Case Report
Hepatorenal Bypass for Renal Salvage: A Forgotten Option in the Endovascular Era
Vascular and Endovascular Surgery 1-4 ª The Author(s) 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574418779468 journals.sagepub.com/home/ves
M. Ghali Salahia, MD, MBA1, Richard D. White, FRCR1, Andrew C. Gordon, FRCR1, and Ian M. Williams, MD, FRCS2
Abstract Introduction: In this era of rapidly expanding endovascular techniques, the use of hepatorenal bypass as treatment for a critically compromised renal perfusion has largely been forgotten. This article highlights the benefits of the technique both as a bailout strategy following complications from angioplasty and as a primary treatment in cases deemed unsuitable for endovascular intervention. Materials and Methods: Two patients are described whose renal viability was threatened by vascular compromise. One patient had a single functioning kidney with significant renal artery stenosis secondary to severe atherosclerotic disease and developed acute renal function deterioration following unsuccessful angioplasty. The second patient developed renal artery occlusion 3 years following open thoracoabdominal aortic aneurysm surgery. Both patients underwent successful hepatorenal bypass surgery and remain off dialysis 6 months after admission. Results: Both cases demonstrated the success of hepatorenal bypass with significant improvement in their renal function following open surgical repair. Conclusion: Hepatorenal bypass, although now seldom used because of available endovascular alternatives, remains an effective method of treating complicated cases of threatened kidney secondary to vascular insult. Keywords hepatorenal bypass, renal artery stenosis
Introduction Renal artery stenosis (RAS) is associated with chronic kidney disease, pulmonary edema, and hypertension. Available treatments include conservative medical treatment, endovascular intervention, and open surgical repair.1-4 Endovascular therapy for atherosclerotic RAS has recently fallen out of favor after a number of studies showed no long-term benefit, although it may be necessary in selected cases.5 Extra-anatomical renal artery bypass using the hepatic and splenic arteries is well recognized but is now rarely performed, having been superseded by newer endovascular techniques. This article describes the surgical technique and highlights its use where complications arising from, or failure of, endovascular procedures would have necessitated renal replacement therapy with loss of kidney.
Case 1 A 58-year-old lady who was admitted with renal failure secondary to bilateral RAS underwent computed tomography (CT) angiography as part of workup for renal artery angioplasty. On admission, her creatinine was 369 mg/dL and estimated glomerular filtration rate (eGFR) was 16 mL/min. Computed tomography angiography showed diffusely diseased renal arteries (Figure 1).
The patient had previously undergone a right axillobifemoral bypass for bilateral claudication. Digital subtraction angiography was performed via a right subclavian puncture and a pigtail catheter was positioned in the supraceliac aorta. This demonstrated extensive calcification of the abdominal aorta, celiac artery, and superior mesenteric artery (SMA), although no flow limiting disease was seen. Both renal arteries were significantly stenosed at origin. This was more evident on the right with evidence of origin stenosis (Figure 2). Angioplasty was attempted but failed as it proved impossible to cannulate the renal arteries. The patient developed worsening renal function postprocedure with eGFR dropping to 10 mL/min within 24 hours of the procedure despite optimization of renal function with intravenous fluids. A decision was made to perform bypass surgery and a vein graft was uneventfully
1 Department of Clinical Radiology, University Hospital of Wales, Cardiff, United Kingdom 2 Department of Vascular Surgery, University Hospital of Wales, Cardiff, United Kingdom
Corresponding Author: Ian M. Williams, Regional Vascular Unit, Ward B2, University Hospital of Wales, Heath Park, Cardiff, Wales CF14 4XW, United Kingdom. Email:
[email protected]
2
Vascular and Endovascular Surgery XX(X) from the celiac to the SMA territory. The use of the gastroduodenal artery as the inflow source may obviate the need for a vein bypass as sufficient length may enable a direct anastomosis to the right renal artery. There are series describing this technique in up to 50% of cases.6 The operation was uneventful and the patient’s creatinine had improved to 91 mg/dL and eGFR 55 mL/min at 6-month follow-up.
Case 2
Figure 1. Coronal oblique computed tomography (CT) angiogram Maximal Intensity Projection (MIP) reformat showing heavily calcified abdominal aorta and stenosed renal artery origins.
Figure 2. Digital subtraction angiogram image showing stenoses of the right and left renal arteries (arrowheads).
sutured end-to-side between the common hepatic and right renal artery. The origin of the bypass can be from the hepatic or gastroduodenal arteries and sufficiently contemporaneous crosssectional imaging is essential to exclude a latent stenosis at the origin of the celiac artery. Cross-clamping of the hepatic artery is well tolerated with minimal risk of hepatic necrosis. The gastroduodenal artery is often small in caliber and should not be used if there is any doubt about its ability to serve as a dependable inflow source or in the presence of significant SMA stenosis where it may contribute to the collateral circulation
A 65-year-old man with a history of open thoracoabdominal aortic aneurysm repair 3 years previously presented with acute kidney injury (creatinine: 687 mg/dL and eGFR: 7 mL/min). During the original surgery, both renal arteries had been perfused via a bypass arising from the main aortic graft posteriorly which bifurcated to supply both kidneys. Separate bypass grafts supplied SMA and celiac axis (Figure 3). Computed tomography at the time of the acute presentation showed the renal artery bypass to have occluded, with only a tiny posterior stump evident, although native renal arteries did show some filling (Figure 4). The aortic sac has reduced in size. Grafts to SMA remained patent. The left kidney exhibited loss of corticomedullary differentiation and was considered to be nonsalvageable. Given the potential complications following his previous thoracoabdominal aortic aneurysm repair, endovascular treatment was deemed nonfeasible. Following careful scrutiny of the CT scan with regard to the arterial supply of the liver and foregut via celiac axis and SMA, the patient underwent hepatorenal bypass with a vein graft. The long saphenous vein was harvested and reversed and an end-toside anastomosis with the common hepatic artery was performed. At the renal side, the origin of the right renal artery was ligated flush with the aortic wall and transposed laterally and anteriorly on top of the inferior vena cava where a spatulated end-to-end anastomosis was performed. There was residual right renal function via collateralization as excellent backflow of blood upon transection of the right renal artery was observed. At 2-month follow-up, the patient’s creatinine improved to 122 mg/dL and eGFR to 52 mL/min. The patient is due to be seen at 6-month follow-up. Both patients were taking aspirin prior to their operations and this was continued postoperatively. No additional anticoagulation was deemed necessary.
Discussion In both these cases, surgical revascularization of the right renal artery was performed as a salvage procedure. Without intervention, both patients would almost certainly have required dialysis and ultimately long-term renal replacement therapy. The surgical risks of the technique are few as hepatic artery clamping is well tolerated and the bypass to the right renal artery is short. It is also feasible to use the hepatic artery for revascularization of the left renal artery.7 Attention should be paid to the course of the hepatorenal bypass in relation to the porta hepatis,
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Figure 3. A and B, Axial Maximal Intensity Projection (MIP) computed tomography (CT) angiogram reformats, 3 years before acute presentation. The graft to the renal arteries (white arrows) arises posteriorly from the aorta, passes to the left, and bifurcates to supply left and right renal arteries. Grafts to the superior mesenteric artery (SMA; black arrows) and celiac axis (arrowhead) arise from the right side of the aorta.
Figure 4. A and B, Axial Maximal Intensity Projection (MIP) computed tomography (CT) angiogram reformats from acute presentation. The renal artery graft (white arrows) has occluded with only a tiny posterior stump evident, although native renal arteries do show some filling. The aortic sac has reduced in size. Grafts to the superior mesenteric artery (SMA; black arrows) and celiac axis (arrowhead) remain patent.
noting that placing the hepatic anastomosis on the most proximal segment of the common hepatic artery would allow a smooth course anterior to the porta hepatis. The indication for surgery in both cases was acute renal failure; one due to occlusion and the other a critical stenosis of the right renal artery origin. Both underwent open surgical intervention when endovascular techniques were deemed unsuitable or had proved unsuccessful, and in both cases, there was significant and sustained improvement in renal function. Prior to the widespread use of endovascular interventions, the indications for extra-anatomical renal artery bypass included diffuse atherosclerotic aortic disease, abdominal aortic aneurysms, and previous aortic surgery. The first report was
by Libertino in 1976 and there followed sporadic publications over the next few years.2,3 Nowadays, hepatorenal bypass can be a valuable option if debranching of the renal arteries is planned to improve sealing at a landing zone during an endovascular aortic repair (EVAR) or thoracic EVAR. The evidence supporting renal revascularization was evaluated in the Angioplasty and STent for Renal Artery Lesions (ASTRAL) trial in which 806 patients with renovascular disease were randomized to receive either renal artery angioplasty and best medical therapy or best medical therapy alone.5 The trial concluded that there were initial high risks with minimal long-term benefits from renal revascularization and high initial risks, although critics stated those enrolled in the trial did not
4 have pressure gradients measured across the renal arteries with the majority of the stenoses measuring less than 60%. The eligibility criteria for the trial were also questioned with certain patients who may benefit from angioplasty not being included. The ASTRAL trial has compared endovascular stenting versus medical treatment among patients with hypertension. Our patients’ most urgent clinical problem was their compromised renal function and threat of requiring long-term dialysis. More recently, The Society for Cardiovascular Angiography and Interventions produced a consensus statement supportive of renal artery stenting for global kidney ischemia associated with deteriorating function.7 Nevertheless, there do remain potential complications associated with angioplasty and stenting including a deterioration in renal function due to embolization or vascular trauma, and for this reason, some suggest stricter patient selection might be used to reduce complications.8,9 There has been no comparative study to examine the outcomes of endovascular treatment of RAS versus hepatorenal bypass surgery as a treatment of hypertension and renal failure. Hepatorenal bypass remains an important procedure to consider when endovascular procedures may not be the best option or fail. For specific indications such as imminent occlusion of the right renal artery and consequent kidney injury, bypass remains an excellent option and should not be overlooked. Although not a new procedure, it may have been superseded recently by endovascular options. However, it remains a durable method of right renal revascularization when the alternative could be permanent dialysis. Urgent hepatorenal bypass should be considered when acute renal failure occurs following endovascular intervention. Authors’ Note Informed consent has been obtained from the patients for publication of the case report and accompanying images.
Vascular and Endovascular Surgery XX(X) Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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