English William P, Pearce Jeffrey D, Craven Timothy E, Wilson David B, Edwards Matthew S, Ayerdi Juan, Geary Randolph L, Dean Richard H, Hansen Kimberley J
Division of Surgical Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
J Vasc Surg. 2004 Jul;40(1):53-60. doi: 10.1016/j.jvs.2004.03.024.
This retrospective review describes the surgical management and clinical outcome for renal artery aneurysms (RAAs) in 62 consecutive patients.
From January 1987 through July 2003, 804 patients had operative renal artery (RA) repair involving 1206 kidneys at our center. A subgroup of 62 patients (42 women, 20 men; mean age 46 +/- 18 years) received repair of 72 RAAs. Demographic data, comorbidity, and surgical technique were examined. Blood pressure and renal function response were determined. Patency of repair was evaluated by renal duplex sonography. Primary patency and patient survival were estimated by life-table methods. Tests of association were performed using chi(2) and the Student t tests.
Seventy-two RAs were repaired for RAA with a mean diameter of 2.6 cm (range, 1.3 to 5.5 cm). Bilateral RAAs were present in 21 patients. Associated conditions included fibromuscular dysplasia, atherosclerosis, and arteritis in 54%, 35%, and 7%, respectively. Hypertension was present in 89% (mean blood pressure, 171 +/- 35/95 +/- 19 mm Hg; mean medications, 2.2 +/- 1.2 drugs) and renal insufficiency was present in 8% (mean serum creatinine, 1.9 +/- 0.6 mg/dL). RAA repair included bypass (67%), aneurysmorrhaphy (15%), or a combination (17%). One planned nephrectomy (1%) was performed for un-reconstructable disease. Branch RA reconstruction in 78% used ex vivo cold perfusion in 50%, in situ cold perfusion in 29%, and warm in situ repair in 21%. Of 9 bilateral RAA repairs, 7 (78%) were staged and 2 (22%) were simultaneous. Combined aortic reconstruction was required in 6 (10%) patients. Perioperative death occurred in 1 patient (1.6%), and significant morbidity was observed in 8 patients (12%). Hypertension was considered improved in 54%, cured in 21%, and unchanged in 25% at mean follow-up of 48 months (range, 1-156 months). Among patients with renal insufficiency, renal function was improved in 3 (60%), unchanged in 1 (20%), and declined in 1 (20%). Follow-up patency (mean, 33 months; range, 1-118 months) was determined for 64 (91%) RA reconstructions. Product-limit estimate of primary patency at 48 months was 96%. Product-limit estimate of survival was 91% at 120 months.
RAAs were repaired with low morbidity and mortality. Complex branch RAA repair using cold perfusion preservation and ex vivo techniques resulted in no unplanned nephrectomy, with an estimated primary patency of 96% at 48 months. Beneficial blood pressure response was observed in the majority of hypertensive patients. These results support selective surgical management of RAA.
本回顾性研究描述了连续62例肾动脉动脉瘤（RAA）患者的手术治疗及临床结果。
1987年1月至2003年7月，我院中心804例患者接受了1206侧肾脏的肾动脉（RA）手术修复。62例患者（42例女性，20例男性；平均年龄46±18岁）接受了72例RAA修复。对人口统计学数据、合并症及手术技术进行了检查。测定了血压及肾功能反应。通过肾双功超声评估修复通畅情况。采用寿命表法估计初次通畅率及患者生存率。使用卡方检验和学生t检验进行相关性检验。
72例RA因RAA接受修复，平均直径2.6cm（范围1.3至5.5cm）。21例患者存在双侧RAA。相关疾病分别为纤维肌发育不良、动脉粥样硬化及动脉炎，占54%、35%及7%。89%患者存在高血压（平均血压171±35/95±19mmHg；平均用药2.2±1.2种药物），8%患者存在肾功能不全（平均血清肌酐1.9±0.6mg/dL）。RAA修复包括旁路手术（67%）、动脉瘤缝合术（15%）或联合手术（17%）。1例（1%）因无法重建的疾病行计划性肾切除术。78%的分支RA重建术中，50%采用体外冷灌注，29%采用原位冷灌注，21%采用原位热修复。9例双侧RAA修复中，7例（78%）分期进行，2例（22%）同期进行。6例（10%）患者需要联合主动脉重建。围手术期死亡1例（1.6%），8例（12%）患者出现严重并发症。平均随访48个月（范围1至156个月）时，54%患者高血压改善，21%治愈，25%无变化。肾功能不全患者中，3例（60%）肾功能改善，1例（20%）无变化，1例（20%）下降。对64例（91%）RA重建术进行了随访通畅情况测定（平均33个月；范围1至118个月）。48个月时初次通畅率的乘积限估计为96%。120个月时生存率的乘积限估计为91%。
RAA修复的发病率和死亡率较低。采用冷灌注保存和体外技术进行复杂分支RAA修复未导致计划外肾切除术，48个月时估计初次通畅率为96%。大多数高血压患者观察到有益的血压反应。这些结果支持对RAA进行选择性手术治疗。
