Johan L. Terpstra

Ischemic and hemorrhagic stroke in patients on oral anticoagulants after reconstruction for chronic lower limb ischemia.

Background and Purpose Information on the long-term fate of patients with chronic lower limb ischemia is limited. We investigated the long-term risk of the first ischemic and hemorrhagic cerebral stroke in patients on long-term anticoagulant therapy after reconstruction for chronic limb ischemia. Methods In a retrospective study, 376 consecutive patients were seen at regular intervals according to a standard protocol. Only 3 (0.7%) were lost during follow-up (mean duration, 5.9 years). Anticoagulation was with coumarin derivatives followed by prothrombin times periodically. Primary end points were ischemic and hemorrhagic cerebral stroke events, which were confirmed by CT scan, autopsy, or operation in 85% of the cases. Major vascular events were analyzed as a composite secondary end point. The influence of several clinical variables on these outcome events was evaluated in univariate and multivariate analyses. Results Thirty-nine patients (10%) had 41 stroke events (23 ischemic, 18 hemorrhagic); 22 of these patients (56%) died from stroke. The cumulative ischemic stroke risk was 5% at 5 years and 12% at 15 years. Prior myocardial infarction was the only independent predictor (relative risk [RR], 3.1; P<05). The cumulative hemorrhagic stroke risk was 3% at 5 years and 17% at 15 years. Systolic hypertension (RR, 4.8; P<.01) and insulin-dependent diabetes mellitus (RR, 5.4; P<.01) were significant and independent predictors. The risk for a major vascular event was 29% at 5 years and increased to 56% at 15 years. Independent predictors were advanced age (RR, 1.4; P<.005), insulin-dependent diabetes (RR, 2.2; P<.005), and prior myocardial infarction (RR, 1.8; P<.01). Conclusions Patients with chronic lower limb ischemia, notably those with prior myocardial infarction, are at high risk for ischemic stroke. Those with systolic hypertension or insulin-dependent diabetes mellitus are at high risk for hemorrhagic stroke. (Stroke. 1993;24:1655-1663.)

Long-term Results of Prosthetic and Non-prosthetic Reconstruction for Obstructive Aorto-iliac Disease

In this retrospective study the results of 518 prosthetic aorto-iliac reconstructions (PRS) and of 229 thrombo-endarterectomies (TEA) were evaluated, with inclusion of follow-up results up to 20 years after surgery. Patients in the PRS group had presented with more severe ischaemic symptoms and more extensive arterio-sclerotic obstructions than the patients in the TEA group. Results in the TEA group were further analysed according to the extension of arterio-sclerotic disease: there were 93 patients with obstructions limited to the aorta or common iliac arteries and 136 patients with more extensive lesions. Patients with limited obstructions were younger, proportionally more often female, had fewer risk factors, and presented with less severe ischaemic symptoms than patients with more extensive obstructions. Operative mortality and early technical and functional results were similar in the PRS and TEA group, but long-term survival and patency rates were significantly better, and the need for late, additional operations was less in the TEA group. Late functional success rates were similar in both groups. The differences in outcome were explained by patient selection. Within the TEA group significantly superior results regarding survival, patency, need for late, additional surgery, and functional success were observed in the subset of patients with obstructions limited to the aorta or common iliac arteries. Considering these results and the risks inherent in a prosthetic reconstruction, such as prosthetic infection and the chance for false aneurysms, we advocate the use of an aorto-iliac TEA in properly selected patients.

Long-term results of in situ and extracorporeal surgery for renovascular hypertension caused by fibrodysplasia

In this study the early and late results of surgical reconstruction for renovascular hypertension caused by fibrodysplasia are evaluated in 53 patients treated between 1962 and 1983. There were 40 female and 13 male patients. The mean blood pressure was 208/126 mm Hg before medical therapy and 171/109 mm Hg thereafter. Bilateral renal artery stenoses were present in 12 patients. In situ revascularization was used in 26 patients and extracorporeal surgery to repair branch artery lesions was performed in 27 patients. Surgical therapy reduced the blood pressure to normal levels with minimal antihypertensive medications. This effect was already apparent 6 to 12 months after operation (mean blood pressure level of 140/90 mm Hg) and it was maintained during a mean follow-up period of 8.4 years (range 1 to 20 years) (mean blood pressure level of 134/85 mm Hg). At 6 to 12 months after operation, 79% of the patients were classified as either cured or improved. At this time the results did not appear to have been influenced by the preoperative duration of hypertension, nor by manifestations of extrarenal arteriosclerosis (ERA) as found in 10 patients, or by the surgical technique applied. But at the end of the long-term follow-up period (mean 8.3 years) the beneficial response rate of 87% appeared to have been adversely influenced by the presence of preoperative ERA, since beneficial response rates were 93% for those without and 67% for those with ERA (p = 0.17). We conclude that renal revascularization is effective both early and late for the treatment of renovascular hypertension caused by fibrodysplasia and that complex renovascular obstruction can be treated effectively with extracorporeal repair.

Long-term results of renal artery reconstruction with autogenous artery in patients with renovascular hypertension.

Renal artery reconstruction for the treatment of renovascular hypertension is preferably performed with an autologous graft when a graft is required. Although satisfactory results with vein grafts have been reported, stenosis and dilatation are not infrequent complications which have been observed only occasionally in arterial grafts. We have analysed our long-term results obtained with autogenous arterial grafts for renal artery reconstruction to determine the functional and anatomical results with regard to these complications. The data from 57 survivors operated on from 1959 through 1983 were analysed. All patients were hypertensive and the average systolic and diastolic blood pressure was 173/109 mmHg (mean number of 2.2 drugs). The renal artery stenosis was caused by arteriosclerosis and fibrodysplasia in 24 and 33 patients, respectively. In situ repair was performed in 30 patients (arterial bypass: 17 patients; splenorenal bypass: 13 patients). Extracorporeal repair of fibrodysplastic branch lesions was performed in 27 patients using branched hypogastric artery grafts (mean number of 2.4 branch anastomoses per kidney). Results were evaluated in the short (mean 8.3 months) and long term (mean 7.5 years) and the blood pressure response classified as either beneficial (cured/improved) or failed. Anatomical results were evaluated by angiography in the short-term in 87% of the patients and the long-term in 70%. A beneficial blood pressure response was obtained in 77% and 86% of patients in the short and long-term, respectively. The average blood pressure level after an interval of several years (long term) was 144/87 mmHg (mean number of 0.9 antihypertensive drugs). After in situ reconstruction, 2 and 1 anatomical failures were observed in the short and long-term, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

AORTOILIAC AND AORTOFEMORAL RECONSTRUCTION OF OBSTRUCTIVE DISEASE

This retrospective study evaluates our strategy to limit prosthetic reconstructions for aortoiliac obstructive disease to the diseased segments in 518 patients. There were 363 (70%) reconstructions without femoral anastomotic sites (FEM-0), 107 (21%) reconstructions with one femoral anastomotic site (FEM-1), and 48 (9%) aortobifemoral reconstructions (FEM-2). The ischemic symptoms and the extent of obstructions were significantly more severe in the FEM-1 and FEM-2 groups than in the FEM-0 group. Early operative results were comparable in all three groups. The difference in outcome became apparent when the long-term results were considered. Long-term follow-up continued for up to 20 years after the operation. Primary and secondary patency rates were significantly higher in the FEM-0 group (9% and 4% recurrent obstructions per 5 years, respectively) than in the FEM-1 and FEM-2 groups (both 14% and 10%, respectively), which was explained by patient selection. Late additional surgery was performed after aortoiliac procedures in most cases for recurrent aortoiliac obstruction and after aortofemoral procedures in most cases for false aneurysms. The risk of late additional operations during long-term follow-up were significantly lower in the FEM-0 group than in the FEM-1 and FEM-2 groups. These results support our strategy to tailor prosthetic reconstructive surgery to the individual status of the aortoiliac arteries.

Renal Artery Stenosis in Kidney Transplantation

Transplant renal artery stenosis (TRAS) of the main renal artery is one of the most frequent vascular complications in clinical renal transplantation. It may be the cause of hypertension as well as interfere with graft function.

Extracorporeal renal artery reconstruction for renovascular hypertension

Extracorporeal reconstruction can be applied to the successful repair of stenoses in the distal renal artery and its hilar branches. This study evaluates the short- and long-term results of extracorporeal renal artery reconstruction in 65 patients, including 5 children, with renovascular hypertension who were treated from 1974 through 1989. The mean age of the patients was 37 years (range, 7 to 67 years). The cause of the stenoses was arteriosclerosis in 8 patients, fibrodysplasia in 54 patients, and miscellaneous in 3. Hypertension was severe before treatment with a mean blood pressure of 187/147 mm Hg that was reduced to a mean of 159/102 mm Hg after medical therapy. Ten patients had renal dysfunction. Results were evaluated both at short-term intervals (mean, 7.9 months; 64 patients) and long-term intervals (mean, 5.9 years; 60 patients), after surgery. Blood pressure responses were classified as beneficial (cured/improved) or failures. Anatomic results were evaluated by angiography in 98% of the patients at the short-term interval and in 77% of the patients at the long-term interval. Extracorporeal renal artery surgery was performed on 78 kidneys among 65 patients (unilateral, 45 patients; bilateral, 13 patients; unilateral extracorporeal and contralateral in situ, 7 patients). In most of the cases autologous arterial graft was used for reconstruction. Early in the series one patient died as a result of the operative procedure (1/65, 1.5%). A beneficial blood pressure response occurred in 53 patients (53/65; 82%) at the short-term interval and in 49 patients (49/61; 80%) at the long-term interval, with the average blood pressure at the short-term interval being 138/85 mm Hg and at the long-term interval being 139/85 mm Hg. Renal function improved in all patients with preoperative renal dysfunction. Graft stenosis or occlusion of the main renal artery was neither observed at the short-term interval nor at the long-term interval. However, residual stenoses were observed in 9 of the 163 reconstructed distal branches (5.5%). Extracorporeal renal artery reconstruction with autologous arterial grafts can be effectively applied to lesions of the distal main renal artery and its hilar branches with durable functional results.

Influence of preoperative risk factors and the surgical procedure on surgical mortality in renovascular hypertension

The present study was undertaken to assess surgical risk in 112 severely hypertensive patients with renovascular disease secondary to atherosclerosis. The influence of preoperative risk factors and the surgical procedure on surgical mortality was also investigated. Extrarenal atherosclerosis was present in 51 percent of the patients, and hypertensive target organ damage was present in 66 percent. Renal artery reconstruction was performed unilaterally in 92 patients and bilaterally in 20 patients. Simultaneous aortoiliac operations were performed in 25 patients. There were nine operative deaths (8 percent). The presence of extrarenal atherosclerosis was particularly associated with mortality (14 percent compared with 1.8 percent when it was absent; p = 0.02). The surgical procedure also represented a significant risk; the mortality rate was 1.4 percent if surgery was restricted to unilateral reconstruction, but otherwise it increased to 20 percent (p = 0.001). This increase in mortality rate was clearly associated with aortoiliac surgery (20 percent compared with 4.6 percent when aortoiliac surgery was not performed; p = 0.025) and could be explained by the increased blood loss during operation. We conclude that the surgical treatment of renovascular disease secondary to atherosclerosis can be safely performed, provided that extrarenal atherosclerosis is absent and that simultaneous aortoiliac surgery can be avoided.

In Situ and Extracorporeal Reconstruction: Technical Aspects of Surgical Therapy for Renovascular Hypertension

Surgical therapy for renovascular hypertension has currently made excellent results available (10). Overall failure may be as low as 11% in some large series (9) but has been reported 35% by others (4). Overall failure rates reflect to a large extent the effectiveness of pre-operative diagnostic procedures. In addition, however, they are negatively affected by surgical failure like persistent or recurrent stenosis or occlusion of the reconstructed renal artery (early and late technical failure) and, of course, operative mortality.

Clinical Results of Surgical Therapy for Renovascular Hypertension

Renovascular hypertension is caused by one or more stenotic lesions in the main renal artery or its segmental branches. At the time, the diagnosis cannot be made with certainty in any other fashion than by means of reconstruction of the stenotic renal artery. Only a favourable response to technically successful surgical or angioplastic repair (i.e. a significant decrease of blood pressure), allows retrospectively for the definitive diagnosis (8).