Eur J Cardiothorac Surg 2003;24:1046-1049
© 2003 Elsevier Science NL
Superior mesenteric artery stenting to augment splenorenal arterial bypass for intractable complex renovascular hypertension
Madathipat Unnikrishnan*,
Sathyaki Purushotham,
Arun Kumar Gupta
Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India
Received 31 December 2002;
received in revised form 6 September 2003;
accepted 10 September 2003.
* Corresponding author. Tel.: +91-471-2443152; fax: +91-471-2444633
e-mail: unni{at}sctimst.ker.nic.in
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Abstract
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An alternative source of visceral arterial inflow is sometimes necessary for renal revascularization when aortorenal endarterectomy or bypass is inappropriate due to severely diseased aorta. We report the case of a 46-year-old male with recurrent intractable renovascular hypertension in renal failure secondary to occlusion of the celiac axis due to progression of aortoarteritis following splenorenal arterial bypass performed 5 years before. Aortogram visualized intestinal arterial arcade supporting patent bypass with critically stenosed superior mesenteric artery. Successful angioplasty with stenting of superior mesenteric artery restored adequate renal flow through the bypass leading to recovery and easy control of hypertension.
Key Words: Aortoarteritis • Renal failure • Renovascular hypertension • Splenorenal arterial bypass • Superior mesenteric artery stenting
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1. Introduction
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Renovascular hypertension accounts for fewer than 3% of hypertension cases in the general hypertension population. It constitutes a distinct entity and after coarctation of aorta forms the second commonest cause for surgically correctable hypertension. Percutaneous angioplasty provides good results, particularly in the setting of aortoarteritis. However, ostial disease and extensive arterial involvement preclude angioplasty and form standard indications for surgery. In a small subset of critically ill patients with totally occluded suprarenal aorta, visceral artery inflow provides a reliable source for renal revascularization.
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2. Case report
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In 1996 a 46-year-old male was referred to us with intractable hypertension in renal failure and episodes of flash pulmonary edema. Clinical examination noted feeble lower limb pulses with right upper limb blood pressure recordings of 240/120 mmHg despite being on six antihypertensive drugs. Cardiac evaluation was unremarkable except for left ventricular hypertrophy. Serum creatinine was elevated to 3.2 mg%. He was clinically diagnosed to have aortoarteritis with involvement of the renal vessels. Abdominal ultrasonography showed shrunken right kidney and smaller than normal (8 cm) sized left kidney with intact corticomedullary differentiation. Duplex scan revealed suprarenal aortic occlusion with no demonstrable renal flow and reformation at the level of femoral vessels. Angiography confirmed complete aortic occlusion below the level of SMA, totally non-visualized right renal artery with prominent celiac axis and delayed reformation of distal left renal artery. He underwent splenorenal arterial bypass with spleen in situ with complete recovery of his renal function. He was discharged with well controlled pressures on two antihypertensive drugs and was subsequently lost for follow up for 5 years. In 2002 he was referred to us once again following admission in a nearby hospital with dyspnea and severe uncontrolled hypertension upon discontinuation of all medications and continued use of tobacco and abuse of alcohol. Duplex scan documented sluggish flow across patent splenorenal anastomosis. A trans axillary DSA showed totally occluded celiac axis with 80% stenosis of superior mesenteric artery (SMA) (Fig. 2a). The splenorenal anastomosis was seen filling from SMA branches, the inferior and superior pancreatico-duodenal, gastroduodenal and hepatic vessels into the splenic artery (Fig. 1)
. The left renal parenchymogram was normal. The significant SMA stenosis was dilated with 4 mmx2 cm balloon followed by deployment of a 6-mmx2-cm Bridge stent. The post stent angiogram showed adequately filling SMA (Fig. 2
b). Follow-up Doppler study showed stent in situ with good flow in SMA and normal wave pattern in arcuate arteries of left kidney. Following the procedure creatinine levels returned to normal (1.4 mg/dl) and control of hypertension was achieved with two antihypertensives compared to the six drug regimen required earlier. On follow-up (August 2003), he is a professional driver, with blood pressure recorded 140/90 mmHg on three drugs and preserved renal function.
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Fig. 2. (a) Digital subtraction aortogram showing suprarenal aortic occlusion, occluded celiac axis and 80% stenosis of superior mesenteric artery. (b) Deployed stent in superior mesenteric artery.
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Fig. 1. Aortogram visualizing patent splenorenal arterial bypass filling from superior mesenteric artery through pancreaticoduodenal arcade–gastroduodenal, hepatic, splenic arteries.
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3. Discussion
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The most well known entity in the subgroup of aortoarteritis is Takayasu's disease believed to be post inflammatory sequelae involving all the layers of aorta and major arteries as well as perivascular tissues. Thoracoabdominal aortic involvement presenting with atypical coarctation, renovascular hypertension, and mesenteric ischemia was first reported by Kimoto in 1979 [1]. The disease is more common to the Orient and India with the diffuse form particularly prevalent in Indian patients. It presents at a young age and progresses insidiously with episodes of constitutional symptoms. These systemic manifestations may go unnoticed and only years later, when clinical evidence of occlusive or aneurysmal disease becomes apparent, is the diagnosis made. The clinical features are determined by location and extent of arterial disease process. Renovascular hypertension seen in significant number of these patients is refractory to medical therapy and is an independent predictor of poor long term survival and premature death [2]. Sharma et al. reported excellent results with endovascular techniques in appropriate cases [3]. However, with tight ostial or long segment disease surgical revascularization remains the only option, in the form of aortorenal bypass, renal thromboendarterectomy, renal artery reimplantation and auto transplantation. Alternatively extra-anatomic bypass – splenorenal on the left and hepatorenal on the right – is a distinct option in a subset of patients with severely diseased aorta [4].
Combined surgical reconstruction for high aortic occlusion with bilateral renal artery disease is fraught with prohibitive risk in the setting of uncontrolled hypertension, azotemia and flash pulmonary edema. Ever since the first reported splenorenal arterial anastomosis for renal preservation by Thompson and Smithwick in 1952 [6], several workers have established its efficacy for renal revascularization associated with severely diseased aorta [4,5]. Insidiously progressing fibrotic process of aortoarteritis is known to result in occlusion of origin of celiac axis, as in our case, contrary to its extreme rarity in atherosclerosis [2].
The angiogram is noteworthy in that the entire intestinal arterial arcade including inferior and superior pancreaticoduodenal, gastroduodenal, hepatic, splenic and splenorenal anastomosis are visualized. To the best of our knowledge this is the first ever case where angioplasty with stenting of SMA has been documented to restore blood flow to splenorenal arterial bypass thereby supporting the entire mesenteric and renal circulations.
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Acknowledgments
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The authors place on record their profound gratitude to Prof K. Mohandas, Director of the Institute, Prof K.S. Neelakandan, Head Department of CVTS and to Professor Ramdas Pisharody (1996) and Professor A Vimala (2002) Nephrologists, Medical College Trivandrum, for rendering unconditional Nephrology back up throughout the management of this critically ill patient.
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References
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- Kimoto S. The history and present status of aortic surgery in Japan particularly for aortitis syndrome. J Cardiovasc Surg 1979;20:107-126.[Medline]
- Subramanyan R., Joy J., Balakrishnan K.G. Natural history of aortoarteritis (Takayasu's disease). Circulation 1989;80:429-437.[Abstract/Free Full Text]
- Sharma B.K., Jain S., Bali H.K., Jain A. Kumari S. A follow-up study of balloon angioplasty and de-novo stenting in Takayasu arteritis. Int J Cardiol 2000;31(75 Suppl 1):S147-S152.
- Khauli R.B., Novick A.C., Ziegelbaum M. Splenorenal bypass in the treatment of renal artery stenosis: experience with sixty-nine cases. J Vasc Surg 1985;2(4):547-551.[CrossRef][Medline]
- Moncure A.C., Brewster D.C., Darling R.C., Atnip R.G., Newton W.D., Abbott W.M. Use of the splenic and hepatic arteries for renal revascularization. J Vasc Surg 1986;3(2):196-203.[CrossRef][Medline]
- Thompson J.E., Smithwick R.H. Human hypertension due to unilateral renal disease with special reference to renal artery lesion. Angiology 1952;3:493-505.
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Abstract
1. Introduction
