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Hepatorenal bypass using autogenous, free internal iliac artery graft: An attractive alternative to revascularize the right kidney in Takayasu's disease.
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MedLine Citation:
PMID:  22919139     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Nonspecific aortoarteritis or Takayasu's disease (TD) is a chronic pan endarteritis of unknown origin involving the aorta and its major branches affecting young adults especially women. The disease is more common in eastern Asian countries. Hypertension in these patients generally reflects as renal artery stenosis, which is seen in 28-75% of patients. Surgical revascularization is occasionally needed in patients with failed medical management or endovascular interventions. We report two cases of Takayasu's arteritis in young women where renal revascularization was done using free internal iliac artery hepatorenal bypass graft with excellent control of hypertension in the postoperative period.
Authors:
Nikhil Khattar; Sandeep Guleria; Sanjeev Sharma
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Indian journal of urology : IJU : journal of the Urological Society of India     Volume:  28     ISSN:  1998-3824     ISO Abbreviation:  Indian J Urol     Publication Date:  2012 Apr 
Date Detail:
Created Date:  2012-08-24     Completed Date:  2012-08-24     Revised Date:  2013-05-30    
Medline Journal Info:
Nlm Unique ID:  8510441     Medline TA:  Indian J Urol     Country:  India    
Other Details:
Languages:  eng     Pagination:  199-201     Citation Subset:  -    
Affiliation:
Department of Urology, PGIMER & Dr. Ram Manohar Lohia Hospital, New Delhi, India.
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Full Text
Journal Information
Journal ID (nlm-ta): Indian J Urol
Journal ID (iso-abbrev): Indian J Urol
Journal ID (publisher-id): IJU
ISSN: 0970-1591
ISSN: 1998-3824
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © Indian Journal of Urology
open-access:
Print publication date: Season: Apr-Jun Year: 2012
Volume: 28 Issue: 2
First Page: 199 Last Page: 201
ID: 3424900
PubMed Id: 22919139
Publisher Id: IJU-28-199
DOI: 10.4103/0970-1591.98466

Hepatorenal bypass using autogenous, free internal iliac artery graft: An attractive alternative to revascularize the right kidney in Takayasu's disease
Nikhil Khattaraff1
Sandeep Guleria1
Sanjeev Sharma2
Department of Urology, PGIMER & Dr. Ram Manohar Lohia Hospital, New Delhi, India
1Department of Surgery, AIIMS, New Delhi, India
2Department of Cardiac Radiology, AIIMS, New Delhi, India
Correspondence: For correspondence: Dr. S. Guleria, Department of Surgery, AIIMS, New Delhi 110029, India. E-mail: sandeepguleria@hotmail.com

INTRODUCTION

Takayasu's disease (TD) is a chronic pan endarteritis, involving the aorta and its major branches affecting young adults especially women. The disease is more common in Asia. Type 1 (cranial vessels) and type 2 (aortic arch) disease are common in Japan, whereas types 3 (abdominal aorta) and 4 (diffuse vessel involvement) are common in India. In India, TD accounts for almost 60% of cases of renal artery stenosis (RAS).[1] Hypertension occurs in approximately 50% of patients. Steroids are the mainstay of treatment. Renal artery (RA) involvement is best treated by percutaneous transluminal angioplasty (PTA). Surgical revascularization is indicated in cases of failed PTA. We report two cases of TD in young women managed successfully using autologous internal iliac artery (IIA) hepatorenal bypass graft.


CASE REPORTS
Case 1

A female aged 32 years presented with uncontrolled hypertension on four drugs for 5 years. She also had a history of recurrent spontaneous abortions. She had been treated for TD with steroids. Her blood pressure in both arms was 180/116 mm Hg. Abdominal examination revealed a bruit in the umbilical region. Her serum creatinine was 1.6 mg/dl, erythrocyte sedimentation rate (ESR) 18 mm/h (Wintrobe's), C-reactive protein (CRP) 4.2 mg/dl, normal hepatic functions, and a negative lupus anticoagulant. Computerized tomography (CT) scan of the abdomen showed a left kidney of 7.5 cm with poor contrast uptake, while the right kidney was 10 cm with good contrast uptake. An isotope renal diethylene triamine penta acetic acid (DTPA) scan showed global glomerular filtration rate to be 40 ml/min and differential function right: left::80%: 20%. Angiogram showed bilateral RAS (right 50% and left 90%), fusiform dilatation of abdominal aorta in infrarenal region, and early branching of the right RA [Figure 1a]. Because of unfavorable morphology of aortoiliac region, endovascular therapy was not attempted and surgical revascularization of the right kidney was planned. The patient was not put on any steroids as her inflammatory markers were normal. On exploration, right RA was normal distally. Hepatic artery and gastroduodenal artery were exposed. A free IIA graft was taken along with origins of both anterior and posterior divisions (Y-graft) as conduit. The hepatic artery was occluded and the gastroduodenal artery was ligated and divided at its origin. The ostium was enlarged and the Y-graft was sutured end to side with the hepatic artery and end to end with both the RA branches [Figure 1b]. The anastomosis time was 9 min and no perioperative cooling was used. The right kidney was well-vascularized on a postoperative angiogram [Figure 1c]. Her serum creatinine was 1.4 mg/dl. She is being followed up now for last 2 years and on a single antihypertensive with normal blood pressure.

Case 2

A 26-year-old female presented with a history of intermittent throbbing headache and four previous spontaneous abortions. She was a known hypertensive for 7 years on four antihypertensive drugs. On examination, the pulses in the left arm were feeble. Blood pressure was 170/110 mmHg in the right arm and 158/70 mmHg in the left. There was no palpable bruit. On investigations, the creatinine was 0.8 mg/dl. Liver function tests and the lipid profile were normal. ESR was 20 mm/h, CRP was 4 mg/dl, and lupus anticoagulant was negative. On ultrasound, the right and left kidneys measured 8 and 11 cm, respectively. An isotope renal DTPA scan revealed 32% function on the right side. Angiography revealed left subclavian stenosis, narrowed abdominal aorta with dilated thoracic aorta, stenosis with beaded appearance of right RA at the origin, and a normal left RA [Figure 2a]. The celiac axis, hepatic trunk, and the gastroduodenal artery were normal. A diagnosis of TD was made and she was started on steroids. Once her inflammatory markers were normal, PTA was attempted but was unsuccessful. The patient was taken up for hepatorenal bypass using IIA free graft. In this case as there was no early branching, the free graft was a tubular conduit [Figure 2b]. The rest of the procedure was similar and the anastomosis was completed in 8 min. Postoperatively, at 3 months the patient is controlled on just one antihypertensive and her serum creatinine is 0.8 mg/dl.


DISCUSSION

Seventeen percent of patients with TD require surgical revascularization.[2] Operative intervention should preferably be delayed till a period of quiescence is achieved on steroids and the markers of active disease (ESR and C-reactive protein) are within normal limits as such interventions carry more chances of graft thrombosis and revision.[2] The surgical options include aortorenal bypass using saphenous vein or polytetrafluoroethylene (PTFE) graft, iliorenal bypass, aortic replacement graft-renal bypass.[3] Splenorenal bypass, renal autotransplantation using either direct or indirect reimplant, meandering collateral from inferior mesenteric arterial system,[4] or hepatorenal bypass.

We chose hepatorenal extra-anatomic bypass with internal iliac graft for renal revascularization as celiac axis is rarely involved in TD and the use of IIA as free graft has additional advantage of being able to tackle branches (as in our second case) or accessory RA requiring fewer number of anastomoses, as compared to prosthetic or saphenous vein graft. A good hepatic function is to be ensured before surgery.

As the disease frequently affects young women, obstetric complications are a common mode of presentation as in both of our patients. Maternal complications reported include superimposed pre-eclampsia, congestive cardiac failure, and progressive renal impairment. Abdominal aortic involvement and a delay in seeking medical attention are predictors of a poor perinatal outcome.[5] Almost all maternal and fetal complications result from uncontrolled blood pressure and outcomes can be improved with renal revascularization.

Postoperatively, the patients are kept on steroids and occasionally on cytotoxic drugs as the disease is believed to have an immunologic origin. They need careful follow-up because of incidences of restenosis and disease making appearance at new sites especially in cases operated in active phase of disease.[2] Long-term disease survival is excellent.

In conclusion, hepatorenal bypass using free IIA graft is an effective tool for renal revascularization in selected cases of TD.


Notes

Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES
1. Jain S,Kumari S,Ganguly NK,Sharma BK. Current status of Takayasu arteritis in IndiaInt J CardiolYear: 19965495100
2. Fields CE,Bower TC,Cooper LT,Hoskin T,Noel AA,Panneton JM,et al. Takayasu's arteritis: operative results and influence of disease activityJ Vasc SurgYear: 200643647116414389
3. Teoh MK. Takayasu's arteritis with renovascular hypertension: results of surgical treatmentCardiovasc SurgYear: 199976263210519671
4. Guleria S,Khazanchi RK,Aggarwal S,Sharma S. The meandering collateral.an alternative for renal revascularization?Br J UrolYear: 19988132459488083
5. Sharma BK,Jain S,Vasishta K. Outcome of pregnancy in Takayasu arteritisInt J CardiolYear: 20007515962

Figures

[Figure ID: F1]
Figure 1 

(a) Angiogram showing right renal artery stenosis. (b) Intraoperative photograph showing internal iliac artery anastomosed to hepatic artery and renal arteries. (c) Postoperative angiogram showing revascularized right kidney.



[Figure ID: F2]
Figure 2 

(a) Preoperative angiogram showing right renal artery stenosis. (b) Intraoperative photograph showing tubular IIA graft anastomosed to the hepatic arteryIntraoperative photograph showing tubular IIA graft anastomosed to the hepatic artery



Article Categories:
  • Case Report

Keywords: Takayasu's disease, hepatorenal bypass, hypogastric artery.

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