Chiche Laurent, Kieffer Edouard, Sabatier Jean, Colau Alexandre, Koskas Fabien, Bahnini Amine
Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France.
J Vasc Surg. 2003 Feb;37(2):353-61. doi: 10.1067/mva.2003.84.
The purpose of this study was to evaluate the early and late outcomes of renal autotransplantation (RAT) according to the etiology of the underlying renal artery disease.
Between January 1985 and April 2001, we performed 68 RAT procedures in 57 patients. The surgical indications were fibromuscular dysplasia (FMD) for 34 RAT procedures in 30 patients (11 men, 19 women; mean age, 41.3 +/- 14.6 years), Takayasu's disease (TD) for 26 RAT procedures in 19 patients (five men, 14 women; mean age, 33.0 +/- 12.3 years), and atherosclerosis for eight RAT procedures in eight patients (seven men, one woman; mean age, 66.5 +/- 7.9 years). The incidence rate of hypertension was 87% in patients with FMD and 100% in patients with TD and atherosclerosis. The incidence rate of renal dysfunction was 75% in patients with atherosclerosis, 27% in patients with FMD, and 16% in patients with TD. Autotransplantation was isolated in 31 cases and was associated with another vascular procedure in 37 cases, including 22 thoracoabdominal aorta repairs and 11 abdominal aorta or iliac artery repairs. The technique used to achieve renal revascularization was direct reimplantation in 17 cases and indirect reimplantation in 51 cases. The conduit used for indirect reimplantation was an arterial autograft in 42 cases, a vein autograft in seven cases, and a prosthetic graft in two cases. Simultaneous revascularization of the contralateral kidney was performed in 21 patients and included nine RAT procedures. Contralateral nephrectomy was performed in five patients.
In the FMD group, early segmental infarction was observed in four cases. Secondary nephrectomy was necessary in one case (at 88 months). Actuarial survival rates were 96.2% +/- 0.03% at 5 years and 84.1% +/- 0.11% at 10 years. Secondary patency rates were 100% at 5 years and 92% +/- 0.07% at 10 years. Hypertension normalized or improved in 96% of patients. Renal function improved in 50% of patients. In the TD group, one patient died of multiple organ failure 4 days after the procedure. Nephrectomy was necessary in one case. The actuarial survival rate was 94.7% +/- 0.05% and the secondary patency rate was 91.3% +/- 0.05% at both 5 and 10 years. Hypertension normalized or improved in 89% of the cases, and kidney function improved in all cases. In the atherosclerosis group, nephrectomy was necessary during the early postoperative period in three cases and during late follow-up in two cases (at 9 months and at 68 months, respectively). Actuarial survival rates were 54.7% +/- 0.2% at 5 years and 18.2% +/- 0.16% at 10 years. The secondary patency rates were 50.0% +/- 0.17% at 5 years and 33.3% +/- 0.18% at 10 years. Hypertension normalized or improved in 50% of cases, and kidney function improved in 33% of cases.
RAT is highly effective for treatment of complex renovascular lesions related to FMD and TD. Although RAT is less effective for atherosclerosis, it may be the only alternative in cases involving extensive renovascular disease.
本研究旨在根据潜在肾动脉疾病的病因评估自体肾移植（RAT）的早期和晚期疗效。
1985年1月至2001年4月，我们对57例患者进行了68例RAT手术。手术适应证为30例患者的34例RAT手术的纤维肌性发育异常（FMD）（11例男性，19例女性；平均年龄41.3±14.6岁），19例患者的26例RAT手术的高安氏病（TD）（5例男性，14例女性；平均年龄33.0±12.3岁），以及8例患者的8例RAT手术的动脉粥样硬化（7例男性，1例女性；平均年龄66.5±7.9岁）。FMD患者的高血压发病率为87%，TD和动脉粥样硬化患者的高血压发病率为100%。动脉粥样硬化患者的肾功能不全发病率为75%，FMD患者为27%，TD患者为16%。31例为单纯自体肾移植，37例与另一血管手术相关，包括22例胸腹主动脉修复和11例腹主动脉或髂动脉修复。实现肾血管重建的技术为直接再植17例，间接再植51例。间接再植所用的管道为自体动脉移植42例，自体静脉移植7例，人工血管移植2例。21例患者对侧肾同时进行了血管重建，包括9例RAT手术。5例患者进行了对侧肾切除术。
在FMD组，4例观察到早期节段性梗死。1例（88个月时）需要进行二次肾切除术。5年时的精算生存率为96.2%±0.03%，10年时为84.1%±0.11%。5年时的二次通畅率为100%，10年时为92%±0.07%。96%的患者高血压恢复正常或改善。50%的患者肾功能改善。在TD组，1例患者术后4天死于多器官功能衰竭。1例需要进行肾切除术。5年和10年时的精算生存率分别为94.7%±0.05%和二次通畅率为91.3%±0.05%。89%的病例高血压恢复正常或改善，所有病例肾功能均有改善。在动脉粥样硬化组，3例在术后早期需要进行肾切除术，2例在后期随访中需要进行肾切除术（分别在9个月和68个月时）。5年时的精算生存率为54.7%±0.2%，10年时为18.2%±0.16%。5年时的二次通畅率为50.0%±0.17%，10年时为33.3%±0.18%。50%的病例高血压恢复正常或改善，33%的病例肾功能改善。
RAT对治疗与FMD和TD相关的复杂肾血管病变非常有效。尽管RAT对动脉粥样硬化的疗效较差，但在涉及广泛肾血管疾病的病例中可能是唯一的选择。
