Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 88 • Renal Revascularization 951

◆ If bilateral renal revascularization is required, a 14 ⫻ 7 or 12 ⫻ 6 Dacron or PTFE bifur-

cated graft is used (Figure 88-3). Saphenous vein or hypogastric artery can be used as

alternative conduits, especially in young adults and children with branch vessel disease. If

the infrarenal aorta is severely diseased, the inﬂ ow of the bypass can originate from the

supraceliac aorta or common iliac arteries.

◆ After the renal anastomosis is completed, heparin is reversed with protamine sulfate

(1 mg/100 U heparin), and 40 mg furosemide is administered.

3. CLOSING

◆ The retroperitoneum is closed with 2-0 Vicryl, and the incision is closed with running

looped monoﬁ lament 1-0 polydioxanone (PDS) or polypropylene suture.

◆ Dressings

◆ Cover the wound with saline-soaked gauze and a nonconstricting bandage.

Right renal artery

Right renal vein

Inferior

vena cava

Bifurcated

prosthetic graft

Left renal vein

Abdominal aorta

Left renal artery

Inferior

mesenteric artery

FIGURE 88 –3

952 Section XII • Vascular

STEP 3: OPERATIVE STEPS—AORTORENAL ENDARTERECTOMY

Endarterectomy is used in selected patients with bilateral focal oriﬁ cial atherosclerotic RAS.

1. INCISION

◆ The aorta is approached through a midline or transverse incision.

2. DISSECTION

◆ The aorta is mobilized from the level of the celiac artery to the inferior mesentery artery.

This requires division of the diaphragmatic crural ﬁ bers, and the dense neural tissue that

surrounds the origins of the celiac and superior mesenteric and renal arteries.

◆ This dissection should isolate a sufﬁ cient segment of aorta to allow safe placement of the

proximal clamp above the renal or superior mesenteric arteries, if these vessels are so close

that a clamp cannot be safely placed between them. The lumbar arteries are occluded with

removable clips and clamps applied in sequence to the renal arteries, the superior mesen-

teric artery, and the infrarenal and suprarenal aorta.

◆ A longitudinal arteriotomy is made extending from the left side of the superior mesentery

oriﬁ ce to below the renal arteries (Figure 88-4, A). The technique involves removal of the

aortic intima in this section of the aorta. Once the aortic intima has been dissected proxi-

mally, each individual renal artery is approached. The aortic intima is grasped and gentle

traction is applied, pulling to the opposite side. The renal ostial lesion is then dissected

from the media by prolapsing the renal artery into the aorta (Figure 88-4, B).

◆ Gentle advancement of the renal artery toward its oriﬁ ce by the assistant facilitates feather-

ing of the end point. The process is repeated on the contralateral side.

◆ The distal intima of the aorta is divided and secured with interrupted 6-0 polypropylene

tacking sutures (Figure 88-4, C). The arteries are ﬂ ushed of atheromatous debris and air,

and the arteriotomy is closed with running 4-0 polypropylene suture (Figure 88-4, D). The

adequacy of the renal endarterectomy is evaluated by intraoperative duplex ultrasound. If

any residual plaque is detected, a transverse arteriotomy is made in the affected renal artery,

the plaque is extracted, and the distal end point is secured with tacking sutures. The arterio-

tomy is closed with interrupted 7-0 polypropylene sutures.

CHAPTER 88 • Renal Revascularization 953

Abdominal

aorta

Right

renal artery

Left

renal vein

Left

renal artery

Inferior

vena cava

Right

renal artery

Left

renal vein

Aortorenal plaque

Inferior

vena cava

Abdominal aorta;

Secured distal

end point

Right

renal artery

Left

renal vein

Left

renal artery

Inferior

vena cava

Completed

arteriotomy closure

FIGURE 88 –4

954 Section XII • Vascular

3. CLOSING

◆ The closure of the abdomen is similar for both aortorenal bypass and renal endarterectomy.

The retroperitoneum is closed with 2-0 Vicryl, and the incision is closed with running

looped monoﬁ lament 1-0 PDS or polypropylene suture.

STEP 3: OPERATIVE STEPS—SPLENORENAL BYPASS

◆ Both aortorenal bypass and renal endarterectomy may be contraindicated in elderly patients

with severe aortoiliac occlusive or aneurysmal disease and multiple comorbidities. The pres-

ence of a dense ﬁ brotic reaction from previous operations or renal angioplasty makes dis-

section difﬁ cult and increases the operative risk. The addition of an aortic bypass to renal

revascularization, which may be indicated in younger patients, is associated with increased

morbidity and mortality in older individuals. In these patients, alternative bypass proce-

dures, such as splenorenal bypass for high-grade left RAS and hepatorenal bypass for dis-

ease on the right, should be considered. The more ischemic kidney is repaired ﬁ rst unless it

is atretic.

◆ Careful angiographic assessment of the hepatic and splenic arteries with anterior posterior

and lateral views is imperative before undertaking these alternative renal revascularization

procedures, because extensive plaque may be present in the donor vessels, which may not

be detected on standard anterior posterior angiographic views.

◆ For both splenorenal and hepatorenal bypass, the patient is positioned supine on the oper-

ating table with a sandbag elevating the affected side and prepped from nipple to knee.

1. INCISION

◆ The abdomen is entered via a left subcostal incision that can be extended medially and

laterally if necessary. The splenocolic ligament, spleen, and pancreas are reﬂ ected medially,

and a self-retaining retractor is placed (Figure 88-5, A-B).

CHAPTER 88 • Renal Revascularization 955

Left subcostal

incision

Pancreas

Left kidney

Left renal vein

Spleen

Splenic vein

Splenic artery

Stomach

FIGURE 88 –5

956 Section XII • Vascular

2. DISSECTION

◆ The left renal vein is mobilized by dividing the lumbar and adrenal branches to expose the

renal artery. The pancreas is retracted cephalad to expose the splenic artery and vein. The

splenic arterial and venous branches to the pancreas are divided between 4-0 silk suture lig-

atures. A segment of splenic artery of sufﬁ cient length close to its origin (where its diameter

is largest) is mobilized (Figure 88-5, C-D).

3. CLOSING

◆ After IV heparin is administered, the splenic artery is occluded and divided between

clamps, and the distal end of the vessel is oversewn with 5-0 polypropylene suture. The

renal artery is then mobilized, the proximal end is oversewn with 5-0 polypropylene suture,

the vessels are spatulated, and an end-to-end anastomosis is constructed between the

splenic and renal arteries using running (posterior wall) and interrupted 6-0 polypropylene

suture (Figure 88-5, E-G). The patency of the anastomosis is evaluated with duplex

ultrasound.

Dividing inferior suprarenal

vein and artery

Ligation and division

of splenic artery

branches

FIGURE 88 –5, cont’d

CHAPTER 88 • Renal Revascularization 957

Retracting

left renal vein

caudally

Divided

splenic artery

Dividing left

renal artery

Distal left

renal artery

Splenic artery

Completed splenorenal

anastomosis

FIGURE 88 –5, cont’d

958 Section XII • Vascular

STEP 3: OPERATIVE STEPS—HEPATORENAL BYPASS

◆ In patients with severe aortic atherosclerosis or aneurysmal degenerative disease and normal

liver function with a high-grade right RAS, hepatorenal bypass should be considered.

1. INCISION

◆ The abdomen is entered via a right subcostal incision (Figure 88-6, A).

Right subcostal

incision

FIGURE 88 –6

CHAPTER 88 • Renal Revascularization 959

2. DISSECTION

◆ The hepatic ﬂ exure is mobilized, a Kocher maneuver is performed to mobilize the duode-

num medially, and the Omni-Tract retractor is placed (Figure 88-6, B).

◆ The hepatic artery is exposed between the portal vein and common bile duct

(Figure 88-6, C).

Lesser omentum

Stomach

Incision of peritoneum

and hepatoduodenal

ligament

Retracting

duodenum

Hepatic artery

Portal vein

Right renal vein

Right kidney

Common bile duct

FIGURE 88 –6, cont’d

960 Section XII • Vascular

◆ The right renal artery is exposed posterior to the vena cava by retracting the right renal vein

cephalad and the vena cava to the left (Figure 88-6, D).

◆ A 10-cm segment of saphenous vein is harvested and gently distended with a papaverine

solution (see Figure 88-2, B). After systemic heparinization and the administration of man-

nitol, the hepatic artery is occluded between clamps and the saphenous vein graft is anasto-

mosed end-to-side to the hepatic artery distal to the takeoff of the gastroduodenal artery

with running 6-0 polypropylene suture (Figure 88-6, E).

◆ The renal artery is similarly divided close to its origin from the aorta, and the proximal end

is suture ligated with 5-0 polypropylene suture. An end-to-end spatulated anastomosis

between the saphenous vein graft and the distal end of the renal artery is constructed with

interrupted 6-0 polypropylene suture (Figure 88-6, F-G). The patency of the anastomosis

is evaluated with duplex ultrasound.

◆ After the renal anastomosis is completed, heparin is reversed with protamine sulfate

(1 mg/100 U heparin), and 40 mg furosemide is administered intravenously.

Inferior vena cava

retracted medially

Hepatic arteriotomy

Right renal vein

retracted cephalad

Right renal artery

Right kidney

FIGURE 88 –6, cont’d