Retroperitoneal approach for bilateral renal and visceral artery revascularization

Revascularization for renal and visceral arterial occlusive disease has traditionally been performed via a transperitoneal approach. Exposing these arteries transperitoneally is often difficult, however, and may require extensive medial visceral rotation. An alternative is a left retroperitoneal approach for renal and visceral arterial revascularization, including procedures involving the right renal artery. Over the past 7 years, a total of 186 such procedures have been performed using this approach. Of 30 that involved primarily the celiac and mesenteric arteries, 20 were completed with a bypass graft and 10 with transaortic endarterectomy. Of 156 procedures performed for renal arterial occlusive disease or aneurysmal disease extending above the renal arteries, 32 were treated with transluminal endarterectomy, 21 were treated with bilateral bypasses, and 72 were treated with unilateral bypass. Concomitant aortic endarterectomy or graft replacement was performed in 110 of this group. Operative mortality was 3.3%. Reconstructions were followed-up (for 1 to 76 months) with serial duplex and renal flow ultrasonography scans. One thrombosis developed in a renal artery bypass. We conclude that the left retroperitoneal approach may conveniently be used to reconstruct the celiac artery, superior mesenteric artery, and both renal arteries. These reconstructions may be performed with either an endarterectomy or bypass technique. In particular, the need to revascularize the right renal artery should not be regarded as a contraindication to using a left retroperitoneal approach.