Efficacy of combined renal and mesenteric revascularization

Objective

Small numbers of patients have advanced renal and mesenteric vascular disease requiring treatment. Open surgical treatment has been considered high risk, and the advent of endovascular intervention has affected management. This study evaluated the safety and long-term efficacy of concomitant mesenteric and renal revascularization with open techniques.

Methods

Data from 90 consecutive patients who underwent mesenteric and renal revascularization during a 30-year period were analyzed. Early and late outcomes were evaluated over two intervals: 48 in period A (1978 to 1995), concomitant open renal and mesenteric revascularization (COR; n = 46) and sequential open renal and mesenteric revascularization (SOR; n = 2); 42 in period B (1996 to 2009), 22 COR, 4 SOR, 13 sequential hybrid open/endovascular repairs (SOER), and 3 sequential endovascular repairs (SER).

Results

There were 26 men and 64 women (median age, 67 years). Renal insufficiency was present in 24% and coronary artery disease (CAD) in 53%. Open surgical reconstruction was performed in 126 renal and 149 mesenteric arteries, with angioplasty/stenting in 15 and 8, respectively; 58 patients had concomitant aortic reconstruction (AR), and 9 had prior AR (8 in period A, 1 in period B). Hospital mortality was 8.8% overall; seven (14.5%) in period A and one (2.3%) in period B. Causes of early death were hemorrhage in three and multisystem organ failure in five. During a median follow-up of 4.5 years (range, 6 days-26.5 years), 11 patients progressed to hemodialysis (7 COR, 4 SOER), and 6 had recurrent mesenteric ischemia (4 COR, 1 SOER, 1 SER). Eight patients in period A and seven in period B required further procedures (9 renal, 9 mesenteric; 11 COR, 2 SOER, 1 SOR, 1 SER). Univariate analysis of COR patients showed CAD (P = .017) and prior AR (P = .035), but not concomitant AR (P = .366), predicted early death. Five-year survival for COR patients was 65% overall, but 74% in patients who survived the operation, with no difference between time periods (P = .55).

Conclusions

Concomitant open mesenteric and renal revascularization is associated with low early mortality and good long-term durability in appropriately selected patients. It remains a viable procedure, especially in patients requiring concomitant aortic reconstruction. High-risk patients with CAD or prior aortic surgery should be considered for endovascular treatment, when anatomically feasible.