Ex Vivo Renal Reconstruction

FOLKERT 0. BELZER, M.D., OSCAR SALVATIERRA, M.D., ALPHONSE PALUBINSKAS, M.D., RONALD J. STONEY, M.D.

Ex vivo renal artery reconstruction and autotransplantation is a From the Departments of Surgery and Radiology, relatively recent addition to the surgical armamentarium for University of California, San Francisco renal vascular hypertension. Ten consecutive patients were con- and the Department of Surgery, sidered for this surgical therapy and form the basis of this com- University of Wisconsin, Madison, Wisconsin munication. The patients were treated by a combination of methods including bilateral ex vivo reconstruction, unilateral in situ and contralateral ex vivo reconstruction, and unilateral ex vivo reconstruction and contralateral nephrectomy. Replacement California, San Francisco. They are summarized in Table of the diseased segment of the renal artery in all ex vivo recon- 1 and were considered inoperable by in situ methods. struction consisted of arterial autografts including hypogastric Five cases are described below in detail to emphasize artery, splenic artery, common iliac, and external iliac artery. In variations in pathology the ex vivo reconstruction, the was either left intact or was and surgical approach. transected and reconstructed by standard ureterovesicle implan- tation. After surgery all patients became normotensive without Case Reports antihypertensive medication. Although this is a relatively small Case 1. A 42-year-old caucasian woman was first noted to be hyper- series, the uniform good results in these patients with extensive tensive four years prior to admission. In January, 1973, renal arteriog- disease suggest that ex vivo renal artery reconstruction is a safe raphy showed severe of both renal and effective method of treatment. Thus, it should be more widely (Fig. 1). The primary branches of the left showed severe disease applicable, especially in those patients with renal with aneurysmal dilatation and ex vivo reconstruction of this kidney who were previously thought to be inoperable or eligible for appeared to be indicated. The stenosis in the right kidney involved a nephrectomy only. segment of the renal artery distal to the first bifurcation but, as no branch arteries were involved, in situ reconstruction appeared feasible. FBROMUSCULAR DYSPLASIA of the renal arteries is In February, 1973, a left ex vivo reconstruction was performed using the usually confined to the main renal artery and is re- hypogastric artery and a right in situ repair using an interposition of in autologous saphenous (Fig. 2). The patient refused a postoperative paired by situ vascular reconstructive techniques. arteriogram and was normotensive until 9 months after surgery at which However, when fibromuscular dysplasia extends into the time she became hypertensive again. Arteriography showed a normal branches of the renal artery, in situ reconstruction may appearing left renal artery but showed stenosis of the interposed be difficult, hazardous, or impossible. In these instances, saphenous vein segment (Fig. 3). In September, 1973, the right kidney temporary nephrectomy and ex vivo repair with micro- was removed and an ex vivo repair was performed, again using the hypogastric artery. The patient is normotensive 6 months after surgery. vascular techniques followed by autotransplantation al- Comment. This case emphasizes the failure of an autologous saphen- lows the precise repair of such lesions.2 ous vein graft for in situ branch renal artery replacement and the Ten consecutive patients with renovascular branch le- feasibility of a successful ex vivo repair following a failed reconstruc- sions underwent microvascular arterial reconstruction tion. using ex vivo techniques between 1972 and 1975. Indica- Case 2. A 46-year-old woman with congenital absence of the right kidney underwent left ureterolithotomy 8 years previously. Two tions for surgery were uncontrollable hypertension on a months prior to admission, the patient had flank pain and hematuria. maximal medical regimen in all but one patient who had a Arteriography showed a large aneurysm arising from one of the segmen- symptomatic aneurysm in a solitary kidney. All were tal branches of the left renal artery (Fig. 3). Renal function was normal. evaluated by the vascular service at the University of In August, 1974, the patient underwent ex vivo repair of her left kidney. At the time, the saccular aneurysm was totally excised and the renal Presented at the Annual Meeting of the American Surgical Associa- artery branches were reconstructed with an arterial autograft applied as tion, Quebec City, Quebec, May 7-9, 1975. a patch. Because of previous ureteral surgery, the ureter was not Reprint requests: F. 0. Belzer, Department of Surgery, University of detached. Following repair, the kidney was placed in its normal position Wisconsin Hospitals, Madison, Wisconsin 53706 and reanastomosis of the main renal artery and was ac- 456 Vol. 182 *No. 4 EX VIVO RENAL ARTERY RECONSTRUCTION 457

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FIG. 2. Schematic drawing of the first arterial repair, patient H.W.

FIG. 1. Preoperative arteriogram of patient H. W. showing localized stenosis of the right renal artery distal to its first bifurcation and exten- sive left renal artery fibromuscular dysplasia. complished. Postoperative arteriography showed a patent arterial repair without evidence of the aneurysm. The patient has been asymptomatic since operation (Fig. 4). Comment. This case demonstrates a successful ex vivo repair for a branch renal artery aneurysm without detachment of the ureter. Case 3. A 54-year-old woman had been hypertensive for the past 5 years. Arteriography at the time of admission showed bilateral fi- bromuscular dysplasia. The disease in the right renal artery involved multiple branches. On the left only the main renal artery was involved (Fig. 5). In November, 1974, the patient underwent a right ex vivo repair and a left in situ repair. The arterial autograft was obtained by resecting the left , the internal iliac (hypogastric) artery and the external iliac artery. Continuity of the iliac vessels was restored with an 8 mm knitted graft. The common iliac artery with its bifurcation of internal iliac (hypogastric) and external iliac arteries was used for the ex vivo repair on the right. The remainder of the external iliac artery was used as an aorto-renal autograft to replace the diseased left main renal artery (Fig. 6). The patient has remained normotensive since surgery. Comment. This case demonstrates the use of two surgical teams to reconstruct bilateral disease-right, ex vivo and left, in situ. Case 4. A 14-year-old high school student was found on routine physical examination to be hypertensive. Complete workup including renal arteriography revealed a normal right kidney but the left kidney was supplied by two arteries. The larger inferior renal artery supplying most of the left kidney appeared to be normal. There was a collateral circulation in the mid portion of the superior renal artery where a focal defect was seen. The distal portion of the renal artery was opacified via the collateral (Fig. 7). In July, 1974, the patient underwent left ex vivo FIG. 3. Arteriogram of patient H.W. prior to second repair showing repair. The entire diseased upper renal artery was excised and recon- stenosis of interposed saphenous vein graft of the right kidney. The left struction was performed using the patient's hypogastric artery (Fig. 8). autotransplanted kidney now has a normal arterial supply. Vol. 182 - No. 4 EX VIVO RENAL ARTERY RECONSTRUCTION 459 Comment. This case demonstrates a successful ex iwivo reconstruc- tion in a child where renal preservation is critical. Case 5. A 22-year-old woman was found to be hypertensive one year prior to admission. Her symptoms progressed in the 5 months prior to admission. Renal arteriography showed atrophy of the right kidney secondary to severe fibromuscular dysplasia. Total renal function was normal. Although the right kidney was atrophied, nephrectomy was not advised because of her age and the possibility of subsequent disease of her left kidney. A right ex vii'o repair was performed using the hypogas- tric artery (Fig. 9). She has remained normotensive since her operation in January, 1975. Comment. This case demonstrates that renal atrophy unless severe is no contraindication to ex lii'o surgical repair. FIG. 4. Pre and postopera- " tive arteriogram on patient _X. E. E. showing the renal ar- Discussion tery aneurysm and post- operative repair. Renal autotransplantation was first described by Hardy in 19639 and was first successfully performed for re- novascular hypertension by Woodruff in 1964.18 Oda first reported nephrectomy with ex vivo microvascular recon- struction and successful autoimplantation in 1967.1' In 1970, we described a technique of reconstruction of renal artery branches in laboratory animals using continuous extracorporeal hypothermic perfusion.1 Cormal et al. were the first to report the clinical use of this technique.5 In the last 5 years, many case reports or nephrectomy and ex vivo repair using either hypothermic perfusion of hypothermia alone have been published.3,78.1,112 Ex vivo surgery should be considered only when in situ surgical repair is deemed Subsequent examination of the upper polar artery revealed a septum impossible. Extension of the completely obstructing flow to the upper pole of the left kidney. This disease to the primary renal artery branches does not area was supplied by collateral circulation only. The patient has e necessarily preclude in situ repair. If the branches are 3 mained normotensive since surgery. mm or more in diameter, in situ bifurcation reconstruc-

FIG. 5. Preoperative ar- teriograms on patient C. H. Note the short segment of ,patent renal artery proxi- mal to the first bifurcation in the left kidney. 460 BELZER AND OTHERS Ann. Surg. * October 1975

FIG. 6. Preoperative left and postoperative right ar- teriograms on patient C. H. showing patent ex vivo re- pair of the right kidney and patent in situ repair of the left kidney.

tion can be performed with relative ease. As suggested by procedures was reported.4'17 An alarming 40 to 60% inci- Fry and others, minimal stenosis of branch arteries, dence of graft abnormality, including thrombosis, dilata- especially if not associated with aneurysm, can be suc- tion, aneurysm formation or stenosis was found. How- cessfully dilated.6 ever, the hypogastric artery has been used in thousands In this report, arterial autografts were used for arterial of renal transplant procedures with only suture line reconstruction, rather than autologous saphenous vein stenosis being observed. Furthermore, a recent survey of grafts. In two recent publications the longterm fate of aorto-renal arterial autografts performed for renovascular autologous saphenous used in aorto-renal bypass hypertension at the University of California Medical Center in San Francisco showed none of these complica- tions during a 10-year follow up period.1 Ex vivo repair can be performed by both continuous

FIG. 8. Postoperative arteriogram on patient S. G. The normal lower polar artery was anastomosed end-to-side to the interposed hypo- 7. Schematic drawing of dissecting platform and perfusion circuit. gastric artery. \Vo1. I%82 o. 4 EX VIV() RENAI ARTERY RECONSTRUCTION 461

Fi(jG 9. Preoperative ar- ter-iogratm on patient P. B. showing moderate attrophy of the right kidney and se- vere fibromuscullar dysplasiat of the right renal artery. The postoperative Cx Villo repair is shown on the right.

hypothermic perfusion and simple cold storage. Three of ureter appears to be no problem if the ureter is left intact the kidneys in this series were reconstructed using and the kidney is reimplanted lower in the . hypothermia alone and 8 were reconstructed during con- However, if the surgeon is completely familiar with the tinuous hypothermic perfusion. The advantages of con- techniques of renal transplantation. ureterovesicle im- tinuous perfusion are: (I) Dissection of the renal plantation should have a complication rate of less than branches is easier as these vessels are distended. (2) 0.5 per cent.'" When one kidney only is being recon- Continued perfusion allows extra protection for the kid- structed, it is simple to leave the ureter intact and per- ney even when the procedure is lengthy. (3) Following form the reconstruction on a specially constructed plat- reconstruction, perfusion pressure can be set at systolic form placed on the patient's lower abdomen (Fig. 10). levels and small anastomotic leaks can be closed prior to For bilateral reconstruction. detachment of the ureter ,autotransplantation. Bleeding after autotransplantation allows complete removal of one kidney from the abdo- from unrecognized anastomotic leaks requires additional men and permits a second team to work on the contralat- sutures iii sitlu. This may be hazardous, especially if the eral kidney in sitiu while the first kidney is reconstructed bleeding site is a small vessel anastomosis in the renal at an adjacent dissecting platform. As bilateral recon- hilum. When hypothermia alone is used, cold Ringer's structions can be lengthy. the use of two surgical teams lactate is an effective solution. There is no evidence that can shorten the operative period. for the short period of time required for repair. hyperos- Arteriography following (x vivo repair has been ad- molar solutions provide greater protection than vised by some authors prior to replantation of the kid- hypothermia with cold Ringer s lactate solution." ney.) Although our dissecting platform permits ex vivo Management of the ureter appears to be relatively un- arteriography. we have not used this technique because important. The ureter can be left intact during the recon- of the possible side effects and toxicities of the contrast struction as long as retrograde bleeding into the kidney medium. Usually the status of the disease has been accu- and/or perfusion is prevented by temporary occlusion of rately identified by preoperative selective arteriography. the ureter with a soft elastic tubing. Redundancy of the Following reconstruction. simple calibration with the commercially available dilators used for Scribner shunts, are useful to assess patency of anastomosis. If a contrast medium is used during or following the ex vivo repair it should not be recirculated and should be washed out of the kidney. The decision whether a kidney should be repaired in situ or ex- vitho should be made prior to surgery. Acting according to the concept that in situi repair should be attempted first and if it proves to be impossible then the kidney should be repaired ex ilvo will probably give poor results. Ex. viio repair requires complete mobilization of the kidney. This requires additional time and is usually not done for in sitiu repair. Furthermore. the warm is- chemia which occurs during an unsuccessful in sitiu repair may make the organ unsuitable for subsequent ex vlito Fii I 0. repair. 462 BELZER AND OTHERS Ann. Surg. October 197S The kidney should be removed under optimum condi- 2. Belzer, F. 0.. Salvatierra. O.. Perloff. D. and GraltS. H.: Surgical tions. This includes the use of mannitol and careful dis- Correction of Advanced FibromusCulatr Dysplasia of the Renal Arteries. Surgery. 75:31-37. 1974. section so that vasospasm does not occur during the 3. Clunie. C. D. A., Murphy. K. H.. Lukin. L.. et al.: Autotransplan- nephrectomy with tubular necrosis as a sequellae later.'4 tation of the Kidneys in the Treatment of RenovasCular Hyper- Tubular necrosis causes reduced renal flow after tension. Surgery. 69:326. 1971. 4. Dean, R. H., Wilson, J.P., Burko. H. and Foster. J. H.: Saphenous reimplantation and thus increased the likelihood of Vein Aorto-renal Bypass Grafts: Serial Arteriographic Study. thrombosis, especially if the repair involves multiple Ann. Surg.. 180:469. 1974. small vessels. The anastomosis should be done with fine 5. Corman, J. L., Anderson. J. T., Taubman. J.. et al.: Ex Vivo Perfusion. Arteriography and Autotransplantation Procedures sutures (6-0 or 7-0 Tycron is used). In young women we for Kidney Salvage. Surg. Gynecol.. ()bstet., 137:659. 1973. have reimplanted the kidney high on the iliac vein and 6. Fry, W. J., Brink, B. E. and Thompson, N. W.: New Techniques in iliac artery. This avoids a pelvic location of the kidney, the Treatment of Extensive Fibromuscular Disease Involving the whould Renal Arteries. Surgery. 68:959. 1970. there be subsequent pregnancies. 7. Gelin, L. E.. Claes. G., Gustafsson. A. and Storm, B.: Total Blood- The indications for ex v4i'o reconstruction should be lessness for Extracorporeal Organ Repair. Surg. Res.. 28:30(5. tailored to the individual patient's needs but in general 1971. are the following: I) of 8. Guerriero. W. G.. Scott. R. and Joyce. L.: Development of Ex- Failure medical means to control tracorporeal Renal Perfusion as atn Adjunct for Bench Renal hypertension, progression of the arterial lesions or de- Surgery. J. Urol., 107:4, 1972. crease in renal function. 2) Lesions which are uncorrect- 9. Hardy. J. D.: High Ureteral Injury; Management by Autotransplan- able by in situ vascular reconstructive tation of the Kidney. JAMA. 184:97. 1963. procedures. 3) 10. Hoffman, R. M.. Stieper. L. W.. Johnson. R. W. G. aind Belzer. F. Bilateral disease or unilateral disease in a single kidney, 0.: Renal lschemic Tolerance. Arch. Surg., 109:550. 1974. thus precluding nephrectomy. 4) Unilateral disease with a 11. Lawson, R. K.. Hodges. C. V. and Pitre. T. M.: Nephrectomy. Microvascular Repair and Autotransplantation. Surg. Forum. normal contralateral kidney in patients under 40 years of 23:539, 1972. age. 5) Previously unsuccessful in situ repair (If the first 12. Lim. R. C.. Eastman, A. B. and Blaisdell, F. W.: Renal Auto- reconstruction has failed due to a technical error, a sec- transplantation: Adjunct to Repair of Renal Vascular Lesions. ond in situ reconstruction may be Arch. Surg., 105:847, 1972. possible.) Extensive 13. Lye, C. R.. String. S. T.. Wylie. E. J. and Stoney. R. J.: Aortorenal scarring from the previous procedure might make a sec- Arterial Autografts: Late Observations. (In press. Arch. Surg.) ond in situ procedure extremely difficult and ex iiv,o 14. Najarian, J. S., Gulyassy, P. P.. Stoney. R. J.. et al.: Protection of repair may the Donor Kidney During Homotransplantation. Ann. Surg.. be a safer alternative. Nephrectomy rather 164:398. 1966. than ex vliVO reconstruction is indicated for: 1) Unilateral 15. Ota. K, Mori, S., Awane. Y. and Ueno. A.: Ex Situ Repair of Renal disease in an elderly patient where the chance of recur- Artery for Renal Vascular Hypertension. Arch. Surg.. 94:370. rence of fibromuscular dysplasia in the normal 1967. kidney is 16. Salvatierra. O.. Kountz, S. L. and Belzer. F. 0.: Prevention of unlikely or 2) Severe atrophy of the affected kidney Ureteral Fistula After Renal Transplantation. J. Urol.. 112:445. which would be unimportant to preserve. 1974. 17. Stanley. J. C.. Ernst. C. B. and Fry. W. J.: Fate of 1()0 Aorto-renal References Vein Grafts: Characteristics of Late Graft Expansion and Aneurysmal Dilatation and Stenosis. 1. F. Surgery. 74:931. 1973. Beizer, O., Keveny, T. Z., Reed, T. W. and Prior, J.P.: A New 18. Woodruff, M. F. A.. Doig, A.. Donalds. K. W. and Nolan, B: Renal Method for Renal Artery Reconstruction. Surgery, 68:619. 1970. Autotransplantation. Lancet. 1:433. 1966.

DiSCUSSION reimplanted into the bladder as was first described by James Hardy in 1963. and to protect kidneys on the DR. THOMAS E. STARZI. (Denver, Colorado): It has Belzer machine while diffuse been obvious aneurysms of the abdominal involving the renal blood supply have almost from the moment of its introduction that the preservation been excised techniques of Belzer and replaced. would revolutionize the practice of renal trans- Dr. Stoney's work has shown us how plantation. It is also clear that non-transplant urologic technological advancements in practices and one area of surgery can advance the level of performance in other vascular surgical approaches may be affected as well, as Dr. Stoney has disciplines. shown us so This is a lesson that was eloquently stated by those great beautifully today. Drs. Stoney and Belzer have concen- plastic surgeons. Milt Edgerton and Joe trated on the difficult renal vascular reconstructions Murravy on Wednesday night. which have also in their papers on facial deformities. No better example of this principle provided us with our main published experience now comprising 14 could be cited than Drs. cases involving 18 kidneys. Stoney and Beizers brilliant work. (Slide) There are other indications than vascular lesions for the so- PROFESSOR LARS-ERIK GEL-IN (G6teborg. Sweden): In relation to Dr. called bench work surgery, as Russ Scott has called it. including other- Stoney's beautiful presentation. I wise inoperable should like to report on our series of stone disease. This man had a staghorn caiculus in his patients undergoing extracorporeal kidney surgery and illustrate the only kidney. The kidney was removed, bivalved while on the Belzer usefulness of the extracorporeal method with machine, one special case. cleaned out, and autotransplanted to the location seen here. Since 1968. we have treated 36 kidneys in 33 patients on the following (Slide) This woman had a large carcinoma involving the lower two- indications: Tumors in a single kidney. bilateral kidney tumors, renal thirds of her only kidney. She was treated in the same general way with artery aneurysms and distal renal artery stenosisx coralloid stones in protection of the kidney on the Belzer machine and reconstruction and single kidneys and two cases with aortic aneurysm involving the renal autotransplantation of this rather small remnant. She has no evidence of arteries and the special case I'll come to presently. recurrence now after more than a year. The outcome of the repairs for distal producing severe hypertension appears on this slide. All patients except one We have also used autotransplantation to allow short to be became normotensive after the constrLuction.