Reilly J M, Rubin B G, Thompson R W, Allen B T, Flye M W, Anderson C B, Sicard G A
Department of Surgery, Washington University School of Medicine, St. Louis, Mo., USA.
Surgery. 1996 Oct;120(4):732-6; discussion 736-7. doi: 10.1016/s0039-6060(96)80024-9.
Patients with significant atherosclerotic stenosis involving the artery to a solitary functioning kidney present a clinical challenge.
From August 1987 through August 1995, 35 of these patients (average age, 68.4 +/- 6.9 years) were treated. Comorbid conditions included previous myocardial infarction in 23% of the patients, congestive heart failure (CHF) in 34%, chronic obstructive pulmonary disease in 20%, and diabetes in 20%. The average creatinine level of the patients was 2.5 +/- 1.5 mg/dl. Indications for revascularization were hypertension in 86%, hypertensive crisis with CHF in 17%, and renal insufficiency in 69%. Procedures performed included 19 extra-anatomic bypasses, 8 concomitant with infrarenal aortic reconstruction and 2 concomitant with thoracoabdominal aortic aneurysm repair; 1 visceral segment endarterectomy; 1 renal artery endarterectomy with reimplantation; I superior mesenteric to renal artery bypass; 1 aortorenal bypass; and 2 percutaneous angioplasties with staged nephrectomies.
At discharge, 91% of patients had stable or improved renal function with an average creatinine level of 1.7 +/- 0.8 mg/dl. Hypertension was cured or improved in 85%. Perioperative mortality was 6%, and major morbidity was 43%, including the need for permanent (9%) and temporary (9%) dialysis, respiratory insufficiency (18%), two early reoperations, six cardiac complications, one case of gastrointestinal bleeding, and one stroke. In the follow-up period (mean duration, 39.2 months), survival has been 73%, and no additional patients have required dialysis.
Although significant perioperative morbidity exists in this high risk population, the long-term preservation of renal function and improvement in hypertension make solitary renal revascularization worthwhile.
患有严重动脉粥样硬化性狭窄且累及单肾动脉的患者面临临床挑战。
从1987年8月至1995年8月，对35例此类患者（平均年龄68.4±6.9岁）进行了治疗。合并症包括23%的患者既往有心肌梗死，34%有充血性心力衰竭（CHF），20%有慢性阻塞性肺疾病，20%有糖尿病。患者的平均肌酐水平为2.5±1.5mg/dl。血运重建的指征为86%的患者有高血压，17%的患者有伴有CHF的高血压危象，69%的患者有肾功能不全。所施行的手术包括19例解剖外旁路手术，8例同时行肾下腹主动脉重建术，2例同时行胸腹主动脉瘤修复术；1例内脏段内膜切除术；1例肾动脉内膜切除术并再植术；1例肠系膜上动脉至肾动脉旁路手术；1例主动脉肾动脉旁路手术；以及2例经皮血管成形术并分期肾切除术。
出院时，91%的患者肾功能稳定或改善，平均肌酐水平为1.7±0.8mg/dl。85%的患者高血压得到治愈或改善。围手术期死亡率为6%，主要并发症发生率为43%，包括需要永久性（9%）和临时性（9%）透析、呼吸功能不全（18%）、两次早期再次手术、六种心脏并发症、一例胃肠道出血和一例中风。在随访期（平均时长39.2个月），生存率为73%，且没有其他患者需要透析。
尽管该高危人群围手术期存在显著并发症，但长期保留肾功能和改善高血压使单肾血运重建是值得的。
