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24
III. ХИРУРГИЯ
UDC 616.61-007:616.136.7007.271-089
SURGICAL TREATMENT OF RENOVASCULAR HYPERTENSION WITH BILATERAL RENAL ARTERY STENOSIS.
ABOUT THE AUTHORS
KospanovA.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;
Keywords:
renovascular hypertension, bilateral renal artery stenosis, surgery.
Khanchi Mead, Kospanov N.A., Demeuov T.N., Akanov E.K., Matkerimov A.Zh., Baubekov A.A., Zhakubayev M.A., Asratov B.I., Tergeussizov A.S.
Science senter surgery A.N. Syzganov
Summary
Retrospective analysis of the survey results of 48 patients with RVH in conjunction with the defeat of other pools, as well as data on the effectiveness of surgery, allowed us a new aspect to characterize the value of diagnostic tests aimed at determining the functional significance of the defeat of the R.A.
After analyzing the results of surgical treatment, depending on the length of her previous hypertension, it can be concluded: the smaller the duration of the disease, the more frequently observed normalization of blood pressure, with a duration of hypertension is often mentioned as a significant improvement in the reduction of blood pressure numbers on the background of supporting antihypertensive therapy or reduce the antihypertensive drugs. During the combined method of surgical treatment (reconstructive intervention, endovascular angioplasty and the method combining with treatment) the best effect (90%) was achieved after application vasaprostan pre- and postoperatively with a complete rejection of antihypertensive drugs. Results in patients with atherosclerosis better (65%) than with aortoarteritis (35%).
Analyzing the results of surgical treatment with combined forms RVH should be noted that our intervention confirmed the high efficiency single-stage phase and tactics reconstructive surgery in two or more arterial beds (endovascular angioplasty) in patients with atherosclerosis immediate results are better than in patients with aortoarteritis.
БYЙpeк apтepиялapыньщ e^œa^biK тapылyы ^ç^eri вaзopeнaлды гипepтeнзияны xиpypгиялык eмдey
АВТОРЛАР ТУРАЛЫ
Коспанов Нурсултан Айдарханулы - А.Н.Сызганов атындагы Улттыщ €ылыми Хирургия орталыгыныц кан-тамырлар бол1мЩ мецгерушм, м.г.к., жо€аргы санаттагыхирург - дэргер. E-mail: kospanov.
nursultan@gmaii.com Ханчи Миад - А.Н.Сызганов атындагы Улттык F^/лыми Хирургия орталыгыныц кан-тамырлар бел/мшщхирургы, м.г.к., жо€ары санантты хирург - дэр1гер
TYérnceздep
вазopeналды гипертензия, буйрек артериялардьщ еюжактык тарылуы, хирургиялык емдеу
Ханчи Миад, Коспанов H.A., Демеуов Т.Н., Аканов Е.К., Маткеримов А.Ж., Баубеков А.А., Жакубаев М.А., Асратов Б.И., Тергеусизов А.С.
А.Н. Cbi3f3H0B атындаш Улттык, шлыми хирургия Орталыш
Ацдатпа
Bазopeналды гипертензия (ВРГ) ауруына шалдыккан баcка да бacceйндepiнiн закымдануы арала^ан 4S наукатi тетеру нэтижeлepiнiн, coндай-ак oлаpды жедел емдеудн тиiмдiлiгi туралы дepeктepiнiн peтpocпeктивтiк талда-уы жана атекпде ÁA закымдануынын фyнкциoналдык маныздылытн aныктayfa баfытталfан диагнocтикалык тесгтердщ кундылытн cипаттаyfа мумюндк бepeдi.
Онын гипepтeнзияfа дeйiнгi iлecпe ауруынын узактытнан жедел турде емдеу нэтижeлepi тэyeлдiгiнiн талдауын жаcай oтыpып, келеа кopытынды жаcаyfа бoлады: каншалыкты аурудын coзылyы аз бoлfан жащайда, coншaлыкJы AK (артериялык кан кыcымы) кеpceткiштepiнiн нopмада бoлyы байкалады, гипертензиянын coзылy мepзiмiнeн aca жащайда, гипoтeнзивтi терапияны кйлдайтын аяcында AK cандаpынын накты темендеу '1 репнде нeмece гипoтeнзивтi дэpi дэpмeктepдi кабылдауын азайту жащайы жиi дурышлуы байкалады. Хирургиялык емдеуд 'щ кypамбелiктi тэciлiн ^^нагру^ив^ хирургиялык apaлacy, эндoваcкyляpлык ан^пла^-ка жэне емдеудн кypaмбелiк тэт '!) кoлдaнfaн кeзiндe ен жакш acepœ o жетюзе алады (90%). Aтepocклepoзfa (65%) шалдыккан аурулардын нэтижeлepi aopтoapтepиитпeн (35%) ayыpaтындapfa кapafaндa жа^ырак.
ВРГ apaлac туpлepiмeн aopтoapтepиитoт дер™ жедел турде емдеу нэтижeлepiн талдай oтыpып, ею жэне oдaн да ашм артериалды бacceйндepiндe peкoнcтpyктивтiк apaлacyдын кезен-кезенмен жэне б'р cank такти^ы/нын (эндoвacкyляpлык aнгиoплacтикa жэне E пpocтaглaндинмeн киcындacтыpy тэcrni) жofapы тмдлИн рашды, aтepocклepoзfa шалдыккан аурулардын ткелей ндтижeлepi aopтoapтepиитпeн ауыратындардын ндтижeлepiнe кapafaндa айтарлыктай дypыcыpaк eкeндiгiн атап еткен жен.
44
ВЕСТНИК ХИРУРГИИ KA3AXCTAHA № 1-2016
Хирургическое лечение вазоренальная гипертензия при двустороннем стенозе почечных артерий
Ханчи Миад, Коспанов H.A., Демеуов Т.Н., Аканов Е.К., Маткеримов А.Ж., Баубеков A.A., Жакубаев М.А., Асратов Б.И., Тергеусизов A.C.
Национальный научный Центр хирургии им. А.Н. Сызганова
Аннотация
Ретроспективный анализ результатов обследования 48 больных с ВРГ в сочетании с поражением других бассейнов, а также данных об эффективности их оперативного лечения, позволил нам в новом аспекте характеризовать ценность диагностических тестов, направленных на определение функциональной значимости поражения ПА. Проведя анализ зависимости результатов оперативного лечения от длительности предшествующей ее гипертен-зии, можно прийти к выводу: чем меньше продолжительность заболевания, тем чаще наблюдалась нормализация показателей АД, при более же продолжительных сроках гипертензии чаще отмечалось улучшение в виде достоверного уменьшения цифр АД на фоне поддерживающей гипотензивной терапии или уменьшения приема гипотензивных препаратов.
При проведении комбинированного способа хирургического лечения (реконструктивные вмешательства, эндова-скулярная ангиопластика и способ комбинирования с лечением) наилучший эффект (90%). Результаты у больных с атеросклерозом лучше (65%), чем с аортоартериитом (35%).
Анализируя результаты оперативного лечение с сочетанными формами ВРГ следует отметить, что проведенные нами вмешательства подтвердили высокую эффективность поэтапной и одномоментной тактики реконструктивных вмешательств на двух и более артериальных бассейнах (эндоваскулярные ангиопластики и способ комбинирования с простагландин Е), у больных с атеросклерозом непосредственные результаты лучше, чем у больных с аортоартериитом.
ОБ АВТОРАХ
Коспанов Нурсултан Айдарханович - заведующий отделением ангиохирургии АО ННЦХ им.А.Н.Сызганова. к.м.н., врач высшей категорий. E-mail: kospanov.nursultan@gmail.com Ханчи Миад - врач-хирург отделения ангиохирургии АО ННЦХ им.А.Н.Сызганова. к.м.н., врач высшей категорий.
Ключевые слова:
вазоренальная гипертензия, двусторонние стеноз почечных артерий, хирургическое лечение
It is very complex and still debated is the question of general and specific indications for reconstructive surgery for patients with severe bilateral lesion of the Palestinian Authority and with the defeat of the only functioning kidney arteries.
Malignant hypertension for the majority of these patients, and the possibility of renal failure in the case of an unsuccessful reconstruction significantly increases the risk of surgery. Several authors (AV Pokrovsky, A. Spiridonov; Foster et al., 1973) is considered to make surgery in stages, we do believe it is necessary to produce the two-stage correction of abnormal renal arteries (R.A).
Material and methods. With 2000 to 2010, Department of Vascular Surgery Syzganov observed 270 patients with symptomatic hypertension caused by renovascular hypertension (RVH).
The main etiological factors in this process are: atherosclerosis, nonspecific aortoarteriit PA. Of these, stenosis of both renal arteries are 48 cases of 20 with atherosclerotic etiology, 28 patients with aortoarteritis .
Surgical treatment of bilateral lesions depends on the general condition of the patients and accompanying whitening, and when combined with Leriche syndrome and aortic aneurysm requires one-stage reconstruction of the R.A and the abdominal aorta. When combined lesions of the R.A and the aortic arch branches made 14 surgeries in this group of
Figure 1
Angiogram. aortoarteritis. Stenosis of abdominal aorta in the infrarenal section. King King of the abdominal aorta. Renovascular hypertension. Occlusion of both renal arteries
patients. Reconstructive surgery aimed not only at eliminating systemic hypertension, but also to restore regional blood circulation disorders. In this regard, the correct definition of treatment policy and related issues with her choice of surgical intervention, surgical approaches and methods of correction of disorders of blood circulation in the different vascular territories is of paramount importance.
The choice of surgical tactics in the reconstruction of the renal artery
Against the background of atherosclerosis are the main options for reconstruction after aortic
Figure 2
Angiogram patient B.
Multiple lesions of aortic arch branches and visceral branches of the abdominal aorta. Stenosis of the right subclavian artery
Figure 3
Schematic representation of the I and II stages of the operation. The first step performed abdominal aortic prosthesis. Endar-terectomy from the mouth of the left renal artery.
Prosthetics right artery. The second stage is made splenotomiya right. Subclavian, axillary alloshunt
Figure 4
Angiogram. Syndrome Denereya-Leriche. A critical stenosis of both renal arteries
endarterectomy, prosthetics, or renal artery bypass grafting or replantation it into the aorta. When aor-toarteriit endarterectomy not shown, and the most effective method of reconstruction of the renal artery in these cases it is, or bypass prosthesis. The long artery stenosis is an indication for prosthetic surgery for any cause of the disease.
The development of endovascular surgery technology occlusive vascular lesions allowed in certain situations to give up direct reconstructive opera-
tions on the R.A [1,2,3,4,5,6]. That, according to the authors [7,8,9,10,11,12] is especially important for elderly patients with underlying renal disease, diabetes and low functional reserves of the body and life support systems, where particularly high risk of surgery and anesthesia.
The first step performed abdominal aortic prosthesis. Endarterectomy from the mouth of the left renal artery. Prosthetics right artery. The second stage is made splenotomiya right. Subclavian, axillary alloshunt
Results of surgical treatment of renovascular hypertension
Retrospective analysis of the survey results of 48 patients with RVH in conjunction with the defeat of other pools, as well as data on the effectiveness of surgery, allowed us a new aspect to characterize the value of diagnostic tests aimed at determining the functional significance of the defeat of the R.A.
Assessment of the immediate and long-term results of surgical treatment we conducted by comparing the blood pressure before and after the operation. In addition, we found it appropriate to use as an additional criterion for the efficiency 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 the operation, and no more than 140/90 mm Hg without medication, 2) satisfactory results - in this group were off sick, which reduced blood pressure after surgery to limit values, ie, not more than 160/100 mm Hg, and disappeared refractory to antihypertensive drugs, and 3) poor performance - in this group of patients in whom blood pressure greater than 160/100 mm Hg
As can be seen from the data presented in the tables, the results of surgery were positive (good, satisfactory) at 26, which was 90%, unsatisfactory results were observed in 2 patients - 9.6%.
Blood pressure before surgery in patients with atherosclerosis of 210/120 mm Hg up to 280/140 mm Hg - 2 cases with Aortoarteritis of 210/120 mmHg up to 300/150 mm Hg - 1 case.
In the group with atherosclerotic lesions of the RA in 18 patients before surgery the average blood pressure were as follows: systolic - 181±20,0 mm Hg and diastolic from 105±13,5 mmHg After surgical treatment in this group of patients showed a significant reduction (P <0.05) in systolic and 140± 11,0 mmHg and diastolic 93±3,0 mm Hg In patients with aortoarteritis - 25 of blood pressure patients before surgery were as follows: systolic 182±23,0 mm Hg, diastolic - 108±16 mm Hg After surgical treatment showed a significant reduction in average
blood pressure (P <0.05) - 147±110 mmHg and diastolic 94±3,0 mm Hg
After surgeries, we studied 48 patients with RVH results of operations. As can be seen from the data, the results of operations were positive (good and satisfactory) in 44 (90%), and the group "good" could include 24 patients and the group "satisfactory" - in 20 patients. Unsatisfactory results of the operation were observed in 3 patients (8.3%).
The analysis results of the operations depending on the nature of surgical intervention and etiology found that the results in patients with atherosclerosis better than with Aortoarteritis (Table 2).
After analyzing the results of surgical treatment, depending on the length of her previous hypertension, it can be concluded: the smaller the duration of the disease, the more frequently observed normalization of blood pressure, with a duration of hypertension is often mentioned as a significant improvement in the reduction of blood pressure numbers on the background of supporting antihypertensive therapy or reducing antihypertensive drugs (Table 3).
Post operative complications
Postoperative complications were observed in 1 patient T., 41, she entered the clinic February 14, 2002 Clinical diagnosis: suprarenal aneurysm, interrenalnogo and infrarenal abdominal aorta. Renovascular hypertension. Stenosis of both the PA. Nephroptosis right of II degree. Chronic pyelonephritis. Chronic renal failure I of a degree. Acute postoperative renal failure, anuria stage. Produced thoraco Fresne-lumbotomy left. Aorto-birenalnoe alloprotezirovanie bifurcation. Resection
Etiological factors RVH blood pressure
150-90 mmHg 170-100 mmHg 180-100 mmHg 200-110 mmHg 210-120 mmHg over
Atherosclerosis 20 4 6 8 2
Aortoarteritis 28 2 14 8 4
Etiological factors RVH number of transactions Good satisfactory unsatisfactory
№ % № % № % № %
Atherosclerosis 20 41,7 15 75 4 20 1 5
Aortoarteritis 28 58.3 9 32 16 57 3 10,7
Total 48 100 24 50 20 41,7 4 8.3
Duration-of hypertension in years Short-term results of surgical treatment
number of patients Good satisfactory unsatisfactory
1-5 20 12 8 0
6-10 16 10 5 1
11-20 10 2 6 2
over 20 2 0 1 1
Total 48 24 20 4
Figure 5
Schematic representation of both transluminal balloon angioplasty of the renal arteries
Figure 6
Schematic representation of the steps (I - II) operation. The first stage of the operation performed: Transluminal balloon angioplasty a.subclavia sin., A. axilaris sin., a.lumbalis sinistrae on both sides of the vertebral and carotid arteries of the right to good effect, the second stage, after 3 months, the operation was planned -both balloon angioplasty of the renal arteries
Table 1
Shows the blood pressure of the etiological factors before surgery.
Table 2
Short-term results of surgical treatment
Table 3
Short-term results of surgical treatment in patients with VRH depending on the duration of hypertension
Figure 7
Angiogram. Aortoarterit. Renovascular hypertension. Occlusion of the right, left renal artery stenosis. Stenosis of the infrarenal abdominal aorta
Figure 8
Schematic representation of of the operation. Aorto-birenal alloshunti
of abdominal aortic aneurysm with a linear allopro-tezirovaniem. In the postoperative period in the 1st day developed acute renal failure (anuria, hypera-sotemia, hyperkalemia, hyperhydration) - intensive care patients were in full: nasogastric tube; antibiotic therapy: tsefabol 4 g / day., metrogil 200 ml / day / in; stimulation of the intestine: Reglan 2 ml 4 p / day., Neostigmine 1 ml 4 p / day .; cardio-meta-bolic therapy: Riboxinum 10 ml 2 p / day., aktovegin 200 mg 2 r / d., a mixture of 200 ml of polarizing a / c, vitamin; nootropic therapy. Following initial treatment, the patient's condition progressively deteriorated - anuria persisted, growing phenomenon of uremia (creatinine 0.3 mg / dL, urea 26 mmol / L, hyperkalemia 6.48 mmol / l was growing Clinic of acute renal, respiratory, cardiovascular disease. 23.02.2002 the patient was pronounced dead Long-term results of surgical treatment Long-term results of surgical treatment of 20 patients with combined forms of RVH, we studied in terms from 6 months to 5 years. According to the etiology: the basic group consisted of patients with atherosclerosis - 10 (50%), with aortoarteritis - 10
(50%). In assessing the hypotensive effect after the operation on the RVH in the late postoperative period, we studied in 20 patients yielded the following results: 1 year after the operation a positive hypoten-sive effect was maintained in 18 (85%), in 2 years - in 17 (82% ), after 5 years - 14 (70%) patients.
Analysis has shown that in the long-term period after surgery in 14 patients (70%) patients showed normalization of blood pressure and no longer necessary in the application of antihypertensive drugs in 5 (25%) patients had a hypotensive effect, but blood pressure was within the "border" of values (140 / 90-160 / 100 mm Hg) and maintained the need for maintenance medication. The operation did not affect the nature and degree of hypertension in 1 (5%) patients. The positive results in the long-term period after surgery "good" and "satisfactory" overall were seen in 18 patients, satisfactory results (no hypotensive effect) - 2 patients, the mean systolic blood pressure in this group of patients before surgery were 186±20,0 mm Hg diastalicheskogo of blood pressure 105±9,0 mm Hg (Figure 4.1)
In the late postoperative periods, these figures decreased significantly, respectively, to 135±13,0 and 88,6±2,1 mm Hg The difference 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 the surgery died of increasing chronic renal failure. Nearest results of operations of these patients were also unsatisfactory.
Patient K., 65 years old, to operate with a diagnosis of atherosclerosis, Leriche syndrome, VRG, both baked artery stenosis. Malignant over, carried out the operation - aortofemoral bifurcation bypass (ABBSH) with TAE from both baked arteries. The patient died from myocardial infarction. It seems possible comparative evaluation of tactical approaches and a comparison of the incidence of late postoperative complications revascularized pools at the landmark and simultaneous operations, and non-operated patients due to progression of atherosclerosis and aortoarteritis.
As the analysis of long-term results of conservative treatment, for five years died 3 (20%) patients, one of them died on the rise of chronic renal failure, and 2 - from myocardial infarction.
Analysis of the results, of course, shows that the risk of disaster in the uncorrected vascular regions is higher than in the renovated pools. Within five years of stability to complications after surgery was 5.7% and the uncorrected blood pool amounted to 20% of patients.
The best method of treatment is angioplasty, open surgical procedures continue to be carried out
in the absence of experience or ability to radiologists at comorbidity, when the reconstruction of the renal artery efficiently perform simultaneously with aortic or other arteries from one access.
When choosing the type of surgery at wellhead stenosis Renal artery atherosclerosis background main options for reconstruction are transaortal endarterectomy, prosthetics, or renal artery bypass surgery, or replantation it into the aorta.
When aortoarteriit endarterectomy is not shown, and the most effective method of reconstruction of the renal artery in these cases, it is replacing or bypass surgery. The long artery stenosis is an indication for prosthetic surgery for any cause of the disease.
The choice of method of surgical reconstruction at the local lesion resection can be modified portion of the renal artery anastomosis with end-to-end or replantation of the aorta. In diffuse arterial lesions show her prosthetic.
In severe bilateral disease, including stenosis, elongation and roughness of the course of the renal arteries. The unusually long length of the arteries allowed resect segment changes and, despite this,
Reimplantirovat both artery and the aorta without the use of additional strain relief and the plastic material.
The operation was carried out from the median laparotomy. Laparotomy is convenient for simulta-
References
1. Arabidze., GG, Arabidze Gr.G. Diagnosis of arterial blood pressure - Angiology and Vascular Surgery 2000; 1: 123. 125.
2. Dzhakupov VA Surgical treatment of rare and combined forms of symptomatic hypertension. Diss ... cand. honey. Sciences: 14.00yu.44 -Alma Ata -1988
3. Y. Belov, AN Kostenkov, Gavrilenko AV et al. Long-term Results of surgical treatment of patients with renovascular hypertension // chest. and cardiovascular surgery. -1993. -№ 4. -P.20-23.
4. Pokrovsky AV Clinical Angiology. -2004. -P.95-114.
5. B .V. Petrovsky et al. 40 years of experience in reconstructive surgery at renovascular hypertension // Angiology and Vascular Surgery. - 2003. -№ 9. -S.8-12.
6. Carmo M., Bower TC Mazes G. Surgical management of renal fibro -muscular dysplasia. Ann surg 2005; 19: 208-217.
neous correction of two renal arteries. The main advantage of the opportunity to perform the reconstruction of the access not only to the renal arteries, but if necessary, and infrarenanal aorta, inferior mesenteric and iliac arteries. This access is ideal for patients with fibro muscular dysplasia.
Single-stage reconstruction of both renal arteries of laparotom has established itself very well and is now the method of choice for bilateral renal artery stenosis. As a result, a one-time recovery of blood flow in the renal artery blood pressure reduction in patients sometimes have reserved the blackness on the operating table, whereas a phased correction pressure often normalized after the final reconstruction.
Analyzing the results of surgical treatment with combined forms RVH should be noted that our intervention confirmed the high efficiency single-stage phase and tactics reconstructive surgery in two or more arterial beds (endovascular angioplasty) in patients with atherosclerosis immediate results are better than in patients with aortoarteritis.
7. Pokrovsky AV, Barabbas BN, VI Yudin et al. Surgical tactics in combined aortic arch branch and its thoracoabdominal segment in aortoarteriit // Surgery. -1991. -№ 6. -P.12-19.
8. Abugova SP, GR Arabidze 27 years of experience in the clinical study of nonspecific aortoarteritis // Nespetsifechesky aortoarteriit. -M., -1984. -P.50-51.
9. Sugraliev AB Arabidze GG, Nasonov EL Cardiac involvement in aortoarteriit // Cardiology. -1995. -№ 3. -P.83-87.
10. BV Petrovsky et al. 40 years of experience in reconstructive surgery at renovascular hypertension // Angiology and Vascular Surgery. -2003. -№ 9. -P.8-12.
11. Golosovskaya MA NAA pathological anatomy // Arch. pathological. -1972. -m. 34. -№ 1. -P.40-45.
12. Pokrovsky AV, Zotikov AE, VI Yudin - aortoarteriit // -Moscow. -2002. -P.127-135
