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32
III. ХИРУРГИЯ
10 - YEAR EXPERIENCE IN OPERATIONS OF RENOVASCULAR HYPERTENSION. THE COMPLETE SURGICAL TREATMENT OF VASO-RENAL HYPERTENSION
Khanchi Mead, Kospanov N.A., Demeuov T.N., Alzhanova A.B., Akanov E.K., Matkerimov A.Zh., Zhakubayev M.A., Tergeussizov A.S.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan Department of angiosurgery
Abstract
From the year 1995 to May 2010 in Syzganov Scientific Centre of Surgery there were167 patients in admission, who suffer from VRH and those having stenosis-occlusive lesion of other arterial bases and who's having other diseases.
The direct surgical reconstruction was done on 146 patients and includes reconstructions of various types as: aorto-renal shunts, trans-renal thrombendarterectomy, trans-aortal thrombendarterectomy, re-plantation of renal artery, reconstruction of the renal artery branch, nephrectomy.
The endovascular treatment method includes balloon angioplasty dilatation and stint formation renal artery. Therefore, when using vasaprostan in combination with multi-focal lesion of other arterial bases, quick lowering of the arterial pressure is noted, absence of risk of arterial thrombosis during the post-surgical period, the need for administering anti-hypertensive drugs is over-ruled, the risk of re-stenosis is eliminated.
UDC 616.12-008.331.1:616.136.7-002
About the authors:
Kospanov A. Nursultan - head of the department of angiosurgery, can. med., a high level certificate physician;
Khanchi Mead - surgeon of the department of angiosurgery, can. med., a high level certificate physician.
Key words:
complex surgical treatment, direct surgical reconstruction, endovascular treatments.
Реноваскулярлык гипертензияны емдеудеп 10 жылдык тэж1рибе. Артериалды-та-мыр буйрек гипертензияны кешенд1 хирургиялык емдеу
Ханчи Меад, Коспанов H.A., Демеуов Т.Н., Элжанова А.Б., Аканов Е.К., Маткер1мов А.Ж., Жакубаев М.А., ТергеуЫзов A.C.
А.Н. Cbi3f3H0B атындаш Улттык, шлыми хирургия орталыш, Алматы, К,азак,стан Кан тамырларды емдеу бел1мшеС
Ацдатпа
1995жылдан бастап 2010жылдын, мамыр айы мерз'тнде А.Н.Сызганов атындагы Улттык гылыми хирургия ортальгында 167 пациентдэргердщ кабылдауында болды, аталмыш пациенттер артериалды-тамыр буйрек гипертензия ауруына, баска артериялык аяк жагы тарылу-окклюзиялык закымдануларга ±шырап, езге де ауруларына да шалдыккан.
Т1келей хирургиялык реконструкция ретнде ота 146 пациентке жасалды, сонын, ¡ш1нде эртурлi реконструкцияларды келесщей косканда: аорто-буйрек шунттар, транс-буйрек тромбэндартерэкто-мия, транс-аорталды тромбэндартерэктомия, буйрек артериясыныц реплантациясы, буйрек артерия бутактарыныц реконструкциясы, нефректомия.
Эндоваскулярлык емдеу эдiсiне баллонды ангиопластика, дилатация жэне буйрек аретриясыныц пайда болуын шектейд'1. Сонымен, езге артериялык базалардын, мульти-ошак, аскынуымен аралас вазапрастанды колданган кезнде артериялык кан кысымы жылдам темендеу'1, операциядан кейшп мерз 'тнде артериялык тромбоз пайда болу катер'1 болмауы, антигипертониялык дэрiлердi енпзу кажеттiлiгi байкалады, кайталама тарылу катер'1 жойылады.
Авторлар туралы:
Коспанов Нурсултан Айдарханулы - А.Н. Сызганов атын. YFXO кан-тамырлар хирургиясы белiмшесiнiц мецгерушiсi, м.г.к., жогаргы санатты дэргер; Ханчи Меад - А.Н. Сызганов атын. YFXO кан-тамырлар хирургиясы белiмшесiнiц дэрiгерi, м.г.к., жогаргы санатты дэрiгер.
Тушн сездер:
кешендi хирургиялык ем, лкелей хирургиялык реконструкция, емдеудщ эндоваскулярлык эдiстерi.
10 - летний опыт работы в лечении реноваскулярной гипертензии. Комплексное хирургическое лечение артериально-сосудистой почечной гипертензии
Об авторах:
Коспанов Нурсултан Айдарха-нович - заведующий отделением ангиохирургии ННЦХ им. Сызганова, к.м.н., врач высшей категории, хирург, e-mail: [email protected]; Ханчи Меад - врач-хирург отделения ангиохирургии ННЦХ им. Сызганова, к.м.н., врач высшей категории, e-mail: [email protected]
Ключевые слова:
комплексное хирургическое лечение, прямая хирургическая реконструкция, эндоваскуляр-ные методы лечения.
Ханчи Меад, Коспанов H.A., Демеуов Т.Н., Альжанова А.Б., Аканов Е.К., Маткеримов А.Ж., Жакубаев М.А., Тергеусизов A.C.
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан Отделение ангиохирургии
Аннотация
В период с 1995 по май 2010 года в Национальном научном центре хирургии им. Сызганова было 167 пациентов на приеме, которые страдают артериально-сосудистой почечной гипертензией и имеют стеноз-окклюзионные поражения других артериальных оснований, и те, кто имеют другие заболевания.
Прямая хирургическая реконструкция была сделана 146 пациентам, и включала в себя реконструкции различных типов как: аорто-почечных шунты, транс-почечная тромбэндартерэктомия, транс-аортальная тромбэндартерэктомия, реплантация почечной артерии, реконструкции почечной артериальной ветви, нефректомия.
Метод эндоваскулярное лечение включает в себя баллонную ангиопластику дилатацию и ограничение образования почечной артерии.
Таким образом, при использовании вазапрстана в сочетании с мульти-очаговым поражением других артериальных баз, отмечалось быстрое снижение артериального давления, отсутствие риска артериального тромбоза во время послеоперационного периода, необходимость введения анти-гипертонических препаратов переисключено, устраняется риск повторного стеноза.
The problem of diagnosis and surgical treatment of renovascular hypertension (RVH) whitening in which persistent increase in blood pressure caused by lesions (stenosis, occlusion, aneurysm) of the renal arteries or their branches without a primary lesion of renal tissue and urinary tract, remains valid today. (5)
Presently, arterial hypertension (AH) ranked first in the structure of morbidity and is a leading cause of temporary or permanent disability, premature disability and death. That is why the problem of treatment is of great socio-economic importance.
Recently, complex examination included ultrasound, angiography, MRA, scintigraphic research methods, which significantly increased the percentage of detection of surgical forms of hypertension. (4,5,6)
A special place among patients with renovascular hypertension take patients with multifocal arterial stenotic lesions of various etiologies (atherosclerosis, aortoarteritis). Multifocal lesion of blood vessels difficult and increases the risk of surgical treatment (direct and endovascular) in various arterial beds (3).
The purpose of the study - to show the effectiveness of an integrated approach in the choice of surgical approach for the treatment of patients with RVH and multifocal vascular lesions.
Materials and methods. From 1995 to 2010 in the department of vascular surgery of the National scientific center of surgery named after A.N. Syzganov there were observed 167 patients with AH caused by RVH. The main etiological factors in this process are: atherosclerosis, aortoarteriit RA (Table. 1).
Table 1
Distribution of patients according to the etiology of renovascular hypertension
Etiological factors RVH number of patients Men Women
абс. % абс. % абс. %
Atherosclerosis 96 57,5 86 51,5 10 6
Aortoarteritis 71 42,5 36 21,5 35 21
Total 167 100 122 73 45 27
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BECTHÈK ХИРУРГИИ KA3AXCTAHA № 2(43)-2G15
We observed 167 patients with VRH - 96 atherosclerotic etiology, accounting for 57.5%, 71 (42.5%) patients with aortoarteritis.
Distribution of patients by sex and age shows a clear predominance of male patients - 86 men (51.5%) and 10 women (6.0%). In men aortoarteritis - 36 (21.5%), women - 35 (21.5%). The combination of RVH patients with aortic aneurysm various localization: 12 men and 4 women. Etiologic factor in the development of aortic aneurysm was atherosclerotic 10, and aortoarteritis in 6 patients, stenosis of the RA in combination with abdominal aortic aneurysm was observed in 10 patients, abdominal aneurysm thoroco - combined with RV^ in 5, RVÍ with an aneurysm of the aortic arch - in 1 patient.
This group of patients, we have identified separately because it was subject to surgical interventions for health reasons.
RVH for atherosclerotic etiology is characterized by a combination of RA and distal lesions of the affected segment of the aorta and lower extremity arteries. Thus, of the 96 patients with mixed form RVH atherosclerotic etiology was observed in 55 patients, most often, such cases are indicated in combination with Leriche syndrome, which accounted for 63.9%, and only 29.1% of the observations had a combination of defeats the RA with brachiocephalic vessels - 31 patients. In accordance with the literature, we have observed that the systemic lesion of atherosclerosis is characterized by arterial other pools. So, RVH is most common in conjunction with aorto-iliac lesion (AI) (63.9%) and branches of the aortic arch (BAA)
n -
no -
I2i -
ia& -80 ■ 60 ■
■1u --
0 ■
age
The most severe group of patients (in terms of surgical treatment and progressive course) with the defeat of the Palestinian Authority and other arterial beds consists of patients suffering from nonspecific aortoarteritis.
Compare different methods of surgical treatment - direct reconstructive operations, endovascular angioplasty and way of combining them with treatment of vazaprostan (1.2).
(10.5%) and in the defeat of several segments of the aorta in 25.57%.
Indicating the etiological factor in atherosclerosis lesions, there are cases of additional RA (5 patients - 5.8%).
In our observations branches of RA stenosis combined with abdominal aortic aneurysm was observed in 10 patients, abdominal aneurysm thoroco- combined with RVH - in 5, RVH with an aneurysm of the aortic arch - in 1 patient.
In our study, 65 (39%) patients with aortoarteritis. Men - 34, women - 31, which is different from the literature, which indicates to the predominant involvement of female patients.
At aortoarteritis there are cases of stenosis of both the RA in combination with a king-king syndrome abdominal aortic syndrome or chronic abdominal ischemia (SCHAI) and patients with congenital aplasia kidney abnormalities forms of development, and the mechanism of the HS may be twofold. On the one hand, at the last occurrence of renal aplasia, and on the other as a result of stenosis, aplasia and RA.
Most patients with RVG in conjunction with the defeat of the other basins of the arterial system had on patients with aortoarteritis, whose age ranged from 41 to 78 years (mean age 54 ± 0,5), according to the literature on the second place is the MDF, but, according to our data in second place is the aortoarteritis, aged 7 to 40 years (mean age 27,4 ± 1,5). Over age were patients with atherosclerosis, and the youngest with aortoarteritis and abdominal aortic aneurysm (mean age 57,2± 1,7) (Fig. 1).
Atherosclerosis
—Aortoarteritis
aortic aneurysm
Total Trial
Surgical reconstruction of the direct (148 patients) included the following types of renovations: aortorenal bypass, dia-renal thrombendarterectomy, transaortic thrombendarterectomy, replantation of the renal artery, renal artery reconstruction branches, nephrectomy.
Endovascular treatment includes balloon angioplasty (53 patients) and stenting (4 patients) summarizes the patients with aortoarteritis in
167
as
Fig. 1
Distribution of patients according to disease etiology and age summarizes the patients with aortoarteritis in combination with other lesions PA and arterial beds.
combination with other lesions PA and arterial beds.
Along with the surgical treatment of hypertension there have been attempts medical correction of high blood pressure, but the usual antihypertensive drugs had no significant effect in renovascular hypertension. This state of affairs was observed before the opening of prostaglandin E.
Both methods aim to improve kidney blood flow and reduce the release hormones into the blood-vasoconstrictors.
Between the ways there is a significant difference: the surgical treatment of trunk marked improvement in renal blood flow, whereas prostaglandin E has a positive impact mainly on the microcirculation in the ischemic kidney.
However, the known methods have a number of significant drawbacks, namely the first (endovascular) affects mainly on macro-and requires some time to adapt renal microvasculature, long existed in conditions of high blood pressure, which requires the support of antihypertensive treatment and anticoagulant therapy; second (drug) only affects the microcirculation mechanism and thrombus formation, but does not lead to the restoration of the main blood flow, which in turn is reflected in the short-term antihypertensive effect and requires further of multiple courses of treatment (3-4 times a year throughout life) .
The objective of the combined method of treatment of patients with arterial hypertension caused by renal artery stenotic lesions, is that the combined treatment avoids the long-term maintenance therapy or repeated courses of drug antihypertensive therapy, as well as reducing the risk of thromboembolic complications in the postoperative period.
The most common, especially in patients with atherosclerosis, makes dia-aortic endarterectomy from the mouth of the renal artery. With the defeat of fibrous dysplasia -Muscular proximal and middle thirds of the renal artery in a relatively small area of operation is the optimal resection of the lesion with anastomosis end to end.
With the defeat of the renal arteries nonspecific aortoarteritis best proven shunt surgery. As a plastic material there were used autovein and synthetic prostheses. Particularly noteworthy are the patients with bilateral lesions of the renal artery stenosis or renal artery only bilateral renal artery lesion occurred in 52 (28.5%). Severe general condition of patients in this group, the malignant nature of hypertension in most of them, the possibility of renal failure in case of failure of reconstructive surgery makes the risk of surgery is very high, the risk of progression of the underlying disease and thrombosis of both renal
arteries necessitate reconstructive interventions in this group of patients .
Assess the immediate and long-term results of surgical treatment, we carried out by comparing the level of blood pressure before and after the operation. In addition, we found it useful to use as an additional criterion for the effectiveness of the operation - its effect on renal function.
Depending on the effectiveness of treatment of the operated patients were divided into three groups:
1) good results - this group included patients whose blood pressure returned to normal after surgery and no more than 140/90 mm Hg without drug therapy,
2) satisfactory results - in this group were off sick, which BP after surgery decreased to limit values, ie no more than 160/100 mm Hg, and disappeared refractory to antihypertensive medication, and 3) unsatisfactory results - in this group of patients in whom blood pressure was greater than 160/100 mm Hg
As can be seen from the data, the operation results were positive (good, satisfactory) at 132, that was 90.4%, unsatisfactory results were observed in 14 patients - 9.6%.
Blood pressure before surgery with atherosclerosis more than 210/120 mm Hg up to 280/140 mm Hg - 18 cases, with aortoarteritis more than 210/120 mm Hg up to 300/150 mm Hg - 14 cases.
In atherosclerotic lesions of the group with the PA in 90 patients before surgery average blood pressure were: systolic - 192 ± 3,5 mm Hg and a diastolic from 109 ± 2 to 150 mm Hg. After surgical treatment in this group of patients there was a significant decrease (P <0.05) in systolic to 139 ± 1,5 mm Hg, diastolic and 90 ± 7 mm Hg. In patients with aortoarteritis - 56 AD patients before surgery was: systolic 194 ± 4.9 mm Hg, diastolic - 110,35 ± 2 mm Hg. After surgery there was a significant reduction in average blood pressure (P <0,05) - 135,5 ± 1,5 mmHg and diastolic 90 ± 2 mm Hg
After the surgeries, we studied 146 patients with VRG's results of operations. As can be seen from the data presented in the graph, the results of surgery were positive (good and satisfactory) in 132 (90.4%), and to the group of «good» could include 50 patients, as a group, «satisfactory» 82 patients. Unsatisfactory results of the operation were observed in 14 patients (9.6%) - in 11 of them (7.5%) positive dynamics has not come, and 3 patients (2.5%) died in the early postoperative period. In the analysis results, depending on the nature of the operations performed surgery and etiology found that the results in patients with atherosclerosis (57.6%) is better than with aortoarteritis (32.9%) (Table 2).
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2(43)-2015
Etiological factors RVH Number of operations good satisfactory unsatisfactory
Pat. % Pat. % Pat. % Pat. 52
Atherosclerosis 90 61,6 32 22 52 35,6 6 4
Aortoarteritis 56 38,4 18 12,3 30 20,6 8 5,5
Total 146 100 50 34,3 82 56,2 14 9,5
Table 2
Short-term results of surgical treatment
Postoperative complications occurred in 10 (6.8%) patients, most often in 4 patients (40%) were observed complications from lung and pleural cavity, which usually was associated with the opening of the pleural cavity during thoraco Fresne-lumbotomy. The development of these complications have contributed to the error management of patients in the postoperative period, inadequate drainage of the pleural cavity, late activation of patients, as well as in the postoperative period, 2 patients developed venous thrombosis, 1 patient -postoperative bleeding and hematoma that required additional surgery to remove it. These complications significantly extended periods of treatment, but in all cases, there is a successful outcome and recovery. Postoperative mortality was 2.1% of all patients with VRG. After the operation as a result developed severe postoperative complications 3 patients died.
Long-term results of surgical treatment of 52 patients with combined forms VRG we have studied in the period from 6 months to 5 years. Etiology: a core group consisted of patients with atherosclerosis - 32 (61%), with aortoarteritis - 20
(39%). In assessing the hypotensive effect after operations on the VRG in the late postoperative period, we studied 52 patients, obtained the following results: 1 year after surgery hypotensive effect remained positive in 44 (85%), after 2 years -in 42 (82%) at 3 years - 41 (79%) after 5 years - 36 (70%) patients.
Analysis has shown that in the long-term period after surgery in 36 (70%) patients showed normalization of blood pressure and no longer needed the use of antihypertensive drugs, 13 (25%) patients had a hypotensive effect, but blood pressure was within the "border" of values (140 / 90-160 / 100 mm Hg) and saves the need for supportive medical therapy. The operation did not affect the nature and degree of hypertension in 3 (5%) patients. It can be seen that the positive results in the long-term period after surgery "good" and "satisfactory" in general were observed in 49 patients, satisfactory results (no hypotensive effect or death) - in 3 (9.3%) patients, the mean systolic blood pressure in patients with this group before surgery were 174 ± 11,2 mmHg diastolic blood 112 ±3.7 mmHg
In the late postoperative periods, these figures have declined significantly, respectively, to 142,5 ± 6,1 and 88,6 ± 2,1 mm Hg Differences between pre- and postoperative blood pressure levels in the long term was statistically highly significant (p <0.001).
Causes of poor results in the late postoperative period were subjected to special analysis. Two of the 3 patients within three years after surgery
died of increasing chronic renal failure. The early results of operations of these patients were also unsatisfactory. Thus, the patient D., 48 years, operated on for thoracoabdominal aneurysm resection of the aneurysm with endarterectomy from the mouth of the right VA. One year after surgery, the patient developed end-stage renal failure, the patient died of the myocardial infraction. Pri conducting combined method of
surgical treatment (reconstructive intervention, endovascular angioplasty and way of combining the treatment of vasaprostan) best effect (90%) was achieved after application of vasaprostan before and after Full operation waiver of antihypertensive drugs. Results in patients with atherosclerosis are better (65%) than with aoroarteritis (35%). In the group of patients after combined endovascular treatments and there was a significant improvement in results in the postoperative period after application vasaprostan (mean blood pressure decreased in the group after combined treatment of
128+9,6 and 84+5. Without the use of vasaprostan blood pressure was 140+ 8,3 m 87+68). Remote results of surgical treatment after endovascular surgical we have studied, in a period of 1 year to 3 years, a comparative evaluation carried out on 20 patients with combined forms VRG - 10 patients after use of vasaprostan obtained the following results: 1 year after surgery hypotensive effect remained positive in 9 ( 90%), after 2 years - in 8 (80%), after 3 years - in 7 (70%), without the use of vasaprostan (Alprostadilum) also analyzed in 10 patients: antihypertensive effect was maintained in 7 (70%) after 2 years - in 6 ( 60%) after 3 years - 5 (50%) patients.
Figure 3
Long-term results of surgical treatment of endovascular surgical
Analyzing the results of surgical treatment with combined forms RVG should be noted that our intervention confirmed the high efficiency singlestage phase and tactics reconstructive operations on two or more arterial beds (endovascular angioplasty and way of combining with vasaprostan - Alprostadilum) in patients with atherosclerosis immediate results better than patients with aortoarteritis.
Thus, the renal artery revascularization achieves stable positive result in patients with renovascular hypertension. To improve outcomes it is required early diagnosis and the upgrade during a benign course of the disease. The most common, especially in patients with atherosclerosis, makes through the kidney endarterectomy from the mouth of the renal artery.
With the defeat of fibrous dysplasia - Muscular proximal and middle thirds of the renal artery in a relatively small area of operation is the optimal resection of the lesion with anastomosis end to end.
Using vasaprostan (Alprostadilum) in the combined treatment of patients with renovascular hypertension and multifocal lesions of other arterial beds faster decrease in blood pressure, there is no danger of arterial thrombosis in the immediate
postoperative period, eliminating the need for antihypertensive drugs significantly reduced the risk of restenosis.
References
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2. Dudarev V.E., et al, Effectiveness of vasaprostan in improving long-term results of endovascular interventions. Angiology and Vascular Surgery. 2002; 8: 1: 13-16.
3. Bokeria L.A., et al. Endovascular treatment of patients with multifocal atherosclerosis. - Annals of Surgery. 2002, - №1, p. 11-17.
4. Petrovsky B.V., et al. 40 years of experience in reconstructive surgery at renovascular hypertension. - Angiology and Vascular Surgery. -2003, № 9, pp 8-12.
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6. DeBekey M.E. New Life heart. - Moscow, 1998
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ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2(43)-2G15
