Iliorenal Bypass: Indications and Outcomes following 41 Reconstructions

Article Outline

• Abstract
• Introduction
• Clinical Material
  • Demographics
  • Renal Artery Disease
  • Clinical Presentation
  • Reason for Selecting an Iliorenal Bypass
  • Operative Technique
  • Specific Outcomes
  • Statistical Analyses
• Results
  • Patient: Bypass Status
  • Renal Function
  • Hypertension
• Discussion
• References
• Copyright

Iliorenal bypass is a nonanatomic means of renal revascularization usually performed in high-risk patients. Its efficacy was assessed in this review of 35 patients (17 males and 18 females, two children and 33 adults) ranging in age 8–84 years, who were subjected to 41 iliorenal bypasses at the University of Michigan Hospital during 1975–2003. Renal artery lesions included arteriosclerosis (n = 20), developmental narrowing (n = 10), arterial fibrodysplasia (n = 3), penetrating trauma (n = 1), and aortorenal dissection associated with Marfan disease (n = 1). All patients had hypertension attributed to their renal artery disease. Twenty patients exhibited renal insufficiency (serum creatinine >1.8 mg/dL). Primary reasons for selecting an iliorenal reconstruction over a more conventional open revascularization included advanced aortic arteriosclerosis (n = 9); prior aortoaortic, aortoiliac, or aortofemoral reconstruction (n = 7); a small aortic aneurysm not justifying aortic surgery (n = 6); prior aortorenal surgery (n = 6); congenital abdominal aortic coarctation (n = 4); a hostile retroperitoneum (n = 2); or compromised cardiac status (n = 1). Eleven patients had prior ipsilateral renal artery interventions. Iliorenal bypasses were to the right kidney (n = 20), the left kidney (n = 9), and bilateral (n = 12). Conduits were saphenous veins (n = 29), synthetic prostheses (n = 11), or direct renal artery-iliac artery reimplantation (n = 1). Initial bypass patency was 93%. Follow-up averaged 7.5 years. Three early and six late graft complications resulted in eight secondary operations. The mean preoperative and postoperative serum creatinine of all 35 patients did not vary (1.9 vs. 1.8 mg/dL), although on an individual basis renal function improved in eight, remained stable in 21, and deteriorated in six patients. The series' mean preoperative blood pressure of 180/97 mm Hg decreased postoperatively to 140/78 mm Hg (P < 0.001). Hypertension was cured in three patients, improved in 27, and became worse in four. Antihypertensive medication numbers decreased postoperatively, from a median of three to two (P < 0.0001). Surgical mortality was limited to one patient succumbing from perioperative intestinal infarction. Iliorenal bypass is an effective means of renal revascularization in patients not amenable to more conventional open or transluminal procedures.

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Introduction 

Renovascular hypertension is usually the consequence of aortic arteriosclerosis extending into the proximal renal artery or fibrodysplasia involving the midportion of the renal artery.¹ These lesions account for 97% and 2% of patients with newly diagnosed renovascular hypertension, respectively. Congenital developmental narrowings, aortic dissections, and trauma involving the renal artery are relatively rare causes of renovascular hypertension.

Magnetic resonance arteriography (MRA) and thin-slice computed tomographic arteriography (CTA), because of their noninvasive nature, have become more common than catheter-based arteriography as a means of diagnosing renovascular occlusive disease. The former studies have resulted in greater numbers of patients being diagnosed with renovascular hypertension, including many advanced arteriopaths who would not have been studied decades ago. Percutaneous transluminal angioplasty (PTA) has liberalized treatment indications and increased the number of diagnostic studies being performed for suspected renovascular disease.², ³

A small subset of renovascular hypertensives have extensive aortorenal disease, a hostile aorta, or such precarious cardiac function that either PTA or conventional renal artery reconstructions requiring aortic clamping are not acceptable therapeutic options. Nonanatomic reconstructions may be considered in this setting. Splenorenal or hepatorenal bypasses are the most common of these procedures.⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹ However, celiac artery occlusive disease is frequently present and precludes these alternative reconstructions. It is in these uncommon circumstances that an iliorenal bypass may be an appropriate means of revascularizing a kidney. This review was undertaken to assess both the early and long-term efficacy of iliorenal bypass as a means of renal revascularization.

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Clinical Material 

Demographics 

Thirty-five patients, 17 males and 18 females, ranging in age 8–84 years (two children, 33 adults), underwent renal artery reconstructive surgery with 41 iliorenal bypasses at the University of Michigan Hospital during 1975–2003 (Table I). These 35 patients were culled from a total renal artery reconstructive experience encompassing over 600 patients treated during the same time period. The operative indications, details regarding the bypass procedure, subsequent morbidity and mortality, as well as the effects on blood pressure control and renal function were determined from patient records and follow-up questionnaires. This investigation was approved by the University of Michigan Institutional Review Board (2001-0455).

Table I. Patient characteristics, procedure, and postoperative outcomes

Renal Artery Disease 

Preoperative angiography was performed in all patients, confirming the presence of severe renal artery disease. This included conventional catheter-based arteriograms in 32 patients and MRA in three patients. The hemodynamic and functional significance of all lesions was established by one or more of the following: (1) demonstration of collateral vessels to the renal parenchyma circumventing the stenosis, (2) clear evidence of at least an 80% stenosis, or (3) catheter-measured pressure gradients exceeding 15–20 mm Hg across the stenosis. The underlying renal artery lesion included proximal arteriosclerotic stenoses (n = 20), developmental stenoses of both the aorta and the renal arteries (n = 10), arterial fibrodysplasia of the midrenal artery (n = 3), Marfan syndrome with a dissection affecting the pararenal aorta (n = 1), and penetrating trauma resulting in renal artery occlusion (n = 1). Among the 35 patients undergoing iliorenal bypass, prior ipsilateral renal artery reconstruction failures in five patients and prior PTA failures in four patients complicated the underlying vascular lesion being treated. In addition to the nine former patients, two additional patients had undergone earlier open renal artery surgery.

Clinical Presentation 

All patients presented with difficult-to-control or uncontrolled hypertension, and in every case the blood pressure elevations were attributed to the renal artery occlusive disease. All patients were classified failures of medical therapy, with refractory mean preoperative blood pressure on antihypertensive drugs being 180/97 mm Hg. Twenty patients exhibited significant chronic renal insufficiency (serum creatinine >1.8 mg/dL). These latter patients had a mean preoperative serum creatinine of 2.6 ± 17 mg/dL. Creatinine clearances were inconsistently calculated among this series' patients. Tobacco use affected 63% of these patients, lipid disorders were recognized in 40%, diabetes mellitus affected 17%, and a history of angina or myocardial infarction affected 23%.

Reason for Selecting an Iliorenal Bypass 

The most common basis for undertaking an iliorenal bypass was severe aortic disease precluding safe performance of an aortorenal bypass or aortorenal endarterectomy. Included in this group of patients were those with extensive arteriosclerotic aortic occlusive disease making aortic clamping risky but not advanced enough to justify an aortic reconstruction (n = 9); prior aortic surgery with either an aortoaortic, aortoiliac, or aortofemoral graft placement (n = 7); an earlier aortorenal reconstruction (n = 6); presence of an infrarenal abdominal aortic aneurysm too small to justify its treatment (n = 6); an abdominal aortic coarctation (n = 4), of whom all but one had a prior aortoplasty or thoracoabdominal bypass; a hostile retroperitoneum due to a massive arteriovenous malformation (n = 1) or extensive retroperitoneal fibrosis (n = 1); and markedly compromised cardiac status in a patient with cardiomyopathy and an ejection fraction of <20% that would have made aortic clamping hazardous (n = 1). Consideration of a nonanatomic renal artery reconstructive procedure was anticipated preoperatively in 32 patients. A hostile aorta was recognized intraoperatively in the remaining three patients.

Clearly, preoperative evidence of aneurysmal disease of the iliac artery or high-grade stenotic disease of the aorta or proximal common iliac artery would preclude safe performance of an iliorenal reconstruction. PTA techniques were not available therapeutic options during the first decade of this experience, and in recent decades in patients having significant renal failure with solitary kidneys as well as patients with complex disease such as an early renal artery bifurcation from an ostial stenosis, an open procedure was considered a safer option than PTA.

Operative Technique 

Simultaneous bilateral renal revascularizations were undertaken in six patients. Among the remaining patients, 20 reconstructions involved the right kidney and nine the left kidney. Transverse supraumbilical abdominal incisions extending from the opposite midclavicular line to the posterior-axillary line on the side of the renal artery reconstruction were favored in this experience. Such exposure offered a technical advantage in the greater ease of handling instruments parallel to the longitudinal axis of the renal artery during complex procedures and provided easy access to the iliac arteries. A midline vertical incision was reincised if present from earlier aortic or other abdominal surgery.

The right renal artery was exposed by incising the lateral parietes from the hepatic flexure to the cecum, then reflecting the overlying right colon, duodenum, and the head of the pancreas medially with an extended Kocher-like maneuver. In some instances of right-sided ostial narrowing, the vena cava was retracted laterally, exposing the proximal renal artery without the necessity of dissecting the more distal renal artery. The left renal artery was exposed using a similar retroperitoneal approach, with medial reflection of the viscera, including the left colon.

The type of conduit used depended upon the renal artery disease being treated, the availability of adequate saphenous vein, and the presence of a previously placed aortic graft. Autologous saphenous vein was used most often (n = 29). A Dacron^® (Meadox Medical, Oakland, NJ) mesh was placed about the vein graft in this series' two children, to prevent late aneurysmal dilation. Synthetic conduits, including 10 Teflon^® (WL Gore, Flagstaff, AZ) grafts and one Dacron graft, (Meadox Medical), were used most often when originating from the limb of a previously placed synthetic aortofemoral bypass (n = 7). One patient with a pelvic kidney had the mobilized renal artery anastomosed to the iliac artery.

Origination of an iliorenal graft was usually possible from the anterior or anterolateral common iliac artery. At that site, even in severe arteriosclerosis, the vessel was usually free of calcific plaque. The iliac arteries were not often circumferentially dissected, and in the presence of severe calcific arteriosclerosis, intraluminal occlusion balloons were used in place of macrovascular clamps.

All grafts were spatulated so as to allow for generous end-to-side anastomoses to the iliac artery, following which they were positioned alongside the aorta with a gentle curve at the level of the renal artery, where they were anastomosed to the renal artery in an end-to-end fashion. This reconstruction involved spatulation of the graft and the renal artery so as to create an ovoid anastomosis. Iliorenal grafts in patients having prior aortofemoral bypasses originated from limbs of these conduits rather than from the aortic body of the bypass. Operative assessments of the adequacy of the bypasses were undertaken with either Doppler insonation of graft flow or duplex ultrasonography of the reconstruction.

Specific Outcomes 

Blood pressure responses postoperatively were categorized as a cure when 140/90 mm Hg in adults or an appropriate lower pressure in children, while taking no antihypertensive drugs. The improved category occurred with systolic pressure reductions of 20 mm Hg or more, diastolic pressure reductions of 10 mm Hg or more, or a reduction in the number of antihypertensive drugs. Those patients remaining hypertensive and not meeting the former criteria were categorized as failures.

Renal function was classified as improved with serum creatinine reductions of 20% or more and stable with neither increases nor decreases of 20%. Deteriorations in renal function representing therapeutic failures occurred when serum creatinine increased 20% or more. Mortality and morbidity, especially when resulting in reoperation, were assessed and related to other factors surrounding the initial need for renal revascularization.

The anatomic adequacy of 40 of the 41 bypasses was assessed in the early postoperative period before hospital discharge with imaging, either using conventional arteriography or MRA. Long-term follow-up included careful monitoring of blood pressure and renal function, with abdominal ultrasonographic assessments of renal size and blood flow. Repeat arteriography was undertaken in all cases when recurrent renovascular hypertension was suspected.

Statistical Analyses 

Outcomes were assessed using Student's t-tests and the chi-squared test for nominal and categorical data, respectively. Preoperative and postoperative blood pressures and serum creatinine values were compared using paired t-tests. P < 0.05 was considered significant.

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Results 

Patient: Bypass Status 

All but one patient survived the initial iliorenal bypass procedure (97%). Two patients required nonvascular reoperations shortly after their bypass: one for postoperative bleeding and the second for an acute small bowel obstruction. Both patients recovered uneventfully. The series' only perioperative mortality was due to early postoperative colon ischemia and multisystem organ failure following an otherwise uncomplicated unilateral iliorenal bypass with a vein graft. Excluding this latter patient, the mean follow-up was 7.5 years, ranging from 1 month to 28 years. Among the 34 survivors, 50% were followed 5 years or longer.

Initial iliorenal graft patency was 93%. Three early vein graft occlusions required revision because of thromboses recognized in the first few postoperative days. Three late vein graft stenoses occurred at an average of 39 months postoperatively (range 20-48 months), and all were subjected to secondary revascularizations. Three late prosthetic graft stenoses were also recognized in follow-up. One ePTFE graft stenosis required revision at 36 months, and another went untreated when its occlusion was recognized at 84 months. The series' only Dacron graft functioned well until calcific plaque at both the proximal and distal anastomoses resulted in recurrent hypertension and a need for reoperation 25 years later. No nephrectomies were performed in this experience.

Renal Function 

The entire series' mean preoperative serum creatinine of 1.9 ± 0.16 mg/dL was similar to the postoperative value of 1.8 ± 0.15 mg/dL. Similarly, among the 20 patients who exhibited preoperative renal insufficiency, mean serum creatinine fell only slightly from 2.6 ± 0.17 to 2.3 ± 0.17 mg/dL postoperatively (P = 0.3). Nevertheless, eight of these 20 patients experienced an improvement in their renal function, seven exhibited no change, and five became worse. One additional patient having normal preoperative renal function experienced a significant decline in renal function postoperatively. Altered renal function did not affect the series' remaining 14 patients with normal preoperative renal function. One patient, on dialysis preoperatively, required early dialysis postoperatively. Two patients required later dialysis, one at 3.5 years and the other at 17 years postoperatively. Changes in renal function, when they did occur, were unrelated to the underlying renal artery disease, the type of initial reconstruction, or the need for a secondary revascularization.

Hypertension 

In general, the iliorenal reconstructions performed in this study provided a salutary effect on blood pressure control. However, only three patients were cured of their hypertension. Four additional patients had worsening of their hypertension postoperatively and were considered therapeutic failures. Excluding the series' one perioperative mortality, the remaining 27 patients were classified improved with regard to blood pressure control. The overall mean preoperative pressure of 180/97 mm Hg fell postoperatively to 140/78 mm Hg (P < 0.001). In addition, the median number of preoperative antihypertensive medications decreased postoperatively, from three (range 2-3, 25–75% confidence interval) to two (range 1-2, 25–27% confidence interval), P < 0.0001. The number of antihypertensive drugs used among the series' 34 survivors was decreased in 25, unchanged in six, and increased in three patients.

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Discussion 

Renovascular hypertension is the most common cause of surgically correctable high blood pressure. Certain renovascular hypertensives, because of previous abdominal aortic surgery, hostile retroperitoneums, or precarious cardiac function, cannot tolerate an open reconstruction; and advanced disease makes an occasional patient an undesirable or unacceptable candidate for an endoluminal intervention. It is under these circumstances that a nonanatomic reconstruction warrants consideration. It is noteworthy that among this series' patients treated before 1995 nearly a third may have been successfully treated by PTA with stenting. However, PTA was more selectively used then compared to contemporary practice. Patients with hypoplastic developmental renal artery stenoses were not then, nor would they now be, candidates for PTA.

The most commonly performed nonanatomic renal revascularizations have been those originating from the hepatic or splenic arteries, and both have distinct benefits to patients not amenable to other reconstructive efforts. The celiac artery must be disease-free in these circumstances, but in patients with advanced renal arteriosclerosis, more than half will have a stenosis of this artery exceeding 50%.⁷ The use of the celiac artery branches for a renal bypass in such a setting would be inappropriate. Angioplasty and stenting a stenotic celiac artery may allow some patients to become candidates for hepatorenal or splenorenal reconstructions, but it is generally acknowledged that celiac artery stenting is not as successful or durable as with other similar sized arteries. Compounding this concern is the fact that the splenic artery in the elderly tends to be markedly tortuous and involved with calcific atherosclerosis, causing it to be quite rigid and making its mobilization often difficult. Lastly, the use of the splenic artery or hepatic artery in the reconstruction of renal arteries in the pediatric age group is disfavored given the likelihood of later celiac artery narrowing due to progressive developmental disease. Given the aforementioned concerns, the use of the iliac artery as an alternative site to originate a nonanatomic renal artery bypass has been pursued in select patients.

The first description of an iliorenal bypass to treat renovascular hypertension emanated from a 1966 Baylor University report that included one patient with a unilateral graft and a second with bilateral iliorenal grafts.¹² The University of Michigan experience with iliorenal bypasses commenced with its first case being performed in 1975. A brief report in 1979 from Yale University included a description of successful ilio-birenal reconstructions.¹³

Four reports on iliorenal bypasses from the Cleveland Clinic in 1977, 1979, 1981, and 1995 further defined the usefulness of this alternative means of renal revascularization.⁷, ¹⁰, ¹⁴, ¹⁵ The first three of these publications included only one, two, and three cases, respectively; but the fourth report included 37 iliorenal bypasses, culled from a total of 175 nonanatomic renal revascularizations. A second early experience with alternative renal revascularization procedures was documented in a 1988 Lahey Clinic, Boston, report that included eight iliorenal bypasses in addition to 35 splenorenal and 20 hepatorenal reconstructions.¹⁶ These two former reports, from urologists at the Cleveland and Lahey Clinics, were mirrored by vascular surgeons at the Massachusetts General Hospital, who in 1994 reported seven iliorenal bypasses.⁵ These seven cases combined with 62 hepatorenal and 52 splenorenal reconstructions represented 37% of their renal revascularization procedures during that era. This latter experience was similar to a 1992 report from the Maine Medical Center and the State University of New York, Syracuse, that described 32 nonanatomic renal artery reconstructions, including 11 originating from the iliac arteries.¹⁷ The aforementioned reports included few specific details regarding the iliorenal bypasses themselves.

Two large series of iliorenal bypasses have been previously published with important clinical information. The first, from the Hospital Saint-Joseph in Paris, France, reported 29 reconstructions performed in lieu of conventional aortorenal revascularizations because of abdominal aortic disease (n = 19), contraindications for aortic cross-clamping (n = 7), or prior aortic surgery (n = 3).¹⁸ The authors favored a retroperitoneal approach and ePTFE (n = 24) over autogenous vein (n = 5) for the bypass conduits. They reported no operative mortality. Among their hypertensives, 7% were cured, 79% improved, and 14% were unchanged. Among 16 patients in their experience with renal failure preoperatively, 40% exhibited no change in renal function and 60% improved postoperatively, including two who were able to discontinue their preoperative dialysis. These results were similar to those of the current experience.

The second large series, from Washington University in St. Louis, included 48 patients undergoing 49 nonanatomic renal revascularizations, including 30 iliorenal bypasses.¹⁹ Other procedures in this series included gastroduodenorenal (n = 10), hepatorenal (n = 7), and splenorenal (n = 2) reconstructions. Autogenous saphenous vein (n = 28) was favored over ePTFE (n = 2) for construction of the iliorenal bypasses. There were no operative deaths. The authors also favored a retroperitoneal approach for these reconstructions.²⁰, ²¹ Although the outcomes regarding blood pressure were reported for all alternative reconstructions, not just the iliorenal cases, their overall experience revealed that 12% were cured, 73% improved, and 15% were unchanged. Renal function was improved in six, unchanged in 40, and worse in two patients.

The long-term follow-up of patients subjected to iliorenal bypass described in the University of Michigan experience documents the need for continued assessments of the reconstruction over many years. Nearly 6% of patients required an early intervention for acute graft failures. This complication, although more common in the earlier years of the authors' experience, may also frequent contemporary practice. The longer follow-up of the currently reported series exceeds that of earlier reports and revealed an unanticipated need to intervene after many years of successful graft function in an additional 18% of patients. The salutary effect of secondary procedures in the current experience was notable, but the potential technical difficulties encountered with reoperations should not be discounted.

The relatively long length of follow-up of many patients in the current series negates certain limitations inherent to all retrospective clinical reviews. The late bypass failures requiring reinterventions are hard end points, previously not ascribed to this type of alternative renal revascularization. On the other hand, the number of medications used to control high blood pressures is at best a soft end point. The introduction of more effective antihypertensive drugs during the time of this review suggests that, in some instances, a reduction in medication numbers reflects not a beneficial outcome of surgery but simply a newer, more effective agent replacing multiple less effective agents. Lastly, the heterogenic character of this series' patients, by age and type of renal artery disease, must be carefully considered before applying any general conclusions of this experience to other patient groups.

Iliorenal bypass is an uncommonly utilized means of renal revascularization that provides reasonable outcomes regarding preexistent hypertension and renal insufficiency in carefully selected patients with renal artery occlusive disease. Although the patients in this group may be considered to be at higher risk than those undergoing conventional anatomic renal revascularizations, the initial success of iliorenal bypasses should exceed 90%. When secondary procedures are needed, be they open operative or endoluminal catheter-based interventions, they should afford significant benefit to these patients, who have no other treatment options. Iliorenal reconstructions may be perceived as technically less demanding than other nonanatomic reconstructions, but the current experience suggests that such is not the case. Long-term follow-up of graft function is also underscored in the current series, by the relatively high need for late secondary procedures. Nevertheless, iliorenal bypass is an appropriate alternative and effective means of renal revascularization in patients with renovascular hypertension whose renal artery disease is not amenable to conventional open surgical or endoluminal interventions.

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