Patient
with renovascular hypertension refractory to clinical treatment with
hypertensive crisis and acute pulmonary edema
(Portuguese
PDF version)
Coordinated
by Dr. Fausto Miranda Jr
Telmo
P. Bonamigo*
*
Head, Service of Vascular Surgery, Irmandade da Santa Casa de Porto
Alegre; Associate Professor, Fundação Faculdade Federal
de Ciências Médicas de Porto Alegre.
J
Vasc Br 2003;2(1):85-87
Part
II - What actually happened
At the
time this patient was treated (1994) there was some reasonable experience
in endovascular procedures in our setting. However, as we considered
that only a surgical technique that guaranteed higher success in restoring
renal perfusion in the medium and long run would be recommended, we
carried out the procedure, as described below, after discussing the
initially suggested alternatives.
In this case, surgical results are related to the surgeon's experience
in conducting the procedure.
 Figure
1
The proposed techniques would have the following limitations:
1
- Neither the isolated endarterectomy of the renal artery, nor endarterectomy
of the aorta associated with endarterectomy of the renal artery would
be appropriate, since it would be difficult to implant the infrarenal
plate, due to the dimension of the disease.
2 - Aortofemoral bypass with aortorenal bypass would be highly risky,
considering the patient's clinical status.
3 - Splenorenal bypass could be considered if we were totally sure that
the celiac trunk is normal and that the splenic artery is adequate,
which was not the case.
We carried out the procedure that seemed to be most appropriate, with
shorter aortic clamping time in an area with a more favorable aortic
wall. We opted for implantation proximally to the graft, straight, measuring
8 mm, on the anterior face of the thoracic aorta, isolated by way of
aortic hiatus of the diaphragm. The aortic clamping time was 14 minutes.
Distal anastomosis was performed by passing the graft through the retrogastric
and retropancreatic route, at the upper face of the left renal artery,
before which the kidney received ice-cold saline solution. Immediate
postsurgical outcome was excellent with regard to intraabdominal operation,
but on the fourth day, the patient showed remarkable ischemia of the
left lower limb, with absence of femoral pulse. In view of the clinical
diagnosis of ileofemoral thrombosis, we opted for left axillofemoral
grafting, after common and profound left femoral thrombectomy. The patient
was discharged 14 days after surgery, with a good clinical follow-up
since then.
POSTOPERATIVE EVOLUTION
The
patient has led a normal life. Serum creatinine is elevated, ranging
from 2.2 to 3.8 mg/dl (see figure).
Figure
2
Currently,
the patient is being treated with Renitec 20 mg/day, atensine 0.325
mg/day and AAS 200mg/day, with satisfactory control of arterial pressure,
as demonstrated by the Arterial Blood Pressure Monitoring (see below).
Table
1 - Arterial Blood Pressure Monitoring
 |
| Date |
Wakefulness
|
Sleep
|
Average
(24h)
|
|
| March
13, 2002 |
107
(syst)
|
118
(syst)
|
112
(syst)
|
|
61
(diast)
|
62
(diast)
|
61
(diast)
|
| September
24, 2002 |
152
(syst)
|
148
(syst)
|
151
(syst)
|
|
73
(diast)
|
58
(diast)
|
69
(diast)
|
|
In 2002,
the patient was submitted to gadolinium-enhanced magnetic resonance
angiography (Fig 2) in order to check the condition of the graft at
its distal portion. The exam revealed permeability of the thoracoaortic
graft of the left kidney, with a apparently low level of stenosis at
the distal portion. The left axillofemoral graft was permeable at the
chest and abdominal wall. Since renal function deteriorated in the last
three months, a new challenge was about to be posed.
Figure
3
This clinical case was a great challenge as the patient presented with
hypertensive cardiopathy of renovascular etiology and refractory to
conventional treatment of patients with one single kidney.
At first, the patient was considered unfit for surgery by the clinician,
who overestimated the surgical risk and underestimated the possibility
of vascular recovery of the kidney. The patient survived for eight years
due to the surgery and had a good quality of life.
This
shows the importance of broadly discussing each clinical case, especially
unusual ones, with other specialists, since a wrong decision may determine
a bad prognosis for the patient.
SUGGESTED
REFERENCES
1 - Renal revascularization in patients with single functioning ischemic
kidney
McCready RA, Daugherty ME, Nighbert EJ, Hyde GL, Freedman AM, Ernest
CB:
J Vasc Surg 1987:6:185-90
2 - Renal revascularization for recurrent pulmonary edema in patients
with poorly controlled hypertension and renal insufficiency: a distinct
subgroup of patients with arteriosclerotic renal artery occlusive disease.
Mesina LM, Zelenock GB, Yao KA, Stanley JC:
J Vasc Surg 1992,15:73-82
Note:
Letters to the editor with comments on the therapeutic conduct are welcome.
|
