Komplike Renovasküler Hipertansiyonda Renal Ototransplantasyon

Abstract

Amaç: Renal arterin izole fibroblastik ve aterosklerotik lezyonlarına bağlı hipertansiyonda perkütan translüminal anjioplasti (PTA) tercih edilen ilk tedavidir. Komplike renovasküler patolojilerde ve PTA’nın başarısız olduğu olgularda renal ototransplantasyon (ROT) alternatif bir tedavi şeklidir. Bu çalışmada renovasküler hipertansiyon nedeniyle renal ototransplantasyon yapılan olgular incelenmiştir. Materyal ve Metod: Şubat 1989-Aralık 2005 tarihleri arası ROT uygulanan 5 hasta retrospektif olarak incelendi. Cerrahi teknik olarak tüm hastalara renal eksplorasyon, renal prezervasyon, birden fazla arteri olup tek tek anastomoza uygun olmayan olgularda renal arter rekonstrüksiyonu ve iliak fossaya ototransplantasyon uygulandı. Sonuçlar: R0T uygulanan 5 hastanın 3“ü erkek ve 2’si kadın olup ortalama yaş 31,8±15,2 yıl (14–48 yıl) idi. İki hastada fibromüsküler displazi(FMD), 2 hastada aterosklerotik damar hastalığı ve 1 hastada Takayasu hastalığı mevcuttu. Tüm hastalarda ROT öncesi antihipertansiflerle kontrol edilemeyen hipertansiyon mevcuttu. İki hastada renal arter internal iliak artere uç-uca, çift arteri olan bir hasta “back-table”’de tek ağız haline getirilip eksternal iliak artere uç-yan ve çift arteri olan 1 hastada 1 arter internal iliak artere uç-uca, 2. arter eksternal iliak artere uç-yan anastomoze edildi. Son hastada tek renal arter mevcuttu. Bu hastada renal arterler ayrı ayrı internal iliak arter uç dallarına anastomuze edildi. Tüm hastalarda renal ven eksternal iliak vene uç-yan anastomoze edilirken hiçbir olguda üreteral anastomoz yapılmadı. Hastalar ortalama 9,8±5,7 yıl (1–16 yıl) takip edildi. Takip süresince hiç bir olguda mortalite ve morbidite görülmedi. Hipertansiyon ve böbrek fonksiyonları tüm hastalarda düzeldi. Yorum: Komplike renovasküler lezyonların tedavisinde ROT oldukça etkili bir tedavi şeklidir. Sonuçlar cerrahi tekniğimizin güven ve başarısını desteklemektedir.

Summary Renal autotransplantation for complex renovascular hypertension Objective: Percutaneous transluminal angioplasty (PTA) is the usual treatment for isolated occlusive fibrodysplastic or atherosclerotic lesions of the renal artery. However, PTA may be unsuccessful or even hazardous in patients with a pathologic complex renal vascular condition. Renal autotransplantation (RAT) has been used as an alternative treatment for those patients. The purpose of this study was to evaluate the outcome of patients who underwent RAT at our center. Patients and Methods: Between February 1989 and December 2005, we performed 5 RAT procedures. Our surgical strategy included renal explantation, ex vivo renal preservation, ex vivo reconstruction of the renal artery (if necessary), and renal heterotopic autotransplantation. The subjects consisted of 3 male and 2 female patients (mean age, 31.8 ± 15.2 years; age range, 14-48 years). The surgical indications for RAT were fibromuscular dysplasia in 2 patients, Takayasu’s disease in 1 patient, and atherosclerosis in 2 patients. All patients had hypertension that was refractory to antihypertensive medication before RAT was performed. The renal artery was anastomosed end to end to the internal iliac artery in 2 patients. In 1 patient, the adjacent edges of 2 renal arteries were sutured together to create a single opening and were then anastomosed end to side to the left external iliac artery. One patient who had 2 renal arteries received 2 separate anastomoses (one of which was created end to side to the external iliac artery and the other, end to end to the internal iliac artery). The last patient, who had 3 segmentary arteries, received 3 separate anatomoses, all of which were created end to end to branches of the internal iliac artery. The renal veins were anastomosed end to side to the external iliac vein, and no ureteral reimplantation was needed. The mean posttransplantation follow-up period was 9.8 ± 5.7 years (range, 1-16 years). Results: During the follow-up period, no morbidity was noted and no patient died. In all patients after surgery, hypertension resolved or improved and the function of the autotransplanted kidney improved. Conclusion: RAT is highly effective for the treatment of complex renovascular lesions. The technique of ex vivo repair is a safe and effective surgical procedure that can be performed in a clinical setting