Surgery of the renal artery after complication and/or failure of percutaneous transluminal angioplasty

Purpose. The aim of this work was to study the influence of a complicationor a failure of a percutaneous transluminal angioplasty ofthe renal artery on the difficulties and results of a subsequent operationon this vessel.Material and methods. From 1980 to 2002, 31 patients (13 malesand 18 females) underwent an operation on one or both renal artery(ies) after failure or complication of a previous angioplasty. Themean age was 29.2 ? 17.8 years. These patients had undergonefrom 1 to 4 angioplasties on the same artery (mean: 1.8 angioplastyper patient). In four cases, an endoprosthesis had been placed in therenal artery. The cause of the stenosis was: arterial fibrodysplasia(N = 18 cases), atheroma (N = 11 cases) and Takayasu’s arteritis (N= 2 cases). The angioplasty had been followed by a severe complicationon the renal artery in 11 patients and by a failure in the 20others. The immediate failures were defined either as the impossibilityof the dilatation despite the use of high pressures (> 10 bars) toinflate the balloon or as the persistence of a residual stenosis of atleast 50 % of the arterial diameter after the angioplasty. The secondaryor late failures were the recurrence of the stenosis in theweeks or months following the angioplasty. The immediate complicationson the renal artery were: arterial dissection (N = 3), acutethrombosis (N = 2), covered arterial perforation (N = 2). The secondaryor late complications were: worsening of the initial stenosis(N = 3) and arterial aneurysm at the site of the angioplasty (N = 1).The operation on the renal artery was performed urgently when anacute complication occurred and more or less tardily and up to 10years after the angioplasty (or after the last of them) in case of achronic complication. Due to bilateral lesions, the surgical treat -ment consisted of 35 arterial repairs and 2 immediate nephrectomies.The repairs were performed by extracorporeal surgery (N =7, - 20 % -) and by conventional in situ surgery (N = 28, - 80 % -).Results. One death occurred on the 90th day in a patient with severeatheroma and profound renal insufficiency. Three postoperativethromboses occurred, leading to kidney loss, but only one secondarynephrectomy was necessary. Major technical difficulties wereobserved during the operation in 9 out of 11 patients operated onafter a complication of the angioplasty (82 %): on the fourteen op eratedkidneys, 4 extracorporeal repairs (29 %) and 1 nephrectomywere necessary. After a failure of the angioplasty, technical difficultieswere encountered in only 4 patients out of 20 (20 %), with 3extracorporeal repairs (13 %) and 1 nephrectomy on 23 operatedkidneys. In three patients, the angioplasty was responsible for permanentparenchymatous sequels (segmental infarct). In three otherpatients, a worsening of the stenosis was observed after repeatedangioplasties with extension to distal branches that were free of anylesion at the beginning and extensive fibrosis of the arterial walls.The importance of these lesions seems to be the direct causes of twoof the postoperative thromboses observed in this series.Discussion and conclusions. This series does not question the usefulnessof transluminal angioplasty in the treatment of renal arterystenoses but incites to prudence in its indications and practice.The quality of the results depends on the experience of the interventionalpractitioner. Even if the latter has a wide experience, complicationsmay occur. In case of an acute complication, emergencysurgery gives the best chances of success with conservation of thekidney. Due to technical difficulties that are unforeseeable, it isnecessary to anticipate, in every case, the possibility of an extracoporealrepair. In the majority of patients, the kidney can be preservedand everything must be done to reach this objective.When an endoprosthesis has been placed, its removal depends onthe difficulties of the operation. At least, if it is left in place itshould be trapped in a suture or ligation of the renal artery to avoidsubsequent migration. It should be avoided to dilate both sides during the same procedure.In case of a solitary kidney, the surgical treatment seems preferable.When a stenosis recurs, angioplasty should not be repeated excessively:two attempts seem reasonable but if a new failure occurs, thesurgical treatment is justified.