Department of Vascular Surgery, Hammersmith Hospitals, London, UK.
J Endovasc Ther. 2010 Jun;17(3):326-31. doi: 10.1583/09-3011.1.
To report a salvage maneuver for accidental coverage of both renal arteries during endovascular aneurysm repair (EVAR) of an infrarenal aortic aneurysm (AAA) and survey our surgical colleagues in the UK for their use of this bypass procedure.
A 74-year-old woman who had an EVAR complicated by renal failure secondary to malposition of the stent-graft underwent successful delayed renal revascularization with hepatorenal and splenorenal bypasses. This case prompted a literature review and preparation of an online 6-part questionnaire regarding the incidence and management of renal impairment following EVAR. The survey invitation was sent to all listed members of the Vascular Society of Great Britain and Ireland.
Responses from 68 (10.5%) of the 650 vascular surgeons invited to participate in the survey were analyzed. The combined experience of those who completed the survey was >1500 EVAR procedures per annum. Forty percent (27/68) of the respondents had experienced a case of bilateral renal artery occlusion during EVAR. Two thirds (67%, 18/27) of these surgeons stated a preference for revascularizing the kidneys endovascularly, 7 surgeons would convert to open repair, 1 surgeon favored iliorenal bypass, and another suggested splenorenal bypass. Following intervention, 15 (56%) of 27 surgeons achieved revascularization that resulted in a return to baseline serum creatinine, 7 (26%) achieved partial recovery of the patient's serum creatinine, 3 (11%) had a patient on permanent dialysis, and 2 (7%) had patients who died (after open repair and endovascular procedure, respectively).
Bilateral renal artery occlusion caused by malposition of a stent-graft is probably underreported. If revascularization of the kidneys by endovascular techniques fails, there is no consensus as to the optimal approach. Delayed revascularization should be considered if the kidneys show concentration of imaging contrast. Hepato-spleno-renal bypass, which has not heretofore been indicated for renal salvage post EVAR, can provide a good functional result in this situation.
报告一例在腹主动脉瘤（AAA）腔内修复术（EVAR）中意外覆盖双侧肾动脉的抢救方法，并调查英国的外科同行是否使用这种旁路手术。
一名 74 岁女性因支架移植物位置不当导致肾衰竭而行 EVAR 治疗，后行肝肾和脾肾旁路手术成功进行了延迟性肾脏血运重建。这一病例促使我们进行文献复习，并准备了一个关于 EVAR 后肾功能损害的发病率和处理的在线六部分问卷调查。调查邀请发送给所有英国血管学会的在册成员。
对 650 名受邀参与调查的血管外科医生中的 68 名（10.5%）的回复进行了分析。完成调查的医生的累计经验超过每年 1500 例 EVAR 手术。68 名受访者中有 40%（27/68）在 EVAR 期间发生双侧肾动脉闭塞。其中 67%（18/27）的外科医生表示倾向于腔内血管重建，7 名外科医生会转为开放修复，1 名外科医生主张髂肾旁路，另 1 名外科医生建议脾肾旁路。干预后，27 例中的 15 例（56%）外科医生实现了血管重建，使患者的血清肌酐恢复到基线水平，7 例（26%）患者的血清肌酐部分恢复，3 例（11%）患者需要永久性透析，2 例（7%）患者死亡（分别为开放修复和血管内手术后）。
支架移植物位置不当导致双侧肾动脉闭塞可能报告不足。如果腔内血管重建技术失败，对于最佳治疗方法尚无共识。如果肾脏显示造影剂浓度，应考虑延迟血管重建。肝肾-脾肾旁路，以前没有被推荐用于 EVAR 后肾脏抢救，在这种情况下可以提供良好的功能结果。
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