Splenorenal Arterial Anastomosis for Renovascular Hypertension DAVID C. BREWSTER, M.D., R. CLEMENT DARLING, M.D.

In properly selected patients, the benefits of renal artery reconstruction for renovascular hypertension have been clearly established. Disagreement remains, however, regarding the optimal technique. For most types of left-sided lesions, a splenorenal arterial anastomosis offers decided advantages. Only a single suture line is required and autogenous arterial tissue is employed. Difficulties with a diseased aorta are avoided. The procedure is particularly suitable for a staged approach to bilateral disease or in reoperation for failed prior reconstructions. Our experience with this procedure in 19 patients is reviewed and indications for selection of a splenorenal anastomosis are discussed. There were no deaths, and a single failure due to graft occlusion (5%). Of the remaining 18 patients, 7 are cured and 11 are improved. There were no instances of postoperative renal failure, and renal function improved in all four patients with preoperative renal failure. We conclude that in properly selected patients this procedure is of great usefulness and deserves wider application.

of cure of hypertension by correction of renal artery occlusive disease over two decades ago, surgical management of renovascular hypertension has been applied with increasing frequency and success. Experience over this period has led to emphasis on preservation of renal tissue, with nephrectomy considered only as a last resort for a nonsalvageable kidney or a nonreconstructible situation. In properly selected patients, successful revascularization of an ischemic kidney currently may be expected to achieve cure or improvement of hypertension in approximately 90% of patients.9 Once a surgical candidate has been identified by both angiography and selective renal vein renin determinations, one of many available surgical procedures must be chosen. The variety of methods is due in large part to wide differences in the type, S INCE THE FIRST SUCCESSFUL REPORT

Presented at 50th Scientific Session, American Heart Association, Miami Beach, Florida, November 28, 1977. Reprints requests: Dr. Brewster, 3 Hawthorne Place, Boston, Massachusetts 02114. Submitted for publication: August 21, 1978.

From the General Surgical Services, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School, Boston, Massachusetts

location, and clinical presentation of renal artery occlusive lesions. Many operative procedures are not applicable in all situations, and the surgeon must carefully select a method of renal revascularization appropriate to the individual patient. For almost all types of left-sided lesions, however, a splenorenal arterial anastomosis may be employed, and offers many decided advantages. Our favorable experience at the Massachusetts General Hospital with this procedure, done for selected indications, has now led us to regard it as our method of choice for left renal artery reconstruction, and is the subject of this report. Materials and Methods During the seven year period 1971-1977, splenorenal arterial anastomosis was performed in 19 patients with an established clinical diagnosis of renovascular hypertension. There were 12 males and seven females, ranging in age from 19 to 68 years. In 12 patients, or two-thirds, the stenotic lesion was arteriosclerotic in nature, while six patients had stenoses due to fibromuscular dysplasia. In one patient, hypertension was attributable to blunt abdominal trauma which had caused a circumferential tear of intima and media. Fourteen patients had unilateral disease of the left renal artery. In two of these, however, the right kidney was either nonfunctioning or had been previously removed, so that the stenosis involved a solitary kidney. In five instances, significant bilateral disease involved both renal arteries. In such patients and in those with a solitary kidney, operation was often undertaken as much for preservation of renal function as for hypertension. Four patients had varying degrees of overt renal failure preoperatively.

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TABLE 1. Indications for Splenorenal Anastoomosis

Number of Patients 1. 2. 3. 4.

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Avoidance of diseased aorta Reoperation for failed aortorenal graft Staged approach to bilateral lesions Desirability of autogenous arterial tissue

7 2

5

Indications A decision to employ splenorenal arteri,al anastomosis for renal artery reconstruction was bas ed upon four major indications, as outlined in Table 1. In seven patients, significant arteriosclerotic disease ofthe infrarenal abdominal aorta was evident by cli nical examination and/or angiography, and was felt litkely to interfere with a technically satisfactory proxim;al anastomosis for aortorenal bypass grafting. In twto additional patients with failure of an aortorenal grafft previously performed at other institutions, a splenoreinal graft was chosen to avoid reoperation in the previou:sly dissected aortic field. Five patients with bilateral di sease underwent splenorenal grafting as the initial ste]p of a staged approach, in order to avoid simultaneous , bilateral reconstructions. It was felt that if a rightside d aortorenal graft were subsequently required, it coul[d be carried out in a clean operative field. In fiv e remaining young patients the procedure was selecte d because of desire to employ autogenous arterial tissu e because of the patients' long life expectancy. Technique A low left thoracoabdominal incision w as employed in all patients. The patient's left side is elevated approximately 450 and incision carric,d into the ninth interspace. Rib resection is generailly unnecessary. The spleen and distal pancreas aire mobilized medially, and the splenic artery ideritified as it courses along the superior aspect of tihe pancreas. Dissection of the splenic artery is beguri in approximately its midportion, where it is divided aLnd mobilized centrally toward the celiac axis. The dlistal splenic artery is left undisturbed, being more frcequently tortuous and of smaller caliber and therefore less suitable. Furthermore, use of the distal artery will iasually result in redundancy and thereby increase the likelihood of kinking or other technical problems. The spleen is left in situ, being nourished by branches off the gastroepiploic and short gastric vessels. 1- : The splenic artery is mobilized central]iy to acnieve sufficient length for gentle curvature without redundancy to the level of the renal artery, which usually lies 5-7 cm inferiorly. Locally inistilled heparin solution is utilized without systemic he parinization. Frequently, the splenic artery will go into severe 4-

spasm during its manipulation. This may be overcome, however, by gentle dilatation with a balloon embolectomy catheter or graduated smooth-tipped probes. The left renal vein is next identified in the retroperitoneum, mobilized, and retracted inferiorly. The renal artery lies just superior and deep to the vein. The artery is ligated near its origin from the aorta and then divided. The diseased segment is resected and carefully preserved for pathologic examination. A 12-F catheter is then inserted into the distal renal artery and the kidney flushed with 250-300 cc of chilled renal perfusate, whose composition is detailed in Table 2. Twenty-five grams of Mannitol are also routinely administered intravenously early in the procedure, with Lasix given as well if a good diuresis is not established. End-to-end anastomosis of splenic and renal arteries is then carried out after appropriate beveling of both vessel ends. 6-0 Prolene suture material is usually employed, with the suture line interrupted in at least four locations to avoid any "purse-string" effect. A completed splenorenal anastomosis is shown in Figure la. Results In the group of 19 patients, follow-up periods range from six to 84 months, with the majority of the procedures done within the past 36 months. Cure or improvement in hypertension was achieved in all but one patient (Table 3). Not unexpectedly, of the seven patients considered cured, all were in the younger age group and all but one had stenotic lesions of a nonarteriosclerotic nature. Most of the patients in the larger "improved" category were older with arteriosclerotic disease. Of the five patients with bilateral disease, none were considered cured by unilateral operation. Three were considerably improved, however, and with satisfactory control of blood pressure on relatively low doses of medication, repair of the contralateral right sided lesion has not been felt necessary. In two patients, only modest improvement in hypertension was noted, and repeat renin studies then lateralized to the uncorrected right side. Subsequent right-sided repair was then carried out employing an aortorenal saphenous vein graft in an undissected operative field. One of these patients was rendered normotensive TABLE 2. Renal Perfusion Fluid (Osm 342) I liter Ringer's lactate, chilled to 3° 18 gm Mannitol 20 mg Heparin 500 mg Solu-medrol 300 cc instilled locally into the renal artery

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without medication, while the other had marked improvement in hypertension which was then easily

con-

trolled on lower dosages of medication. One graft occluded at four months, following an excellent initial result, and represents the single

TABLE 3. Results of Splenorenal Anastomosis for Renovascular Hypertension

Result

Number of Patients

Cured* Improvedt Failed Deaths

7 11 1 (graft occlusion) 0 19

* Cured defined as diastolic pressure 90 mm-Hg or less, without medication. t Blood pressure under better control, with reduced dosages of anti-hypertensive medications.

FIG. Ia. End-to-end anastomosis of splenic and renal artery, superior to left renal vein. The distal pancreas is elevated medially by retractor.

FIG. lb. Postoperative aortogram, demonstrating completed splenorenal arterial anastomosis.

failure in our series. In retrospect, this was felt attributable to excessive length of splenic artery utilized which presumably led to kinking and later occlusion. Fortunately, the kidney was salvaged and recurrent severe hypertension improved by successful reoperation. There were no deaths in this series, nor any significant postoperative complications. There were no instances of pancreatitis which has sometimes been mentioned as a hazard due to the required mobilization of the distal pancreas. There were no instances of renal failure postoperatively. It is particularly significant that four patients with varying degrees of renal failure preoperatively all had improvement in renal function following successful splenorenal anastomosis. Two of these patients had a tight stenosis in the artery supplying a solitary kidney while two others had severe bilateral stenoses. Discussion When considering surgical correction of a clinically significant renal artery lesion, the surgeon has numerous options for arterial reconstruction. Because most procedures are not appropriate or possible in all instances, the type of lesion, its location, and the status of the contralateral renal artery must all be considered. Additionally, the existence of any other vascular lesion must be evaluated, particularly associated arteriosclerotic disease of the abdominal aorta. Of the numerous available procedures, endarterectomy and aortorenal bypass grafts have been most widely utilized. While endarterectomy may be employed for focal arteriosclerotic lesions, it is less well suited, in our opinion, to stenoses associated with significant aortic arteriosclerosis, and is inapplicable in fibromuscular disease. Aortorenal bypass grafting is currently the method most frequently chosen for renal artery reconstruction. Autogenous saphenous vein, hypogastric artery or a prosthetic graft may be employed, depending upon individual requirements and preference of the surgeon. On occasion, however, the saphenous vein may be

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surgically absent or inadequate in caliber, or in some instances may be better preserved for possible future use in aortocoronary or femoropopliteal reconstructions. Autogenous hypogastric artery represents an ideal theoretical graft material, but its usefulness is often limited by associated arteriosclerotic disease and the requirement for dissection in a far removed operative field. Knitted Dacron® grafts have been successfully utilized by Kaufman and others," but do involve the occasional problems of prosthetic materials. Prosthetic grafts are also more difficult to work with technically, particularly if a delicate anastomosis must be constructed to the distal aspect of a small vessel as is often the case with fibromuscular lesions. Finally, a frequent problem with any aortorenal bypass graft, irrespective of material chosen, is the presence of associated arteriosclerotic disease of the infrarenal aorta. In our experience, this will often make construction of the proximal anastomosis difficult if not technically unsatisfactory, and may lead to an unacceptably high incidence of both early and late graft failure. Similar technical difficulties may also be anticipated if the aortic field has been previously dissected because of prior operation. Such limitations of aortorenal grafts led us to consider use of splenorenal arterial anastomosis for correction of left-sided renal artery occlusion lesions. This procedure actually represents one of the original methods of renal artery reconstruction, being first reported, although unsuccessfully, in 1952 by Thompson and Smithwick.18 The first splenorenal grafts were described by Hurwitt et al. and DeCamp and associates in 1956 and 1957 respectively.7'10 Since that time, scattered reports have appeared, the largest of which is a recent survey by Novick and colleagues. 1,2,4,5,8,11-17

The relatively infrequent use of splenorenal anastomosis may be due to the opinion of some authors that it is a more difficult procedure with few indications.11'13 Our experience, however, would indicate that such is not the case. The use of a thoracoabdominal incision is preferable, in our experience, to either a midline or bilateral subcostal anterior approach used by others.11'14 The exposure afforded is excellent, which is often one of the major difficulties with any method of renal artery reconstruction. The incision is well tolerated by the patient and in our opinion represents a major factor in our good results with this procedure. We have not encountered undue difficulty with the splenic artery itself, as has been reported by others.""3 The splenic artery will frequently go into severe spasm which may make it appear unsuitable. This may be overcome, however, by gentle dilatation. Problems with its tortuosity are largely avoided by employing only the central one-half of the vessel. In our ex-

Ann. Surg. E March 1979

perience we have rarely found the splenic artery involved with significant arteriosclerotic or fibromuscular disease. The suitability of the splenic artery for grafting has also been reported in the clinical and autopsy experience of other investigators.8'0'14'16 In this regard, however, it is of utmost importance to stress that good preoperative angiographic evaluation of the celiac axis and splenic artery is a prerequisite whenever a splenorenal graft is being considered. Good lateral and often oblique films should be obtained to exclude any associated lesions which might contraindicate use of the splenic artery. The spleen may be left in situ, being adequately supplied by blood flow from the short gastric vessels. The feasibility of retaining the spleen in this procedure has also been reported by others."1",2"14" l6 There appears to be some recent evidence that the spleen may be of immunologic importance even in the adult patient. We favor end-to-end anastomosis of the splenic and renal arteries, feeling this enables construction of a better anastomosis and provides superior flow characteristics. With proper beveling and an oblique suture line, size discrepancy or any tendency to stenosis are rarely encountered. End-to-end anastomosis is favored by other authors,12"14"16 although some recommend an end-to-side technique.7"' The use of renal perfusion fluid, originally developed from the transplantation experience at this institution, has been an important protective adjunct during the period of renal ischemia. Although ischemic time is generally under 30 minutes, the use of such a chilled perfusate safely extends the period of tolerable ischemia to one hour or more, if required, and we feel this may have contributed to the absence of any discernible postoperative renal failure. Specific advantages of this procedure are its ability to avoid use of a diseased abdominal aorta and its usefulness in a staged approach to bilateral disease. As discussed above, if the diseased aorta does not require reconstruction for associated disease, we prefer to manage left-sided renal artery lesions by splenorenal anastomosis. Such an approach is represented in Figure 2a and 2b. If aortic disease is clinically significant, however, we usually advocate combined aortic reconstruction and aortorenal bypass grafting.3 Similar considerations apply to reoperation required for previously performed aortorenal bypass grafts which have occluded or restenosed, or if renal artery reconstruction is required following prior aortic grafting. Technical difficulties are best avoided by a thoracoabdominal approach to the left retroperitoneum in a fresh operative field. Representative angiograms of this type are shown in Figures 3a and 3b. Splenorenal anastomosis is particularly well suited for use in patients with bilateral disease. Such pa-

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tients represent considerable management problems, as renin determinations frequently fail to lateralize to one side and it is often difficult to determine the more important stenosis. We are most reluctant to carry out simultaneous bilateral renal artery reconstructions, however, as we feel this increases the magnitude of the procedure considerably and is associated with a much greater possibility of a period of postoperatively renal dysfunction. Dean and his colleagues have reported their experience with bi-

riU. 5'a. rreoperative aortogram in patient witn severe nypertension and renal failure. Simultaneous bilateral aortorenal grafts had been performed at another hospital, with occlusion of the right and suture line stenosis of the solitary left kidney.

FIG. 2a. Preoperative aortogram showing tight left renal artery stenosis in a patient with associated arteriosclerotic disease of the aorta.

FIG. 3b. Splenorenal anastomosis to the solitary left kidney achieved relief of hypertension and improvement of renal function.

FIG. 2b.

Postoperative aortogram following splenorenal anastomosis

done to avoid the diseased aorta.

lateral stenoses, and have demonstrated a significantly greater incidence of renal failure and technical graft failures when bilateral simultaneous renal artery procedures are elected.6 Such considerations have

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Ann. Surg. * March 1979

sided operation. It does not require dissection in a far removed operative field and has a further advantage that only a single suture line is necessary. The splenic artery is almost always suitable, particularly in the young patient. In conclusion our favorable experience with this procedure and its many advantages have led us currently to regard it as the procedure of choice for surgical correction of left renal artery lesions, and we would advocate its more widespread use.

References

FIG. 4a. Preoperative arteriogram in patient with severe bilateral stenoses and malignant hypertension.

. ^....,.... ~~~~~~~~~~~~~~~~~~~~~~~~..... .......

FIG. 4b. Postoperative study following staged bilateral reconstruction, demonstrating patent left splenorenal and right aortorenal grafts. Cure of hypertension was achieved.

lef-

us to oftenn utilize a staged ma emresl aproratl usedapproach, for prompted with splenorenal anastomosis done initially to correct the left-sided lesion while preserving an undisturbed operative field if a subsequent right-sided repair proves necessary. Such a staged approach is represented in Figures 4a and 4b. A final indication for this procedure is a desire to employ autogenous arterial tissue for the renal artery reconstruction. This has particular importance, we believe, in the young patient in whom a reconstruction must function reliably and without deterioration over the long life expectancy of the patient. While a hypogastric artery segment may be employed in such instances, we believe that the splenic artery

1. Baker, G. P., Page, L. G. and Leadbetter, G. W.: Hypertension and Renovascular Disease: A Follow-up Study of 23 Patients with an Analysis of Factors Influencing the Results of Surgery. N. Engl. J. Med., 267:1325, 1962. 2. Berkley, K. M.: Restoration of Kidney Function by Splenorenal Arterial Anastomosis. Report of a Case. N. Engl. J. Med., 265:734, 1961. 3. Brewster, D. C., Buth, J., Darling, R. C. and Austen, W. G.: Combined Aortic and Renal Artery Reconstruction. Am. J. Surg., 131:457, 1976. 4. Caldwell, J. R., Smith, R. F. and Szilagyi, D. E.: Renal Arterial Reconstruction in the Treatment of Hypertension Due to Renal Artery Stenosis. Henry Ford Hosp. Med. Bull., 14:95, 1966. 5. Clunie, G. J. A., Gordon, R. D., Hartley, L. C. J., et al.: Results of Surgical Treatment of Renovascular Hypertension. Med. J. Aust., 1:225. 1975. 6. Dean, R. H., Oates, J. A., Wilson, J. P., et al.: Bilateral Renal Artery Stenosis and Renovascular Hypertension. Surgery, 81:53, 1977. 7. DeCamp, P. T., Snyder, C. H. and Bost, R. B.: Severe Hypertension Due to Congenital Stenosis of Artery to Solitary Kidney: Correction by Splenorenal Arterial Anastomosis. Arch. Surg., 75: 1023, 1957. 8. Farha, S. J., Willcoxon, R. L. and Farha, G. H.: Abdominal Revascularization Procedures Utilizing the Splenic Artery. Am. Surg., 38:223, 1972. 9. Foster, J. H., Dean, R. H., Pinkerton, J. A. and Rhamy, R. K.: Ten Year Experience with the Surgical Management of Renovascular Hypertension. Ann. Surg., 177:755, 1973. 10. Hurwitt, E. S., Seidenberg, B., Haimovici, H. and Abelson, D. S.: Splenorenal Arterial Anastomoses. Circulation, 14: 532, 1956. 11. Kaufman, J. J.: Dacron Grafts and Splenorenal Bypass in the Surgical Treatment of Stenosing Lesions of the Renal Artery. Urol. Clin. North Am. 2:365, 1975. 12. Luke, J. C. and Levitan, B. A.: Revascularization of the Kidney in Hypertension Due to Renal Artery Stenosis. Arch. Surg., 79:269, 1959. 13. Myers, K. and Johnson, N.: The Surgical Treatment of Renovascular Hypertension: Selection and Techniques. Med. J. Aust. 1:1305, 1971. 14. Novick, A. C., Banowsky, L. H. W., Stewart, B. H. and Straffon, R. A.: Splenorenal Bypass in the Treatment of Stenosis of the Renal Artery. Surg. Gynecol. Obstet., 144:891, 1977. 15. Parton, C. W. and Nabseth, D. C.: Splenorenal Arterial Anastomosis in the Treatment of Stenosis of the Renal Artery. N. Engl. J. Med. 259:384, 1958. 16. Poutasse, E. F.: Surgical Treatment of Renal Hypertension: Results in Patients with Occlusive Lesions of Renal Arteries. J. Urol. 82:403, 1959. 17. Spencer, F. C., Stamey, T. A., Bahnson, H. T., and Cohen, A.: Diagnosis and Treatment of Hypertension Due to Occlusive Disease of the Renal Artery. Ann. Surg., 154:674, 1961. 18. Thompson, J. E. and Smithwick, R. H.: Human Hypertension Due to Unilateral Renal Disease with Special Reference to Renal Artery Lesions. Angiology, 3:493, 1952.

Splenorenal arterial anastomosis for renovascular hypertension.

Splenorenal Arterial Anastomosis for Renovascular Hypertension DAVID C. BREWSTER, M.D., R. CLEMENT DARLING, M.D. In properly selected patients, the b...
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