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Arterial renovascular disease: follow-up of the patients presented as therapeutic challenge in Jornal Vascular Brasileiro 2003;2:35-6,85-7 and 2004;3:288-9,293-4
(Portuguese PDF version)

Telmo Bonamigo,¹ João Carlos Goldani,² Eduardo Lichtenfels³

1 Professor, Vascular Surgery, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil. Head of the Vascular Surgery Service, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
2 Professor, Nephrology, FFFCMPA, Porto Alegre, RS, Brazil. Head of the Nephrology Service, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
3 Resident in Vascular Surgery, Angiology and Vascular Surgery Service, Irmandade Santa Casa de Misericórdia de Porto Alegre, FFFCMPA, Porto Alegre, RS, Brazil.

Correspondence:
Telmo P. Bonamigo
Rua Cel. Bordini, 675/303
CEP 90440-001 - Porto Alegre, RS - Brazil
Tel./Fax: +55 (51) 3333.1642
E-mail: telmobonamigo@terra.com.br

J Vasc Bras. 2006;5(2):160-2

Article submitted March 7, 2006, accepted May 3, 2006.

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CLINICAL CASES

Clinical case 1

Patient with renovascular hypertension refractory to clinical treatment with hypertensive crisis and acute pulmonary edema

A 65-year-old female patient was admitted to the ICU with hypertensive crisis complicated by acute pulmonary edema on June 1994. The patient received clinical treatment and presented worsening of renal function; right renal artery thrombosis and critical stenosis of the left renal artery were diagnosed. At that time, the author suggested left renal revascularization to treat the renovascular hypertension, which was already decompensated. The patient was discharged by the assistant physician, and was deemed to be at prohibitive risk for surgery by the physician. The patient returned 1 month later presenting the same clinical status; she was hospitalized to undergo surgical treatment. A thoracic aorta to left renal artery bypass through the diaphragmatic hiatus was performed, with Dacron graft, on August 1994.

Evolution

The patient progressed with creatinine ranging from 2.2 to 3.8 in the postoperative period and satisfactory control of blood pressure. The patient recovered uneventfully, with blood pressure controlled for a 10-year period (1994-2004). In the past year, she started presenting progressive loss of renal function. She started a hemodialysis program on November 2005, which she is currently undergoing.

Clinical case 2

Patient with renovascular hypertension who progressed with anuria

A 68-year-old female patient was hospitalized presenting acute pulmonary edema and hypertensive crisis on May 2004. Left renal artery thrombosis and critical stenosis of the right renal artery were diagnosed. Endovascular treatment was discarded by the radiologist at that time. The vascular surgeon was not consulted. She was discharge with diagnosis of compensated renal failure and indication to undergo dialysis. She returned 20 days later with a new crisis of acute pulmonary edema associated with anuria. Right renal artery thrombosis was diagnosed, and right renal artery endarterectomy with reimplantation into the aorta was suggested and performed. Immediate postoperative recovery was excellent.

Evolution

The patient remained 14 months without hemodialysis program, with clinical treatment for renal failure, stable creatinine values (4.3), controlled and asymptomatic blood pressure. On December 2005, the patient returned to the emergency center with worsening of renal function, hypertension, oliguria, and right lumbar pain. Chronic renal failure associated with right renal artery thrombosis was diagnosed and hemodialysis was started. The patient is currently undergoing a hemodialysis program and is clinically controlled.

COMMENTS

Both cases are examples of how surgical interventions using proper technique may mitigate renovascular hypertension, remove risk of acute pulmonary edema, avoid imminent death, and delay the hemodialysis program. Another important aspect is the improvement in the quality of life of these people and savings in treatment costs with multiple antihypertensive drugs. The procedures had variable durability, which was compatible with the diagnostic difficulty. It should be stressed that surgery was only accepted late by the physicians, who over-evaluated the risk of a surgical procedure and minimized the risk of the disease's natural history, with no renal revascularization.

The valuable lesson learned from the cases reported herein is the removal of patients from the risk of imminent death. Furthermore, the patients were benefited by a long period of low-dosage antihypertensive treatment, less number of drugs, and absence of clinical complications. Remaining out of the hemodialysis program promoted an increase in the self-esteem and family relationship, which should be mentioned as great benefits at short, medium and long term.

The personal and social gain of these cases may be measured by several forms: by the patients' report, by the economic costs that would be generated by hemodialysis, besides the time spent for the treatment (Tables 1 and 2), as well as its complications with worsening of quality of life.

Table 1 - Demonstration of time saved and hemodialysis sessions avoided by the surgical procedure and its cost

Patient	Time with no hemodialysis	Hemodialysis sessions needed without surgery*	Hemodialysis sessions performed with successful surgery	Cost of surgical treatment (SIH/SUS) (R$)
Patient 1	136 months	1,632 sessions	No sessions	997.86 + 929.01†
Patient 2	14 months	168 sessions	4 sessions	997.86

SIH/SUS = National Hospital Database of the Brazilian Unified Health System.
* Average of three weekly sessions (adapted from Vieira & Luconi1).
† Renal revascularization and axillofemoral procedures.

 

Table 2 - Costs of hemodialysis

Patient	Number of hemodialysis sessions needed (average)	Cost of hemodialysis* (R$)
Patient 1	Monthly: 12.6	Monthly: 1,357.52
	Annual: 152	Annual: 16,376.48
	Total: 1,722	Total: 185,528.28
Patient 2	Monthly: 12.6	Monthly: 1,357.52
	Annual: 152	Annual: 16,376.48
	Total: 177	Total: 19,069.98
Total	1,899	204,598.26

* Cost of one session.

Both patients had reduction in the dosage of the antihypertensive drugs used to control blood pressure, as well as in drug change. With regard to the first clinical case, the patient was taking hydralazine 100 mg 6/6 h and clonidine 0.150 mg 6/6 h; after the surgery, she started taking enalapril 20 mg/day and clonidine 0.325 mg/day. Regarding the second clinical case, the patient was taking atenolol 200 mg/day, hydralazine 100 mg/day, and methyldopa 1.5 g/day; after the renal revascularization procedure, she started taking atenolol 100 mg/day, furosemide 80 mg/day, and nifedipine 60 mg/day.

Table 1 provides a demonstration, according to each patient, of the period of time without hemodialysis, number of sessions avoided due to surgical success and cost of the surgical treatment performed. The data are estimated based on patients with chronic renal failure and standard dialytic treatment. It is important to note that survival of patients with chronic renal insufficiency may not be long (survival of 40% in 5 years), such as patient 1. This fact was used to demonstrate the cost of a prolonged dialytic treatment. Another important observation is that the values given for surgical procedures are the values of the standard table of procedures for hospitalized patients provided by the National Hospital Database of the Brazilian Unified Health System (SIH/SUS).

Table 2 shows the approximate costs concerning the dialytic treatment that would be spent in case the patients had not been successfully operated. The cost of a hemodialysis session is in accordance with the SUS table, i.e., it is equal to R$ 107.74 (Brazilian Ministry of Health, SUS, 2004). It is important to note that the period of time calculated for patient 1 may not be representative of the mean survival time of patients with chronic renal failure. We also stress that the following costs are not included: drugs (erythropoietin, for example), complications of the dialytic treatment, hospitalizations, arteriovenous fistulas, catheter placement for hemodialysis, transportation costs, and personal expenses.

In conclusion, it would be interesting to cite the observation made by radiology professors David Trost and Thomas Sos, from Cornell University Medical Center (Cardiovascular and Interventionist Radiology, New York Hospital): "We believe that any patient should be treated with hemodialysis unless a reversible cause has been discarded, repaired or eliminated."

We acknowledge the editor for publishing this letter, since we believe the improvement in standard patient care can only be achieved by knowing and publishing medium- and long-term results.

REFERENCES

1. Vieira JA, Luconi P. Terapia renal substitutiva: estudo do financiamento da diálise no Brasil. Brasília: Associação Brasileira dos Centros de Diálise e Transplante (ABCDT); 2004.

RECOMMENDED BIBLIOGRAFHY

1. McCready RA, Daugherty ME, Nighbert EJ, Hyde GL, Freedman AM, Ernsr CB. Renal revascularization in patients with single functioning ischemic kidney. J Vasc Surg. 1987;6:185-90.

2. Messina LM, Zelenock GB, Yao KA, Stanley JC. 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. J Vasc Surg. 1992;15:73-80; discussion 80-2.

3. Sos TA, Trost DW. Renal vascular disease as a cause of hypertension. Curr Opin Nephrol Hypertens. 1995;4:76-81.