Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA.
Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA.
Ann Vasc Surg. 2022 Nov;87:31-39. doi: 10.1016/j.avsg.2022.07.012. Epub 2022 Sep 2.
Common etiologies of renovascular occlusive disease include atherosclerosis disease, developmental fibrotic conditions such as fibromuscular dysplasia, and vasculitis. Extrinsic compression of the renal artery is a rarely reported phenomenon but can lead to similar clinical manifestations.
We report recent experience with 2 patients who presented with extrinsic renal artery compression due to entrapment. Diagnosis was made with a constellation of findings on computed tomography angiography, dynamic duplex sonography, and catheter angiography. Both patients had hypertension and 1 had downstream subsegmental renal infarcts. The patients, both with right-sided renal artery entrapment, were treated with open surgical decompression. Exposure was achieved via extended Kocher maneuver followed by mobilization of the right kidney and, in 1 patient, detachment of the right lobe of liver to allow circumferential exposure of the proximal right renal artery to the aorta. All entrapping tissue was circumferentially released.
Both operations were uncomplicated. Intraoperative sonography was used to confirm luminal patency of the released segments. Follow-up of renal artery duplex in both patients demonstrated resolution of dynamic compression. Renal artery peak systolic velocity and accelerations indices were all within normal limits. In both patients, improvement in blood pressure control was noted and discontinuation of anticoagulation was possible in the patient who had recurrent episodes of renal infarct.
Extrinsic compression of renal artery by diaphragmatic crura is rare but should be considered in younger patients or otherwise any patients with no vascular risk factors when renovascular hypertension workup yields no demonstrable intrinsic disease. A high index of suspicion should be raised when an anomalously high origin of the renal artery or proximity to the diaphragmatic crura is seen on cross-sectional imaging. Work-up should include dynamic imaging to assess compression of renal arteries during expiration. Open surgical or laparoscopic decompression of the involved renal arteries can be curative.
引起肾血管闭塞性疾病的常见病因包括动脉粥样硬化疾病、纤维肌性发育不良等发育性纤维性疾病以及脉管炎。肾动脉的外在压迫是一种罕见的现象，但可导致类似的临床表现。
我们报告了 2 例因嵌顿而导致肾外动脉受压的患者的近期经验。通过 CT 血管造影、动态双功超声和导管血管造影的一系列发现做出了诊断。这 2 例患者均有高血压，1 例有下游亚段性肾梗死。这 2 例患者均为右侧肾动脉嵌顿，接受了开放性手术减压。通过延长 Kocher 操作，然后移动右肾，并在 1 例患者中分离右肝叶，以允许对近端右肾动脉到主动脉进行环绕暴露，从而实现了暴露。所有嵌顿组织均被环绕松解。
2 例手术均无并发症。术中超声用于确认释放段的管腔通畅性。对这 2 例患者的肾动脉双功超声随访显示动态压迫得到缓解。肾动脉收缩期峰值速度和加速度指数均在正常范围内。这 2 例患者的血压控制均得到改善，且在 1 例反复发生肾梗死的患者中，停止抗凝治疗成为可能。
由膈脚引起的肾动脉外在压迫较为罕见，但当肾血管性高血压检查未发现任何内在疾病，而患者为年轻患者或无血管危险因素时，应考虑这种疾病。当在横断面成像上看到肾动脉异常高起源或靠近膈脚时，应高度怀疑这种疾病。检查应包括动态成像，以评估呼气时肾动脉的压迫情况。涉及的肾动脉的开放性或腹腔镜减压手术可能是治愈性的。
