Wong J M, Hansen K J, Oskin T C, Craven T E, Plonk G W, Ligush J, Dean R H
Division of Surgical Sciences, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
J Vasc Surg. 1999 Sep;30(3):468-82. doi: 10.1016/s0741-5214(99)70074-1.
This retrospective review describes the surgical management of 51 patients after failed percutaneous renal artery angioplasty (F-PTRA).
From January 1987 through June 1998, 51 consecutive patients underwent surgical repair of either atherosclerotic (32 patients) or fibromuscular dysplastic (FMD; 19 patients) renovascular vascular disease after F-PTRA. These patients form the basis of this report. Surgical repair was performed for hypertension (29 patients with atherosclerosis: mean blood pressure, 205 +/- 34/110 +/- 23 mm Hg; 18 patients with FMD: mean blood pressure, 194 +/- 24/118 +/- 18 mm Hg) or ischemic nephropathy (20 patients with atherosclerosis: mean serum creatinine level, 2.0 +/- 0.8 mg/dL; three patients with FMD: mean serum creatinine level, 2.0 +/- 1.1 mg/dL). Emergency operation was required in four patients for acute renal artery thrombosis (one patient with atherosclerosis, one patient with FMD), renal artery rupture (one patient with atherosclerosis), or infected pseudoaneurysm (one patient with atherosclerosis). Operative management, blood pressure and renal function response to operation, and dialysis-free survival rate were examined and compared with 487 patients (441 patients with atherosclerosis, 46 patients with FMD) treated by operation alone.
Among the patients with atherosclerotic renovascular disease, there were three postoperative deaths (9.4%) after repair for F-PTRA. Secondary operative repair was associated with emergent repair or nephrectomy in 16% of cases, while more extensive renal artery exposure and more complex operative management was required in 50% of patients with atherosclerosis and 65% of patients with FMD repaired electively. Among the 28 operative survivors with hypertension and atherosclerotic renovascular disease, blood pressure benefit after F-PTRA was significantly lower when compared with patients with atherosclerosis who underwent treatment with operation only (57% vs 89%; P <.001). However, blood pressure benefit in the 19 patients with FMD did not differ (89% vs 96%). Among the 28 patients with atherosclerosis, preoperative estimated glomerular filtration rate (EGFR) as compared with postoperative EGFR was significantly increased (47.4 +/- 4.2 mL/min/1.73m(2) vs 56. 6 +/- 5.1 mL/min/1.73m(2); P =.002). However, EGFR prior to PTRA was not significantly different from postoperative EGFR (51.6 +/- 3.4 mL/min/1.73m(2) vs 56.6 +/- 4.9 mL/min/1.73m(2); P =.121). As compared with patients with atherosclerosis who underwent treatment with operation alone, there was no difference in the dialysis-free survival rate.
Operative repair after F-PTRA was altered in 59% of the patients with atherosclerosis and in 68% of patients with FMD. Blood pressure benefit for patients with FMD was unchanged after F-PTRA. However, the blood pressure benefit was significantly decreased among patients with atherosclerosis. Decreased EGFR after F-PTRA was recovered with operative renal artery repair. However, postoperative EGFR as compared with EGFR prior to PTRA was unchanged. Blood pressure and renal function response after F-PTRA for atherosclerotic renovascular disease warrants further study.
本回顾性研究描述了51例经皮肾动脉血管成形术失败（F-PTRA）后患者的手术治疗情况。
从1987年1月至1998年6月，51例连续患者在F-PTRA后接受了动脉粥样硬化性（32例）或纤维肌发育不良（FMD；19例）肾血管疾病的手术修复。这些患者构成了本报告的基础。手术修复针对高血压（29例动脉粥样硬化患者：平均血压，205±34/110±23mmHg；18例FMD患者：平均血压，194±24/118±18mmHg）或缺血性肾病（20例动脉粥样硬化患者：平均血清肌酐水平，2.0±0.8mg/dL；3例FMD患者：平均血清肌酐水平，2.0±1.1mg/dL）进行。4例患者因急性肾动脉血栓形成（1例动脉粥样硬化患者，1例FMD患者）、肾动脉破裂（1例动脉粥样硬化患者）或感染性假性动脉瘤（1例动脉粥样硬化患者）需要急诊手术。检查了手术管理、血压和肾功能对手术的反应以及无透析生存率，并与487例仅接受手术治疗的患者（441例动脉粥样硬化患者，46例FMD患者）进行了比较。
在动脉粥样硬化性肾血管疾病患者中，F-PTRA修复后有3例术后死亡（9.4%）。二次手术修复在16%的病例中与急诊修复或肾切除术相关，而在50%的动脉粥样硬化患者和65%的择期修复的FMD患者中需要更广泛的肾动脉暴露和更复杂的手术管理。在28例患有高血压和动脉粥样硬化性肾血管疾病的手术幸存者中，与仅接受手术治疗的动脉粥样硬化患者相比，F-PTRA后的血压获益显著降低（57%对89%；P<.001）。然而，19例FMD患者的血压获益没有差异（89%对96%）。在28例动脉粥样硬化患者中，术前估计肾小球滤过率（EGFR）与术后EGFR相比显著增加（47.4±4.2mL/min/1.73m²对56.6±5.1mL/min/1.73m²；P=.002）。然而，PTRA前的EGFR与术后EGFR没有显著差异（51.6±3.4mL/min/1.73m²对56.6±4.9mL/min/1.73m²；P=.121）。与仅接受手术治疗的动脉粥样硬化患者相比，无透析生存率没有差异。
59%的动脉粥样硬化患者和68%的FMD患者在F-PTRA后手术修复发生了改变。F-PTRA后FMD患者的血压获益未改变。然而，动脉粥样硬化患者的血压获益显著降低。F-PTRA后降低的EGFR通过手术修复肾动脉得以恢复。然而，术后EGFR与PTRA前的EGFR相比没有变化。动脉粥样硬化性肾血管疾病F-PTRA后的血压和肾功能反应值得进一步研究。
