Surgery of the renal artery: hepato and spleno renal bypass

Hypertension is a devastating disease that affects an estimated 20 million Americans per year and predisposes them to cardiac, cerebral and renal disease. The need to discover and treat the surgically curable forms of hypertension is underscored by the lethal effects of this entity. Restoration of renal blood flow to a stenotic or occluded renal artery for the management of poorly controlled renovascular hypertension or deteriorating renal function is a proven therapeutic modality. The technical advances of digital subtraction angiography, angiotensin-converting enzyme inhibitor challenge, balloon angioplasty and alternative surgical bypass procedures have inspired a more aggressive approach to the diagnosis and treatment of higher risk patients with atherosclerotic disease and the application of bench surgery for difficult branch segmental disease. The indications for surgical correction of patients with atherosclerosis are more limited, owing to the presence of commonly associated diseases of senescence, and the presence of extrarenal vascular disease. Treatment with more effective new potent antihypertensive drugs is warranted initially in this population and may, in fact, be preferred in patients with generalized atherosclerosis. Our own poor results with percutaneous transluminal angioplasty for atherosclerotic lesions has prevented us from offering this option to patients with classic renal ostial lesions which are in essence an aortic disease that does not respond to this modality. The less common short mid-renal artery disease without a significant aortic component frequently responds to balloon dilatation if skillfully applied.