Tsoukas A I, Hertzer N R, Mascha E J, O'Hara P J, Krajewski L P, Beven E G
Department of Vascular Surgery, The Cleveland Clinic Foundation, OH 44195, USA.
J Vasc Surg. 2001 Dec;34(6):1041-9. doi: 10.1067/mva.2001.118584.
We documented the postoperative complication rate and the late results of simultaneous infrarenal aortic replacement and renal artery (RA) revascularization at the Cleveland Clinic and correlated these findings with the preoperative serum creatinine level (S(Cr)) and other baseline risk factors.
A retrospective review of hospital charts and outpatient records was supplemented with a telephone canvass and the invitation to return for a complimentary RA duplex scan, when a scan had not been done within the previous year. Data were collected for 73 consecutive patients (mean age, 69 years) who underwent aortic procedures that were combined with the repair of RA stenosis from 1989 to 1997 (mean follow-up, 44 months). The preoperative S(Cr) was 2 mg/dL or lower in 45 patients (group R1; median, 1.5 mg/dL) and was higher than 2 mg/dL in the remaining 28 patients (group R2; median, 2.6 mg/dL).
Forty-seven of the patients in this series had aortic aneurysms, 15 patients had aortoiliac occlusive disease, and 11 patients had both types of lesions. Bilateral RA revascularization was necessary for seven patients in group R1 (15%) and for eight patients in group R2 (29%). Group R2 contained more patients with medically resistant hypertension (57%) than group R1 (29%, P = .019). Although there was no statistically significant difference between the 30-day mortality rates (group R1, 2.2%; group R2, 11%), the related in-hospital mortality rate for 15 bilateral RA revascularizations (13%) was nearly twice that of 58 unilateral revascularizations (6.9%). Patients in group R2 were at a higher risk for postoperative dialysis than those in group R1 (36% vs 6.7%, P = .008), and patients in group R2 had longer lengths of stay in the hospital (median, 14 days vs 9 days; P = .004). By means of Kaplan-Meier analysis, the 5-year survival rate was lower for patients in group R2 (53%; 95% CI, 33%-73%) than for patients in group R1 (85%; 95% CI, 74%-96%; log rank P = .005). Despite all other liabilities in group R2 patients, however, their resistant hypertension was cured or improved in 88% of cases and their S(Cr) appeared to decline with time.
The early postoperative risk of simultaneous aortic/RA procedures appears to be highest in patients who have an elevated S(Cr), bilateral RA stenosis or occlusion, and a comparatively low long-term survival rate. In this particular group, the adjunctive use of endovascular techniques might conceivably reduce the magnitude of the planned surgical procedure and thus enhance the overall outcome.
我们记录了克利夫兰诊所同期肾下腹主动脉置换术和肾动脉（RA）血运重建术的术后并发症发生率及远期结果，并将这些结果与术前血清肌酐水平（S(Cr)）及其他基线风险因素进行关联分析。
对医院病历和门诊记录进行回顾性研究，并通过电话随访补充信息，若患者前一年未进行RA双功超声扫描，则邀请其回来进行免费扫描。收集了1989年至1997年连续73例（平均年龄69岁）接受主动脉手术并同时修复RA狭窄患者的数据（平均随访44个月）。45例患者（R1组）术前S(Cr)为2mg/dL或更低（中位数为1.5mg/dL），其余28例患者（R2组）术前S(Cr)高于2mg/dL（中位数为2.6mg/dL）。
本系列患者中，47例患有主动脉瘤，15例患有主髂动脉闭塞性疾病，11例同时患有这两种病变。R1组7例患者（15%）和R2组8例患者（29%）需要进行双侧RA血运重建。R2组中难治性高血压患者（57%）比R1组（29%）更多（P = 0.019）。虽然30天死亡率在两组间无统计学显著差异（R1组为2.2%；R2组为11%），但15例双侧RA血运重建患者的院内相关死亡率（13%）几乎是58例单侧血运重建患者（6.9%）的两倍。R2组患者术后透析风险高于R1组（36%对6.7%，P = 0.008），且R2组患者住院时间更长（中位数分别为14天和9天；P = 0.004）。通过Kaplan-Meier分析，R2组患者的5年生存率（53%；95%CI，33%-73%）低于R1组患者（85%；95%CI，74%-96%；对数秩检验P = 0.005）。然而，尽管R2组患者存在其他不利因素，其难治性高血压在88%的病例中得到治愈或改善，且其S(Cr)似乎随时间下降。
同期主动脉/RA手术的术后早期风险在S(Cr)升高、双侧RA狭窄或闭塞且长期生存率相对较低的患者中似乎最高。在这一特定群体中，血管内技术的辅助使用可能会减少计划手术的规模，从而改善总体预后。
