Combined Aortic and Renal Artery Reconstruction

James M. Wong and Kimberley J. Hansen

Management of renal artery disease discovered incidentally during angiographic study of the abdominal aorta is controversial. In this setting, the surgeon must address the need for additional diagnostic study and the decision of whether to perform combined aortic and renal artery reconstruction. Data pertaining to this latter decision may be obtained from a review of the natural history of atherosclerotic renal artery disease compared with the results of combined repair. This information then helps to form a therapeutic plan appropriate to the individual patient. In the following discussion, combined management of aortic and renal artery disease will be considered as either a prophylactic or empiric procedure.

Prophylactic Renal Artery Repair

The term prophylactic repair indicates that renal revascularization is performed prior to any pathologic or clinical sequelae related to the lesion. By definition, therefore, the patient considered for prophylactic renal artery repair has neither hypertension nor reduced renal function. Correction of the renal artery lesion in this setting assumes that a significant percentage of these asymptomatic patients will survive to the point that the renal lesion will cause hypertension or renal dysfunction and that preemptive correction is necessary to prevent a clinically adverse event for which the patient cannot be treated. To test this assumption, review of available data regarding the natural history of renovascular disease will address: 1) the rate at which asymptomatic lesions not associated with hypertension or renal dysfunction progress to clinical significance, and 2) the rate at which clinically significant lesions progress to occlusion.

Data regarding the frequency of anatomic progression of renovascular disease are summarized in Table 18.1. In patients with hypertension, ipsilateral progression of renal artery lesions occurred in 44% and progression to occlusion during medical management occurred in 12%. However, among our reported patients, only one (3%) had loss of a previously reconstructable renal artery.1 In the absence of hypertension, one must assume that the renal artery lesion must progress anatomically to become functionally significant (i.e., produce hypertension). Based on the preceding data, progression of a renal artery lesion to produce renovascular hypertension (RVH) could be expected in approximately 44% of normotensive patients. If one also assumes that the subsequent development of RVH is managed medically, then the next consideration is the frequency of decline in renal function.

Table 18.1. Angiographic progression of renal artery atherosclerosis

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