Multi-branch renal artery lesions: surgical options and results.

Renovascular lesions affecting more than one primary or secondary renal artery branch represent a challenging therapeutic problem. Over the last 5 years, the authors have treated 20 patients with complex multi-branch renal lesions. The number of renal artery branches per kidney ranged from two to seven. The pathological etiology of the multi-branch lesion was atherosclerotic occlusive disease in ten patients, fibromuscular occlusive disease in four (two with spontaneous dissection), renal artery aneurysm in three and abdominal aortic coarctation in three. Ex vivo techniques were used in nine patients, whereas in situ reconstruction was used in 11. Ten patients had a complex procedure involving aortic or other visceral reconstruction; two patients had solitary kidneys. There was one death in the series from an intraoperative anesthetic complication. One primary nephrectomy was performed after ex vivo exploration revealed unreconstructable disease in a significant number of branches. Severe hypertension present in all the patients before surgery was cured in five patients and improved in 14 after the operation. Renal insufficiency, present in nine patients before surgery, was improved in all cases.

Carotid artery replacement in conjunction with resection of squamous cell carcinoma of the neck: preliminary results.

Squamous cell carcinoma can invade the carotid artery. The treatment options then include irradiation, "palliative peeling" of tumor from the artery, and carotid resection with ligation or in-line grafting. Twelve patients with invasion of the carotid artery by cancer had en bloc resection of the artery and tumor. Reconstruction after in-line carotid artery grafting with autogenous vein was completed with a myocutaneous flap. No neurologic events occurred perioperatively or during the follow-up period of 3 to 50 months. Computed tomography and arteriography were unreliable in predicting tumor involvement of the carotid artery. Three patients died during the study--two of unrelated causes, and one of metastases. None of the patients showed evidence of local recurrence from 3 to 50 months. In two of four wound infections the carotid artery graft was exposed. This was successfully treated by a myocutaneous flap. The mean survival for the group was 18 months. Resection and in-line bypass grafting of the carotid artery invaded by cancer can safely be performed in irradiated and potentially infected fields.

Adrenergic response to nicardipine in the management of postoperative hypertension.

Nicardipine, a new dihydropyridine calcium channel blocking agent, has been shown to be effective in the management of hypertension. The adrenergic response to intravenous nicardipine as measured by changes in plasma catecholamine concentrations in seven patients undergoing treatment of postoperative hypertension is reported. Postoperative hypertension was defined as a systolic blood pressure (SBP) greater than 140 mm Hg. Nicardipine or placebo was administered in doses of 10 mg/h, 12.5 mg/h, and 15.0 mg/h for 5 minutes, 5 minutes, and 15 minutes, respectively, to achieve a therapeutic response defined as a reduction of SBP of 15% or more. Once a therapeutic response occurred, patients entered a maintenance period when the study drug infusion rate was reduced to the equivalent of 3.0 mg/h, and the dose was adjusted by 1.0 to 2.5 mg/h every 15 minutes as needed to maintain blood pressure control. Patients who did not respond to the study drug had their treatment code broken and, if on placebo, received open-label nicardipine. Blood samples were taken for the measurement of plasma norepinephrine (NE) concentrations at baseline prior to nicardipine infusion, at the time of therapeutic response, during maintenance, and after discontinuation of nicardipine. There were no significant differences between the baseline heart rate prior to nicardipine infusion and at the time of therapeutic response, during maintenance, or after discontinuation of the infusion. Mean NE concentrations at baseline prior to nicardipine infusion were 589.3 +/- 140.1 pg/mL (normal range, 75 to 480 pg/mL). Thus, hypertensive patients in the recovery room have a high degree of background sympathetic stimulation. Nicardipine did not further increase plasma NE levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Ruptured abdominal aortic aneurysm and horseshoe kidney.

We have described three patients surviving resection of a ruptured abdominal aortic aneurysm in the presence of horseshoe kidney. If division of the renal isthmus is required to gain rapid control of the ruptured abdominal aortic aneurysm, it is not necessarily associated with increased morbidity or mortality. The arterial supply to the horseshoe kidney may complicate arterial reconstruction, but with flexible use of modern vascular surgical techniques, preservation of renal tissue is feasible.

Renal artery aneurysm: selective treatment for hypertension and prevention of rupture.

Thirty-nine patients with renal artery aneurysm (RAA) were seen over a period of 15 years. Among 20 women and 19 men, 31 were found to have solitary aneurysms, and eight had multiple RAA. Thirty-three patients had diastolic hypertension; nine of them proved to be of renovascular origin. Of the 18 patients who underwent RAA resection, 13 had reconstruction for treatment of hypertension, three had a solitary functional kidney, one had recurrent flank pain, and one had resection for prevention of rupture in a woman of childbearing age. Six of the 18 patients had aneurysmorrhaphy with primary repair or patching, seven had a resection with an aortorenal bypass, and five patients had six ex vivo renal reconstructions with multiple anastomoses. Nephrectomy was performed in two patients with RAA rupture at the time of childbirth and in one patient with hypertension and RAA in a poorly functioning kidney. Reconstructive procedures for documented renovascular hypertension in seven patients resulted in improvement in all cases. Blood pressure improved in only six of 10 patients operated on with hypertension and no lateralization of renovascular studies. Eighteen patients were observed for one to 16 years without surgery, and none experienced rupture. Resection of RAA is indicated to treat patients with renovascular hypertension, patients with hypertension and a solitary functional kidney, and selected patients with severe hypertension and to prevent rupture in women who may become pregnant. Other patients with asymptomatic RAA can be safely observed clinically without serial arteriograms and without fear of rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

Penetrating popliteal artery injuries in children.

Two children, aged 8 and 12, were seen recently at the Vanderbilt University Medical Center and Metropolitan Nashville General Hospital with gunshot injury to the popliteal artery. Both patients presented with late complications following missed penetrating injury to the popliteal artery. At presentation, distal pulses were palpable despite significant proximal arterial injury. Arteriography detailed traumatic popliteal artery aneurysms in both children, and an arteriovenous fistula in one child. These two children represent the youngest patients recorded in the surgical literature with gunshot trauma to the popliteal artery, subsequent formation of traumatic aneurysms, and an arteriovenous fistula. The increasing availability of guns and rifles in the household will likely increase the incidence of such injuries to children. As evidenced by these children, palpable pulses distal to an injury do not obviate the need for arteriography when arterial injury is suspected. Autogenous repair of the injured artery or reconstruction with autogenous vein graft is preferable for repair of vascular injuries in children.

Phlegmasia cerulea dolens: therapeutic considerations.

Phlegmasia cerulea dolens (PCD) is a rare venous disorder that continues to be a major therapeutic challenge. We reviewed 16 cases of PCD treated during the past 15 years; 11 of the patients were male, and the average age of all the patients was 59 years. Malignant disease was the most common underlying condition (seven patients). Venous gangrene (VG) was present in seven extremities. Three treatment methods were used alone or in combination--intravenous heparin, venous thrombectomy, and thrombolytic therapy. Heparin was used initially in 13 patients; it yielded a successful result in seven (53%) patients, none of whom had VG. Venous thrombectomy was done in six patients; in three it was the primary procedure, in two it followed failure of heparin, and in one it followed failure of both heparin and thrombolytic therapy. Venous thrombectomy was successful in three (50%) patients, one of whom had early VG. Thrombolytic therapy was used on one occasion in conjunction with both heparin and venous thrombectomy, without benefit. Five patients died, all with VG, three after heparin only, one after heparin and venous thrombectomy, and one after all three treatment methods. Review of the 38 cases reported in the recent literature shows comparable results. These data suggest that nongangrenous forms of PCD respond well to systemic anticoagulation. Combination therapy using venous thrombectomy and heparin is indicated for severe ischemia, early VG, or failure of PCD to improve after six to 12 hours of heparin therapy. Phlegmasia cerulea dolens with VG is the lethal form of the entity and responds poorly to established therapy. Future therapeutic trials need to consider aggressive use of thrombolysis with or without thrombectomy.

Familial fibromuscular dysplasia of the mesenteric arteries.

We have reported the case of a critically ill 17-year-old girl who had an evolving gastrointestinal infarction when she came to our institution 11 months before she died. After surgical revascularization, biopsy of the superior mesenteric artery showed FMD. We interviewed and examined all close consanguineous relatives and found abdominal bruits in the patient's younger sister and mother. Arteriograms showed total occlusion of the celiac and superior mesenteric arteries in the sister, and a subtotal celiac occlusion in the mother. Postprandial abdominal pain and constipation in the sister prompted elective mesenteric revascularization, and biopsy of the superior mesenteric artery confirmed FMD identical to that of her older sister. The mother, who is asymptomatic, has single vessel disease and has not required operative intervention. Our report strongly supports the hypothesis of a genetic basis for this arteriopathy.

Failed percutaneous transluminal renal angioplasty: experience with lesions requiring operative intervention.

Percutaneous transluminal angioplasty (PTA) has received widespread publicity as a safe, simple, and successful alternative to operation for the management of renal artery stenoses and renovascular hypertension (RVH). Although, in our institution, the primary management of RVH remains operative revascularization, with more than 750 such procedures having been done, we have had the opportunity to manage a spectrum of PTA failures in nine patients during the last 5 years. These include (1) acute dissection of atherosclerotic lesions and occlusion of the distal renal artery requiring emergency operation; (2) unilateral perforation and bilateral thrombosis of fibrodysplastic branch renal artery lesions requiring staged ex vivo reconstruction; (3) cholesterol embolization and recurrence to total occlusion of orificial atherosclerotic lesions with loss of excretory renal function; (4) chronic dissection from repeated "temporarily successful" PTAs of medial fibrodysplastic lesions; and (5) rapid recurrence and acceleration of hypertension in a 17-year-old girl with congenital renal artery stenoses. In each instance operation was complicated by an intense perivascular inflammatory response from the previous PTA and required a more complex reconstruction than would have been needed originally. These sequelae argue for moderating enthusiasm for the use of PTA and for limiting its routine use to nonorificial atherosclerotic lesions and fibrodysplastic lesions restricted to the main renal artery. Orificial atherosclerotic lesions, branch fibrodysplastic lesions, and congenital stenoses have a high probability of failure, complications, or both when treated by PTA and should be considered for primary operative intervention.

Ex vivo renal artery reconstructions: indications and techniques.

Ex vivo renal artery surgery has been reported by several investigators and has extended the role of revascularization in the treatment of lesions previously managed by nephrectomy alone. Several techniques are available for use, and selection of the most appropriate method can be tailored to the specific anatomy being managed. Our total experience included 27 kidneys that have been managed by ex vivo renal artery reconstruction. Lesions managed in this manner include two kidneys with renal artery stenosis and renal tumors, one kidney with a congenital branch arteriovenous malformation, and 24 kidneys with branch occlusive or aneurysmal disease from fibromuscular dysplasia. Postoperative angiography was performed in 22 cases and defined successful revascularization without technical error in 20 cases. One operative death occurred as a result of myocardial infarction. One patient required reoperation to control bleeding, and two patients had temporary acute tubular necrosis during the postoperative period. Techniques employed included ex vivo repair with autotransplantation to the iliac system (six kidneys), mobilization and perfusion without transection of the renal vein (10 kidneys), and ex vivo perfusion and repair with replacement into the original renal fossa (11 kidneys). The authors believe this latter technique of reconstruction to be preferable to autotransplantation for the usual patient undergoing ex vivo repair of complex renovascular lesions.

Mycotic embolism and embolomycotic aneurysms. Neglected lessons of the past.

During the past decade, nine patients with bacterial endocarditis have required management of mycotic emboli and/or aneurysms in this center. In these patients, 25 separate mycotic emboli or aneurysms were identified. Among these were four visceral, 11 lower extremity, one aortic, one hypogastric, and eight cerebral lesions. Multiple sites were involved in seven of the nine patients (78%). Presenting symptoms were secondary to acute expansion of mycotic aneurysms in three patients and secondary to rupture of aneurysms in four patients. Mycotic emboli produced cerebral infarction in two patients and acute ischemia in six patients. Asymptomatic mycotic aneurysms of the middle cerebral, hepatic, hypogastric, and profunda femoris arteries and asymptomatic emboli to the profunda femoris and tibial arteries were found during angiographic study. Management included resection alone (7 aneurysms), resection and graft replacement (2 aneurysms and 2 emboli), embolectomy (2), or observation. There was no mortality or loss of limb in these patients. This experience underscores the frequent multiplicity of mycotic emboli and/or aneurysms and stresses the importance of empiric angiographic survey to exclude silent yet potentially lethal visceral and cerebral mycotic foci in patients with bacterial endocarditis and peripheral emboli or aneurysms.

Renal vascular injuries.

Fifteen patients with injuries to the renal arteries and/or veins have been treated in the past ten years. Nine injuries were the result of gunshot wounds, and six were from blunt trauma. Twelve patients presented to the emergency department in shock; two of these did not have a palpable blood pressure. Time from admission to time of operation averaged 6.4 hr for patients with blunt trauma and 1.25 hr for patients with penetrating trauma. Seven patients had ten associated abdominal vascular injuries, and two patients had injuries to both the right renal artery and left renal vein. Associated nonvascular abdominal injuries were found in all 15 patients. Efforts were made to repair renal vascular injuries with suture or grafting of the injured vessel in eight cases (53%). These efforts were successful in four patients, but in four the repair failed and a nephrectomy could not be avoided. Two patients died in the operating room or immediately postop in spite of successful repair of their renovascular injury. One injured left renal vein was ligated and nephrectomy was not necessary. In five patients, ligation of the injured renal artery and nephrectomy were necessary. There were five deaths (33%). Three of the deaths occurred in the operating room and two were postoperative deaths. Only one of the patients who died had a renal vessel injury without other major vessels involved. He did, however, have serious liver and kidney injuries. Multiple associated vascular, nonvascular, and head injuries were present in all four of the other deaths. We have continued to take an aggressive approach to exploration, isolation of the injury, and repair of the vessel whenever possible if a renal vessel injury is suspected.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic mesenteric ischemia in childhood and adolescence.

Chronic mesenteric ischemia is uncommon in the atherosclerotic age group but is particularly rare in childhood. Because of the nonspecific nature of symptoms produced and absence of pathognomonic findings by physical examination or by routine laboratory testing, its recognition is difficult and its true incidence is unknown. Four children treated for chronic mesenteric ischemia in our center demonstrated the spectrum of clinical presentations and operative considerations important in the management of this uncommon malady. Ages at presentation ranged from 30 months to 17 years. These presentations ranged from clinically silent ischemia in the 30-month-old child to evolving gastrointestinal infarction in the 17-year-old adolescent. Coexistence of abdominal aortic coarctation and/or renal artery stenoses was present in three of the four children. Successful bowel revascularization was achieved by superior mesenteric artery revascularization alone in three children (reimplantation in two and a bypass in one) and by multiple celiac and superior mesenteric artery bypasses in one. Delayed distal small bowel and proximal colonic resection was required in one child. This experience increases awareness that mesenteric ischemia does occur in childhood and is a rare but potentially lethal cause of abdominal complaints in children. Finally, the finding of both renal and visceral artery disease in three of the four patients underscores the need for adequate evaluation of mesenteric vessels before renovascular procedures are undertaken in this age group.

Abdominal vascular injuries.

Treatment of major abdominal vascular injuries is a challenge. Since 1973, 93 patients have been treated at our institution for 147 abdominal vascular injuries. The majority of these injuries (67%) resulted from penetrating trauma in young men between 21 and 30 years of age. Upon admission 72% of the patients were in shock. Injured most frequently were the iliac vessels (36%) and the inferior vena cava (20%). Suture repair with preservation of function was possible in 61%; ligation of the damaged vessel was necessary in 24 cases (26%). Overall mortality was 29%. Military anti-shock (MAS) trousers were used in the management of ten patients who had an average admission systolic blood pressure of 52 mm Hg; 50% survived. In six cases of refractory hypotension or cardiac arrest, thoracotomy was done in the emergency room; mortality in this group was 100%. For some abdominal vascular injuries, ER thoracotomy has a very limited application. The key factors for increasing the survival rate in patients with major abdominal vascular injuries include rapid stabilization, reversal of hypotension (especially by the use of MAS trousers), and prevention of coagulopathy, combined with prompt surgical exploration and thoracotomy when indicated.

Retrieval of renal function by revascularization. Study of preoperative outcome predictors.

Results of renal revascularization for retrieval of function in poorly functioning kidneys are variable, but criteria for prediction of benefit and patient selection for operation are ill-defined. This report examines preoperative parameters in 64 hypertensive patients who underwent successful revascularization of poorly functioning kidneys as defined by creatinine clearance less than or equal to 15 ml/min (measured by preoperative split renal function studies [SRFS]) or preoperative serum creatinine greater than or equal to 3.5 mg/dl (range: up to 8.9 mg/dl) to identify markers of value in prediction of a beneficial response in renal function. Ages ranged from 35 to 75 years. There were 35 men and 29 women. The renovascular lesion was atherosclerotic in 58 patients and fibrodysplastic in six. Total renal artery occlusion was present in 32 cases. No urine flow was detectable before surgery on SRFS from 13 kidneys. Kidney lengths ranged from 7.7 cm to 15.1 cm. Fifty-four unilateral and 10 bilateral revascularizations were performed. A beneficial blood pressure response to operation was observed in 94%. Benefit in excretory function was determined by comparison of preoperative and postoperative data which included SRFS parameters, renal length, serum creatinine, isotopically derived split functioning renal mass, and glomerular filtration rates. Overall, 56 patients could be classified in regard to functional response. Twenty-two patients received no or minimal benefit; nine patients received modest improvement, and 25 patients exhibited more marked improvement. Statistical evaluation of preoperative anatomic and functional parameters as predictors of functional response suggested that multiple variables influence the probability of function retrieval by revascularization. Useful among these predictive variables are the status of the distal vessel beyond the occlusion, the bilaterality of reconstructable disease in azotemic patients, the amount of residual renal mass available for revascularization, and the degree of hyperconcentration of nonreabsorbable solutes from the involved kidney after surgery.

Aortic and renal vascular disease. Factors affecting the value of combined procedures.

Assessment of the predictive value of preoperative factors in the determination of operative risk in 50 patients who underwent simultaneous aortic and renovascular procedures over a 10-year period is reported. There were six operative mortalities (12%). Factors associated with increased mortal risk were azotemia (43% vs. 7%), associated complex renal or visceral procedures (31% vs. 5%), treatment of aortic aneurysm vs. occlusive disease (17% vs. 5%), positive EKG (19% vs. 4%), age over 60 years (20% vs. 4%), and a history of diffuse peripheral vascular disease (18% vs. 7%). None of these differences, by themselves, had statistical significance. Through discriminate analysis with assignment of weighted scores to the five most powerful predictors of operative death (complex procedure--4, azotemia--4, aortic aneurysm repair--3, positive electrocardiogram--2, history of diffuse vascular disease--2), a weighted score of greater than or equal to 10 predicted operative death with an 83% sensitivity and 93% specificity (p = 0.003). Although advanced age, diabetes, severity of hypertension, and history of heart disease were associated with increased operative risk, they contributed minimal discriminate value to that provided by the preceding five variables. This was because these weaker risk factors were usually found in association with the predictors in the discriminant score. This study suggests that in patients with high weighted discriminant scores (greater than or equal to 10), consideration of operative risk is particularly important in evaluation of the proposed value of combined procedures.

Gastric ulceration after fundic wrapping. Vagal nerve entrapment, a possible causative factor.

Transabdominal fundoplication is an effective operation for control of gastroesophageal reflux in the majority of patients. The operation is, however, associated with several sell-documented early and late complications. Recently, a few reports have appeared describing benign gastric ulceration (GU) occurring from one month to several years postplication. The etiology of GU in this setting is unknown, but preexisting delayed gastric emptying, pyloric incompetence, faulty wrap construction, local ischemia, and trauma to the vagus nerves have been incriminated. During a recent seven-year period, five cases of GU have occurred among a series of 158 patients who underwent fundoplication. The cases are cited in detail, and the recent literature is reviewed. Discussion is addressed to the various proposed factors and combination of factors thought to contribute to GU. Suggestions are included for the preoperative evaluation of patients with gastroesophageal reflux as an aid to intraoperative management. As trauma to the vagus nerves has been frequently mentioned as a contributing factor to postplication ulcer, an operative technique is described in which the vagus nerves are isolated and protected from the fundic wrap.