Successful surgical treatment of anuria caused by renal artery occlusion

Endovascular salvage of occluded renal artery after >15 hours of ischemic time

In severe cases of acute traumatic injury to the kidney, immediate intervention is necessary to avoid irreversible ischemic damage. This case involves a 24-year-old woman who presented with signs of right renal devascularization after a high-speed all-terrain vehicle accident. Due to transport from an outside hospital, there was >15-hour delay before evaluation by vascular surgery. Considering her young age, we elected to salvage this patient's kidney via percutaneous endovascular stenting to mitigate any further prolongation of renal artery occlusion and prevent long-term sequelae. After intervention, her acute kidney injury resolved, and her creatinine levels normalized. As illustrated in this case, recovery of the renal parenchyma remains a possibility despite an extended warm ischemic time, providing evidence for future young patients to be considered for renal salvage.

Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching

Purpose: To analyze the renal function and outcome after delayed (>6 hours) endovascular revascularization of acute renal artery occlusion (RAO) in patients with fenestrated-branched endovascular aneurysm repairs (EVARs) or open visceral debranching. Methods: A single-center retrospective analysis was conducted involving 7 patients (mean age 61 years, range 49–72; 5 women) with 9 RAOs treated with endovascular revascularization between December 2014 and March 2017. Three patients had a solitary kidney with chronic renal insufficiency; 1 patient had bilateral occlusions as the acute event. Initial aortic surgery included 5 branched and 1 fenestrated EVAR as well as 1 open visceral debranching operation. Revascularization of the RAO was performed using aspiration thrombectomy, local lysis therapy, and stent-graft relining. The median time between initial aortic surgery and RAO was 10 months (range 0.5–17). Results: Median renal ischemic time to revascularization was 24 hours (range 7–168). Technical success was 100%, with 1 procedure-related access complication. Temporary dialysis dependency occurred in 4 patients. Mean in-hospital stay was 17 days (range 7–32) with 1 postoperative death at day 10 due to cardiac arrest of unknown cause. Mean follow-up was 10.3 months (range 1.5–27) in 5 of 6 discharged patients. During follow-up, 1 reintervention for recurrent occlusion was performed. At follow-up imaging, all renal arteries were patent. No permanent dialysis dependency occurred. Conclusion: Renal function can be salvaged by delayed revascularization for RAO with prolonged renal ischemia. The endovascular approach with aspiration thrombectomy, local lysis, and stent-graft relining is a feasible technique for revascularization after RAO in patients with fenestrated-branched EVAR or open visceral debranching.

Renal Artery Injury Secondary to Blunt Abdominal Trauma - Two Case Reports

BACKGROUND

Blunt abdominal trauma is routinely encountered in the Emergency Department. It is one of the main causes of morbidity and mortality amongst the population below the age of 35 years worldwide. Renal artery injury secondary to blunt abdominal trauma however, is a rare occurrence. Here, we present two such cases, encountered in the emergency department sustaining polytrauma following motor vehicle accidents.

CASE REPORT

We hereby report two interesting cases of renal artery injury sustained in polytrauma patients. In these two cases we revealed almost the entire spectrum of findings that one would expect in renal arterial injuries.

CONCLUSIONS

Traumatic renal artery occlusion is a rare occurrence with devastating consequences if missed on imaging. Emergency radiologists need to be aware of the CT findings so as to accurately identify renal artery injury. This case report stresses the need for immediate CT assessment of polytrauma patients with suspected renal injury, leading to timely diagnosis and urgent surgical or endovascular intervention.

Surgical salvage of acute renal artery occlusion in the setting of a solitary kidney

Management of acute renal artery occlusion in patients with a solitary kidney has a poorly defined prognosis. Loss of renal function is reported by some when acute warm ischemia reaches 2 hours. We report a unique case of a patient that had a 24-hour onset of anuria and acute renal failure upon arrival to the hospital. Nuclear imaging showed trace uptake of the right kidney, without evidence of excretion. Conventional digital subtraction angiography was performed; however, evidence of nephrogram or distal filling of the renal artery was not demonstrated. Secondary to conflicting studies, a computed tomography of the abdomen and pelvis with intravenous contrast revealed only minimal cortical perfusion despite complete occlusion of the previously grafted right renal artery. Patient was taken for urgent hepatorenal bypass surgery. Intraoperative return of urine output occurred immediately after completion of the bypass. Hemodialysis, which was required preoperatively, was stopped after <30 days of bypass procedure. Over 2 years following successful renal salvage, the patient has maintained a normal glomerular filtration rate and patency of her bypass by duplex follow-up.

Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank

BACKGROUND

Blunt renal artery injuries are rare and no single trauma center can accumulate substantial experience for meaningful conclusions about optimal therapeutic strategies. The purpose of this study was to assess the incidence of renal artery injuries after different types of blunt trauma, and evaluate the current therapeutic approaches practiced by American trauma surgeons and the effect of various therapeutic modalities on hospital outcomes.

STUDY DESIGN

This was a National Trauma Data Bank study including all blunt trauma admissions with renal artery injuries. Demographics, mechanism of injury, Injury Severity Score, Abbreviated Injury Score for each body area (head, chest, abdomen, extremities) injuries, type of management (nephrectomy, arterial reconstruction, or observation), time from admission to definitive treatment, and hospital outcomes (mortality, ICU, and hospital stay) were analyzed. Multiple and logistic regression analyses were used to examine the relationship between type of management and hospital outcomes.

RESULTS

Of a total of 945,326 blunt trauma admissions, 517 patients (0.05%) had injuries to the renal artery. Of the 517 patients, the kidney was not explored in 376 (73%), 95 (18%) patients had immediate nephrectomy, and 45 (9%) patients underwent surgical revascularization. In 87 of 517 (17%) patients, renal artery injury was the only intraabdominal injury. Of the 87 patients with isolated renal artery injuries, 73 (84%) were observed, 7 (8%) underwent surgical revascularization, and 7 (8%) had early nephrectomy. Multiple regression analysis demonstrated that patients who had surgical revascularization had a considerably longer ICU and hospital stay than observed patients. Patients who had nephrectomy had a considerably longer hospital stay than observed patients.

CONCLUSIONS

Blunt renal artery injury is rare. Nonoperative management should be considered as an acceptable therapeutic option.

Blunt Renal Artery Injury: Incidence, Diagnosis, and Management

Renal artery injury is a rare complication of blunt abdominal trauma. Increasing use of CT scans to evaluate blunt abdominal trauma identifies more blunt renal artery injuries (BRAIs) that may have otherwise been missed. We identified patients with BRAI to examine the incidence and to evaluate the current diagnosis and management strategies. Patients admitted from 1986 to 2000 at a regional Level I trauma center sustaining BRAI were evaluated. Patients undergoing revascularization or nonoperative management were followed for renovascular hypertension. Twenty-eight patients with BRAI were identified out of 36,938 blunt trauma admissions between 1986 and 2000 (incidence 0.08%). Most renal artery injuries were diagnosed by CT scans (93%) with seven confirmatory angiograms. Nine patients had nephrectomy (one bilateral), and three patients with unilateral injuries were revascularized. Sixteen were managed nonoperatively including one patient who had endovascular stent placement. Three patients died from shock and sepsis. Follow-up for all patients ranged from one month to 8 years. Two patients developed hypertension: one who was revascularized (33%) and one was managed nonoperatively (6%). The frequency of diagnosis of BRAI is increasing because of the increased use of CT. Nonoperative management of unilateral injuries can be successful with a 6 per cent risk for developing renovascular hypertension. The role of endovascular stenting is promising, and further study is necessary.

Traumatic renal artery occlusion: a 15-year review

BACKGROUND

To better define what constitutes appropriate treatment for traumatic renal artery occlusion, we report our 15-year experience in managing this injury.

METHODS

A retrospective chart review was performed to evaluate treatment outcomes and complications of 12 patients (13 injuries) who presented to our trauma centers with renal artery occlusion secondary to blunt injury.

RESULTS

Five of 12 patients underwent attempted surgical revascularization with a median warm ischemia time of 5 hours (range, 4.5-36 hours). Of these five patients, one required nephrectomy for inability to establish arterial flow, three demonstrated no function, and one had return to 9% differential function on postoperative renal scan. Seven patients did not have attempted revascularization, and none of them experienced immediate complications. Hypertension developed in three patients (43%) who required nephrectomy to control blood pressure at a mean of 5 months after injury (range, 3-7 months). Four patients remained asymptomatic and normotensive at a mean follow-up of 11 months (range, 4 weeks to 2.6 years).

CONCLUSION

Surgical revascularization for traumatic renal artery occlusion seldom results in a successful outcome. Patients who are observed must have close follow-up for hypertension.

Atherosclerotic ischemic renal disease

Over the past decade, ischemic nephropathy has gained recognition as a distinct and treatable clinical entity. Atherosclerotic renal artery stenosis is the leading cause of ischemic renal disease. Among the aging population entering renal replacement programs, both renal artery and systemic atherosclerosis are common. Over recent years, patients with ischemic renal disease are presenting later and have diffuse atherosclerosis and other comorbid conditions. Improved screening techniques, patient selection, and interventional approaches have resulted in better outcomes in most centers. Percutaneous transluminal renal angioplasty has emerged as the treatment of choice in some centers for nonostial renal artery stenosis. Both percutaneous transluminal renal angioplasty and surgical repair have proven beneficial for renal function salvage. Many studies have elegantly demonstrated the pathophysiologic consequences of acute ischemia to the kidney. The concepts derived from acute studies have served as a springboard for considering the adaptive and maladaptive renal responses to chronic ischemia.

Reversal of acute renal failure by kidney revascularisation

OBJECTIVES

To assess whether acute renal failure, due to total or subtotal renal artery occlusion, can be reversed by kidney revascularisation.

DESIGN

A retrospective review of surgery for kidney salvage in anuric patients at a University Hospital.

METHODS

From 1983 to 1993, eight patients were operated on for occlusive renal artery disease as a cause of acute renal failure, requiring preoperative haemodialysis. On admission the mean serum creatinine was 40 mg/l (354 mumol/dl). The oligoanuria lasted from 12 h to 3 weeks. Renal length of 8 cm or more and visualisation of a patent distal renal artery branches on aortography were arguments that return of renal function could be expected after revascularisation of these non-functioning kidneys.

RESULTS

Revascularisation restored immediate urine flow in six cases, with no further need for dialysis in four. Two patients remained oliguric despite successful reperfusion. One of them could be weaned from dialysis after 1 month. Two patients died postoperatively. Five of the eight patients left the hospital with restored renal function.

CONCLUSIONS

Patients with acute renal function deterioration due to ischemia of a single or both kidneys can benefit from prompt revascularisation, with significant recovery of renal function in most of them.

Reversible renal failure in an elderly woman with renal artery stenosis

Renal artery stenosis not only causes severe hypertension, but if left untreated, can progress to renal failure. A 64-year-old woman with a serum creatinine of 1.8 mg/dL and mild proteinuria developed progressively severe hypertension that was resistant to a calcium channel blocker. The patient received lisinopril, which was discontinued after 2 days because of nonspecific symptoms. One week later, an intravenous pyelogram showed a normal-sized but poorly functioning left kidney and a nonfunctional right kidney. The serum creatinine increased to 11.7 mg/dL and the patient was begun on hemodialysis. A renal arteriogram performed 6 weeks later for persistent hypertension showed bilateral renal artery occlusion; renal vein renin values from the left kidney were higher than those from the right kidney. After 11 weeks of hemodialysis, thrombolytic therapy followed by angioplasty was performed. Three weeks later, the renal function had returned to baseline (serum creatinine of 1.8 mg/dL) and hypertension was controlled with a beta-blocker. Renal artery stenosis is a potentially reversible cause of renal failure and should be considered in the evaluation of elderly patients with hypertension, even in the presence of renal failure.

Reversible acute renal failure as an atypical presentation of ischemic nephropathy

Ischemic nephropathy (IN) is defined as a clinically significant reduction in glomerular filtration rate in patients with hemodynamically significant obstruction to renal artery flow in a solitary functioning kidney or with bilateral renal artery stenosis (RAS). Ischemic nephropathy typically has a subacute to chronic course that may lead to end-stage renal disease. Acute anuric renal failure, which occurs less commonly with IN, is usually associated with moderately severe hypertension and has been attributed to certain risk factors: angiotensin-converting enzyme inhibition, a reduction in blood pressure secondary to antihypertensives or volume contraction, and exposure to contrast media. We present a series of six patients with IN and acute, anuric renal failure without either moderately severe hypertension or the previously defined risk factors. Of these six patients, four had RAS in a solitary kidney and two were found by ultrasound to have disparity in kidney size and bilateral RAS. Within 1 week of surgery, three patients developed renal failure that did not involve the kidney(s) responsible for the anuria and thus mimicked postoperative acute renal failure. Creatinine levels pre-anuria (1.2 to 2.1 mg/dL), during renal failure (5.0 to 12.8 mg/dL), and postrecovery (1.6 to 2.8 mg/dL) showed recovery of renal function, with renal artery bypass in four patients (sustained at 1 year). Two patients refused surgery and are on chronic dialysis. Acute renal failure in IN may occur postoperatively or spontaneously, and emergent intervention (ultrasound, angiography, angioplasty, and/or surgery) in this setting may lead to the correction of RAS and preservation of renal function.

Successful percutaneous balloon catheter treatment of renal artery occlusion and anuria

Progressive renal failure may be due to renal artery stenosis and occlusion. Gradual occlusion of the renal arteries may allow the development of collateral arterial supply sufficient to avoid dialysis. Even when dialysis is required, significant viable renal parenchyma may still be present to allow escape from dialysis following revascularization of one or both kidneys. The chance of success in such cases is thought to be better if the patient still produces a significant amount of urine. We report here a patient who was completely anuric for five days and in whom excellent renal function returned after balloon angioplasty of one of two occluded renal arteries.

Effects of intraaortic balloon position on renal artery blood flow

Debate continues over what happens to renal blood flow when intraaortic balloons are adjacent to the renal arteries. Fourteen dogs were prepared by implanting instruments to measure heart rate; right atrial, pulmonary arterial, carotid arterial, and femoral arterial pressures; cardiac index; mixed venous oxygen saturation; urine output; and left and right renal blood flows. A 12-mL intraaortic balloon was inserted through the left (n = 9) or right (n = 5) femoral artery. The position of the balloon was randomized so that it was initially placed in either the control (thoracic) or renal position (at the level of the renal arteries). Intraaortic balloon pumping was performed for 4 hours in each position. In 8 dogs, at least one of the renal arteries had partial occlusion, 23% to 98% decrease in flow (mean decrease, 66%), while the intraaortic balloon was in the renal position. An intraaortic balloon in the renal position results in lower renal blood flow as well as a high risk (57%) of selective renal artery occlusion. Decreased renal blood flow is not apparent using conventional monitoring, as hemodynamics do not change.

Symptoms and signs of thrombotic occlusion of atherosclerotic renal artery stenosis

Twenty-four patients, with an occluded renal artery diagnosed at angiography or operation, in whom previous angiography had demonstrated an atherosclerotic renal artery stenosis, were compared with a group of patients with a renal artery stenosis that remained patent after a similar interval. The risk of occlusion was found to increase with age, the degree of stenosis and advanced generalised atherosclerosis. At the presumed time of occlusion few patients had symptoms which when present were vague and easily overlooked. The most suggestive sign of occlusion was a rise in serum creatinine which was seen in the majority of the patients.

Renovascular hypertension in children: current concepts in evaluation and treatment

Since 1981, we have evaluated and treated 22 children with renovascular hypertension (RVH). Seventeen patients had stenosis of their native renal arteries, and five had stenosis of the artery in a transplanted kidney. RVH was caused by fibromuscular dysplasia in 13 patients, by trauma in 2 patients, and by arteritis in 2 patients. Among the patients who had transplanted kidneys, three had technical causes for stenosis and two had stenosis due to rejection. The disease was unilateral in 10 patients, bilateral in 5, and present in a solitary kidney in 7, including the five renal transplants. Diagnostic studies that strongly suggested the presence of renovascular disease were an initial diastolic blood pressure greater than 100 mm Hg, an elevated peripheral vein renin activity level, and an abnormal renal scan if the patient's hypertension was being controlled with an angiotensin-converting enzyme inhibitor (ACEI). Only the renal arteriogram was 100% accurate in confirming the presence of RVH. Percutaneous angiographic correction was attempted in 13 patients and resulted in lasting improvement of the hypertension in five (38%). Surgical revascularization was attempted in 17 children, including the 8 with failed angioplasty, with improvement or cure of the hypertension in 15 patients (88%). Combining percutaneous transluminal angioplasty (PTA) and surgical results gave 20 of 22 patients (91%) with cure or improvement of their hypertension. Four of 27 affected kidneys (15%) could not be revascularized and were removed. We conclude from this series of patients that despite improvements in noninvasive studies, renal arteriogram remains the only study that is 100% accurate in evaluating children for RVH.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversal of end stage renal failure with surgical revascularization in patients with atherosclerotic renal artery occlusion

A total of 9 patients with end stage renal failure caused by atherosclerotic renal artery occlusion underwent surgical revascularization with subsequent recovery of renal function. The duration of dialysis preoperatively ranged from 1 week to 13 months. In all cases renal viability was being maintained by collateral vascular supply. Postoperatively, renal function improved immediately and no patient required subsequent dialysis. Excellent over-all rehabilitation was achieved in all patients. Six patients currently are alive at a mean interval of 4.0 years postoperatively and with satisfactory renal function (mean serum creatinine 2.7 mg. per dl.). Three patients died at a mean interval of 6.8 years postoperatively and they all maintained satisfactory renal function (mean serum creatinine 3.0 mg. per dl.) until death. In some patients with end stage renal failure caused by atherosclerotic arterial occlusion surgical renal revascularization can yield extended survival with freedom from chronic dialysis.

Renal revascularization for acute anuria

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Renal artery emboli: the role of surgical treatment

Twelve cases of emboli to the renal artery (one of which was recurrent) were reviewed. In seven patients, emboli were unilateral and the opposite kidney was functional. In five patients, emboli were bilateral or occurred in a solitary kidney, leading to anuria. Cardiac rhythm disorders were encountered in eight patients and were responsible for emboli in other areas in three. Arteriography in ten patients demonstrated seven complete truncal occlusions (one bilateral), two incomplete truncal occlusions, and one distal embolus. One patient with a distal embolus was treated by heparin alone with satisfactory results. One patient in poor general condition was treated with intraarterial streptokinase, resulting in incomplete lysis of the clot. The five patients with anuria were operated on: four regained satisfactory renal function whereas the other patient died. In five patients without anuria who were operated upon, renal function returned to normal in four, and one patient required nephrectomy. Surgical treatment is imperative with anuria and is indicated in unilateral emboli with a functional contralateral kidney, especially when there is complete occlusion of the renal trunk. If the embolus is recent, intraarterial fibrinolytic treatment or percutaneous embolectomy can be attempted, but these techniques are not of proven efficacy. Patients with distal emboli or contraindications to operation should be treated by anticoagulant therapy, alone or with local fibrinolytic treatment.

Thrombosis of the renal artery of a small, solitary kidney: successful return of renal function after prolonged anuria

In the presence of a single functioning kidney, renal artery obstruction produces anuria, which can require hemodialysis. If the problem is diagnosed immediately and surgical intervention is not delayed, revascularization of the ischemic kidney is usually successful. Few authors, however, have reported the return of function to a small solitary kidney after occlusion lasting longer than 2 hours. We describe a case that involved thrombosis of the renal artery to an 8-cm solitary kidney; a successful endarterectomy was performed 29 hours after the onset of anuria. This case shows that the reversibility of renal ischemia is not necessarily determined by either the duration of occlusion or the size of the affected kidney.

Acute occlusion of the left renal artery manifested by hypertensive crisis

Because the signs and symptoms of acute renal artery occlusion mimic those of many more common diseases, prompt diagnosis is aided by an awareness that an occlusive renovascular event may have occurred. No routine, noninvasive laboratory test can confirm the diagnosis. Renal arteriography is the procedure of choice after excretory urograms have ruled out an obstructive uropathy. Early assessment of kidney viability is important. The endpoints of emergency treatment are to decrease symptoms, decrease diastolic blood pressure to less than or equal to 105 mm Hg, and to maintain urine output at greater than 50 mL/h. Restoration of a lower blood pressure must not be so prompt that renal perfusion decreases too rapidly. Definitive surgical treatment versus medical management of the renal artery occlusion remains a controversial topic. Where surgery is not feasible, medical management consists of streptokinase acutely followed by heparin and then chronic coumarin therapy.

Renal revascularization in patients with a single functioning ischemic kidney

From 1965 to 1985, 19 patients with a single, ischemic kidney underwent renal revascularization. Thirteen patients had a single kidney and six had a single functioning kidney. The cause of the renal artery lesions was atherosclerosis in 17 patients and fibromuscular dysplasia in two. All but one were hypertensive with a mean diastolic blood pressure of 119 mm Hg and they were taking an average of 2.6 antihypertensive medications. Most had diminished renal function with a mean serum creatinine value of 3.7 mg/dl (range 0.8 to 9.0 mg/dl) and a mean creatinine clearance of 38 ml/min (range 8 to 75 ml/min). Three patients required preoperative hemodialysis. The first two patients treated died postoperatively, but no deaths have occurred since 1970. Follow-up among the survivors averaged 32.9 months. The mean serum creatinine value decreased significantly to 2.2 mg/dl postoperatively (p less than 0.04); the mean diastolic pressure decreased significantly to 86 mm Hg (p less than 0.001). One patient was normotensive preoperatively. Of the 16 patients surviving operation, 14 had improvement of their hypertension, one was cured, and only one did not benefit. No patient's hypertension was worse. The mean number of postoperative antihypertensive medications decreased significantly to 1.5 medications per patient (p less than 0.02). These data suggest that an aggressive surgical approach is warranted in patients with a single ischemic kidney in need of revascularization because of the gratifying response both in control of hypertension and improvement of renal function.

Surgical treatment of anuria caused by renal artery occlusion. Case report

A patient with anuria caused by renal artery occlusion is presented. Revascularization was performed 42 days after onset of renal failure, and resulted in complete normalization of kidney function. The case demonstrates that surgical treatment of prolonged renal artery occlusion with subsequent return of renal function is possible.

[Transluminal dilatation and other nonsurgical catheter technics in the treatment of renovascular hypertension]

The development of percutaneous transluminal techniques has brought up new possibilities for causative treatment of renovascular hypertension. In renal artery stenosis transluminal angioplasty is meanwhile routinely applied; experience with angioplasty to date exceeds by far the number of 1000 published cases. Technical success is obtained in more than 90%. The clinical success in the therapy of reno-vascular hypertension is approximately 76% over all with nearly equal cure and improvement rates. In fibromuscular stenosis clinical success has been obtained in 95% with a cure rate of 56% and improval in 39%. The cure rate is particularly low in patients with atherosclerotic stenosis with 19%, however in 60% improvement has been obtained, resulting in clinical benefit in 79%. Results obtained by surgery seem to be superior to those of dilatation, especially with regard to cure rates. However, the differences are minor and are compensated by the evident advantages of transluminal dilatation, especially its easy application and lower risk. Thus, 8 years after its introduction in nephrology, transluminal dilatation is the therapy of choice in renal artery stenosis. Other nonoperative interventional techniques, including transcatheter aspiration and embolectomy, intraarterial thrombolysis, embolisation and modified angioplasty provided valuable alternatives to usual surgical therapy. However, experience with some of these procedures is still limited. The complication rate of transluminal angioplasty of 10-20%, necessitating surgery in nearly 5%, prohibits its uncritical use.

Renal infarction

A 43-year-old woman complaining of left flank pain was found to have renal infarction. New-onset atrial fibrillation suggested thromboembolism, which was confirmed by retrograde urogram and intravenous pyelogram. The patient was treated with heparin and was discharged on coumadin after evaluation of her cardiac disease.

Natural history of atherosclerotic and fibrous renal artery disease: clinical implications

Atherosclerotic renal artery disease and the fibrous renal artery diseases are described with respect to their radiographic and clinical characteristics. In a retrospective review, serial renal arteriograms of 85 patients with atherosclerotic renal artery disease and 66 patients with the medial fibroplasia type of fibrous renal artery disease were analyzed to characterize their natural history. Atherosclerotic renovascular disease progressed in 37 patients (44%) with total arterial occlusion occurring in 14 patients (16%). Medial fibroplasia of the renal artery progressed in 22 patients (33%) with no patient progressing to complete occlusion. Reduction in kidney size and increase in serum creatinine were good clinical markers for progressive atherosclerotic renal artery disease, but failed to discriminate between progressive and nonprogressive medial fibroplasia. The adequacy of BP control did not correlate with progressive occlusive disease in patients with either renal artery atherosclerosis or medial fibroplasia. The clinical implications of these observations are discussed with a view toward renal revascularization or transluminal angioplasty for preservation of renal function.

Mortality and renal salvage after renovascular trauma. A review of 94 patients treated in a 20 year period

Ninety-four patients with 96 renovascular injuries underwent operations over a 20 year period. Forty-nine patients had renal artery injury, 45 had isolated venous injury, and 33 had both vessels injured. Arterial revascularization succeeded in four patients, failed in five, and the results were not documented in three. Revascularization of acute renal artery thromboses was unsuccessful. Isolated renal vein injuries were repaired in 28 patients. The mortality rate was 37 percent for renal artery injuries and 28 percent for isolated renal vein injuries, despite the frequent choice of nephrectomy instead of reconstruction in unstable patients. Renal salvage was accomplished in 10 percent of patients with renal artery injury and in 51 percent of patients with isolated renal vein injury. Renal salvage is not often feasible in patients with renal arterial injuries because of associated renal vein injuries. The success of revascularization of traumatically occluded renal arteries is low and should probably be attempted only in unusual circumstances, such as bilateral injuries. Most isolated renal vein injuries are repairable, and reconstruction should be attempted in stable patients.