% (hepatorenal, 62; splenorenal, 52; iliorenal, 7); and aortorenal bypass grafting, 54% (native aorta, 34; combined aortic graft and RAR, 140). Early failure of the RAR occurred in 5% of cases, and the operative mortality rate for the entire cohort was 5.6%. Median follow-up duration was 9.4 years. A comparison of early and late patency for the major types of RAR revealed equivalent (p = 0.44) performance of aortorenal and extraanatomic bypass grafting. Perioperative complications occurred more frequently (p < 0.02) in patients undergoing combined operations. The cumulative 5-year survival rate for all patients was 75%.

Because extraanatomic bypass grafting can provide long-term results equivalent to aortorenal bypass grafting, the choice among techniques for RAR in patients with diffuse atherosclerosis should be based on both technical and operative safety considerations, rather than adherence to aortorenal bypass grafting as an inherently superior technique.