Transposition of the right renal artery to gastroduodenal artery for management of acute, symptomatic renovascular hypertension

Abstract

Renovascular hypertension can be clinically challenging to diagnose. The most common etiology remains atherosclerotic disease. When medical management fails, renal artery revascularization is considered. Since the advent of endovascular interventions and the outcomes of CORAL (Benefits of Medical Therapy Plus Stenting for Renal Atherosclerotic Lesions), surgical management of renal artery stenosis has shown a decrease in prevalence. Our experience demonstrates a viable solution for patients requiring open surgery with limited inflow options.

Endovascular revascularization is not always feasible; as such, surgical approaches remain an important skill to maintain.^1,2 Frequently, circumferential calcification and atheromatous disease involving the aorta and iliac arteries make inflow challenging. In these cases, hepatorenal or splenorenal bypasses/transpositions can be the alternative.2, 3, 4, 5, 6, 7, 8, 9 We present an interesting case of renovascular hypertension managed by renal artery transposition to the gastroduodenal artery. The patient consented for a case report to be written.

Case report

A 64-year-old woman with a history of heavy smoking initially presented to a cardiologist 2 years ago for preprocedural cardiac testing before a colonoscopy for her preexisting shortness of breath and history of coronary disease. Past medical history is remarkable for chronic hypertension (>20 years), chronic kidney disease (baseline creatinine 1.3 mg/dL), active smoker (40 pack-year history), and coronary artery disease (status post cardiac stent placed 11 years prior). During her preprocedural workup, she was found to have a resting systolic blood pressure of >180, which increased to >200 during stress testing. At that time, she was taking two angiotensin receptor blockers, five antihypertensives, a statin, and dual antiplatelet therapy for her coronary artery stent. She was referred to nephrology and was found to have severe left renal artery atherosclerosis with left renal atrophy on duplex and angiogram. Over the course of the following year, the patient experienced gradual worsening of renal function and persistent hypertension despite several medication changes.

She was referred to vascular surgery, and the decision was made to proceed with a left renal angiogram, which found that she would not be a candidate for stent placement owing to chronic occlusion of the left renal artery (measured at 6.8 mm) owing to large calcific occlusive plaque and no distal reconstitution of flow (Fig 1). The right renal artery (RRA) was found to have <50% narrowing. A multidisciplinary discussion was had with vascular surgery, cardiology, and nephrology for consideration of left nephrectomy vs open left renal artery revascularization. Bilateral renal vein sampling was performed, which showed a left:right renin ratio of 1:4, which is highly suggestive for renovascular hypertension and left renal artery lateralization. In addition, her renal MAG3 scan showed little or no function of her left kidney.

Fig 1.

Maximum intensity projection (MIP) showing heavily calcified visceral aorta, not suitable for inflow. (A)Red arrow designating the right renal artery (RRA). (B) Occluded left renal artery (green arrow). (C)Yellow arrow designating the superior mesenteric artery.

Several months later, the patient presented to the emergency room with complaints of fatigue, nausea, and bilateral lower extremity swelling and was found to be in hypertensive emergency, profoundly acidotic, in acute renal and hypoxic respiratory failure, with flash pulmonary edema requiring intubation and initiation of hemodialysis. Renal artery duplex showed evidence of new, high-grade stenosis at the origin of the RRA. Endovascular recanalization was attempted and failed; therefore, a multidisciplinary decision was made to take the patient to the operating room for hepatorenal revascularization for the newly nearly occluded RRA. Preoperative lower and upper extremity vein mapping did not have adequate veins for conduit. A computed tomography angiogram of the abdomen and pelvis showed significant atherosclerotic disease throughout the aorta, iliac arteries, and superior mesenteric artery. Stenting of the superior mesenteric artery was discussed, but ultimately deferred owing to a lack of symptoms suggestive of chronic mesenteric ischemia. However, the celiac artery was patent with a prominent (6-mm) gastroduodenal artery (GDA) in proximity to the RRA (6.2 mm) as it branched off the common hepatic artery.

A right subcostal incision was made, and a Kocher maneuver was performed. The GDA and RRA and vein were dissected out. The patient was systemically heparinized at this point. The RRA was ligated at the aorta, and a focal endarterectomy was performed. The GDA was clamped with Yasergil clips proximally and distally and a lateral arteriotomy was made to match the RRA. The RRA and transposed to the GDA using running Prolene sutures (Figs 2 and 3). At the conclusion of the case, we sequentially removed the clamps and multiphasic signals were found throughout the RRA from origin to hilum, as well as the distal GDA.

Fig 2.

(A) Large calcific burden at the ostia of the right renal artery (RRA). Large gastroduodenal artery (GDA), patent celiac artery. (B) Transposition of the RRA with preserved flow within the GDA.

Fig 3.

Intraoperative photo of completed right renal artery (RRA) to gastroduodenal artery (GDA) transposition.

Postoperatively, the patient did well with rapid recovery of renal function and normal urine output and was gradually weaned off dialysis. She continues to be well-controlled on three oral agents and has abstained from tobacco now with most recent follow-up 1 year out from surgery. No further consideration for left nephrectomy at this time based on her recovery after the right renal revascularization.

The patient's recovery was remarkable with rapid return of renal function, resolution of pulmonary edema, liberation from hemodialysis, and adequate control of her hypertension. She was discharged on postoperative day 7. She remained well-controlled on her oral medication at the 1 year follow-up, with preserved renal function.

Discussion

Here we present the case of a 64-year-old woman with resistant renal hypertensive disease with left atrophic kidney and rapidly progressive renal and pulmonary dysfunction in the setting of acute worsening of RRA stenosis. The patient was initially worked up for an ischemic left kidney with selective renin sampling from both renal veins. The left kidney was atrophic and did not contribute much to her renal function, as demonstrated on a renal functional scan. She was being considered for left nephrectomy when she had sudden worsening for her renal function and hypertensive crises.

The patient's rapid deterioration of symptoms warranted urgent treatment. With her severely calcified origins of both renal arteries, multiple endovascular attempts at revascularizations failed. Owing to heavy calcification at the ostium into the renal artery and an inability to advance the wire into the true lumen, open surgical treatment was seen as necessary for this patient. Her significant atherosclerotic burden in the abdominal aorta and iliac arteries limited options for inflow. The GDA represented a good inflow source given that she did not have any chronic mesenteric ischemia symptoms, but we could not transpose the GDA to the RRA and compromise her visceral flow. Furthermore, she did not have adequate vein conduit for a bypass from GDA to RRA. As such, RRA transposition to the GDA was deemed to be a viable approach. A preoperative computed tomography scan reconstruction demonstrated the proximity of these vessels and the sufficient length of the RRA.

Endovascular procedures have been found to have lower perioperative morbidity; however, in certain instances (such as dense calcification/atheromatous disease), open revascularization techniques may be indicated.^9,10 Aortorenal bypass is a technique with the highest 5-year patency at 80% to 83%. For bilateral focal ostial lesions, transaortic endarterectomy is a suitable option, but is limited by patients with dysplastic or longer segments of disease. To avoid aortic cross-clamping in patients with adequate visceral or iliac inflow, extra-anatomical bypass procedures may be used.9, 10, 11

The GDA has been referenced in the context of visceral revascularization, such as aortogastroduodenal bypass for celiac axis or pancreaticoduodenal artery aneurysms; however, at the time of this publication, the authors are not aware of any documented cases of renal-gastroduodenal transposition for renal revascularization.² The GDA is typically avoided as a revascularization target because, in some individuals with chronic mesenteric disease, it may serve as an important collateral for intestinal perfusion.² In this patient, however, a robust GDA without evidence of mesenteric disease burden existed within a tension-free transposition distance of the RRA.

Conclusions

Here we present a 64-year-old woman with resistant renal hypertensive disease who suffered an acute decompensation in the setting of RRA stenosis. Disease burden at the origin of the renal artery as well as throughout the aorta necessitated splanchnic-renal revascularization. Resolution of her symptoms was obtained via transposition of the RRA to the GDA. Although not a common target for management of renovascular disease, the GDA can serve as a suitable option for renal revascularization. Despite the advent of endovascular therapy, the role for surgical revascularization remains needed. Using the GDA as inflow is a viable option and should be considered when appropriate.

Funding

None.

Disclosures

None.