Journal of Renovascular Disease

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DOI: 10.1102/1473-1827.2003.0014

Tony Nicholson
Vascular Radiology Department,
Hull & East Yorkshire Hospitals Trust, Anlaby Road, Kingston upon Hull HU2 3J, UK E-mail: tonynick@tonynick.demon.co.uk

Here we have a patient with a significant-sized abdominal aortic aneurysm (AAA) that is large enough to require repair [1]. However, it is complicated by bilateral significant renal artery stenosis (RAS) with normal serum creatinine and no significant blood pressure problems. I presume the kidneys are of normal caliber.

Should the RAS be repaired?

There are two scenario’s here:

1. If she undergoes endovascular repair with either a device fixed in the infra or supra-renal position, then there is no indication for preprocedural renal artery stenting. If the patient’s creatinine had been abnormal and rising, then pre graft stenting would have been indicated and technically not a problem. However, there are several studies that suggest that this is unnecessary where renal function is normal[2]. If the patient’s renal function began to deteriorate post stent graft, then it would still not be technically difficult to cross and stent the RAS bilaterally even with supra-renal fixation.
2. The patient might undergo open repair. The rationale behind stenting or open renal artery reconstruction in this scenario is that hypotension might produce renal artery occlusion. This is the same argument used for asymptomatic carotid artery stenosis repair during coronary artery bypass graft (CABG). However, 3.8% of patients with a unilateral asymptomatic stenosis of >50% will suffer hemispheric stroke after CABG[3]. With bilateral critical stenoses the hemispheric stroke rate is 8.3%[3]. The rate of death and ipsilateral stroke for combined carotid endarterectomy (CEA) and CABG in a meta-analysis of 8979 patients was 3.8-7.4%[4]. There is no randomised evidence and this analysis suggests that there is no indication for CEA prior to, after or synchronous with CABG in asymptomatic patients. Similarly, there is no evidence for pre procedural renal artery repair prior to AAA repair in this case. If renal artery reconstruction is required during surgery because of recognised damage to the renal artery, this is said to have no adverse impact on outcome[5]. If renal function does deteriorate post open repair then an endovascular approach to the renal arteries will still be possible.

Conclusion

The available evidence suggests that the AAA should be repaired. The patient should be randomized within the endovascular aortic aneurysm repair (EVAR) trial [6]. The renal artery stenoses do not require preoperative intervention.Renal function should be carefully monitored post procedure and if renal failure is detected, endovascular intervention is indicated as urgent.

References

1. UK Small Aneurysm Trial Participants. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms.. Lancet 1998; 352: 1649-55.

2. Marin, ML et al. Impact of transrenal aortic endograft placement on endovascular graft repair of AAA. . J Vasc Surg 1998; 28:638-46.

3. Schwartz, LB, Bridgman, AH, Kieffer, RW et al. Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass. J Vasc Surg 1995; 21: 146-53.

4. Naylor, R.Which patients undergoing CABG require carotid intervention?. Birmingham Masterclass 2003 (Abstract).

5. Hassen-Khodja, R, Sala, F, Declemy, S et al.Renal artery revascularization in combination with infrarenal aortic reconstruction.. Ann Vasc Surg 2000; 14: 577-82.

6. Powell, JT, Greenhalgh, RM. Clinical practice. Small abdominal aortic aneurysms.. N Eng J Med 2003; 348: 1895-901.

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