Renal Artery Dissection

Abstract

Renal artery dissections are stenotic or occlusive lesions most often observed in hypertensive patients with underlying atherosclerosis or fibromuscular disease. Acute dissections may present spontaneously, as a complication of diagnostic or therapeutic angiography or as an agonal event associated with overwhelming systemic illness. Chronic dissections may produce renovascular hypertension or be entirely asymptomatic. Renal artery dissections [14] were encountered in 9 patients treated during the past decade. Dissections [11] were found in 7 patients with renovascular hypertension. Seven of these dissections were chronic (6 functional, 1 silent) and 4 acute (2 spontaneous, 2 secondary to angiography). Agonal dissections [3] were found in 2 additional patients postmortem: 1 at autopsy and bilateral dissections found at the time of cadaveric donor nephrectomy. Ten bypass procedures, including 5 complex branch reconstructions of which 3 were performed ex vivo, were performed with 100% immediate patency and maintenance or improvement of renal function. Long-term follow-up of these patients has shown sustained patency of the reconstructed renal arteries, excellent blood pressure control, and normal renal function in all. Nephrectomy was not required and there were no associated deaths. Renal artery dissections [77] in 72 patients collected from previous reports have been analyzed. Patient survival (55/72, 76.4%) and preservation of the involved kidney in surviving patients (26/55, 47.3%) were low in these earlier series. Renal failure was associated with 59% of the deaths. The lethality of renal artery dissections and the ease and success of revascularization, which preserves renal function and ameliorates associated renovascular hypertension, emphasize the need for an aggressive approach to the recognition and treatment of this entity. Therapy should be directed toward arterial reconstructions and the preservation of functioning renal tissue.