Figure 341

Diminished operative morbidity and mortality following surgical revascularization for atherosclerotic renovascular disease. Operative morbidity and mortality in patients undergoing surgical revascularization have been minimized by selective screening and/or correction of significant coexisting coronary and/or carotid artery disease before undertaking elective surgical renal revascularization for atherosclerotic renal artery disease. Screening tests for carotid artery disease include carotid ultrasound and carotid arteriography. Screening tests for coronary artery disease include thallium stress testing, dipyridamole stress testing, dobutamine echocardiography, and coronary arteriography. Aortorenal bypass with saphenous vein grafting is a frequently used surgical approach in patients with nondiseased abdominal aortas. Severe atherosclerosis of the abdominal aorta may render an aortorenal bypass or renal endarterectomy technically difficult and potentially hazardous to perform. Effective alternate bypass techniques include splenorenal bypass for left renal revascular-ization, hepatorenal bypass for right renal revascularization, ileorenal bypass, bench surgery with autotransplantation, and use of the supraceliac or lower thoracic aorta (usually less ravaged by atherosclerosis). Simultaneous aortic replacement and renal revascularization are associated with an increased risk of operative mortality in comparison to renal revascularization alone. Some surgeons advocate unilateral renal revascularization in patients with bilateral renovascular disease.

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