This document discusses open surgical procedures for renovascular disease. It describes the indications for open surgery including failed percutaneous procedures or disease not amenable to percutaneous methods. The most common open procedures discussed are aortorenal bypass, renal artery thromboendarterectomy, and renal artery reimplantation. Technical details are provided for each procedure along with considerations for patient selection and operative planning.

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 1
22 OPEN PROCEDURES FOR
RENOVASCULAR DISEASE
Matthew S. Edwards, M.D., Juan Ayerdi, M.D., and Kimberley J. Hansen, M.D., F.A.C.S.
Until comparatively recently, intervention for renovascular disease Disease] is liberally used as an alternative to open renal artery
focused entirely on hypertension. However, the introduction of revascularization, but the data currently available suggest that it
potent new antihypertensive agents and percutaneous endovascu- should be employed selectively.The best results with PTRA alone
lar methods of management has led to substantial changes in atti- have been achieved with nonostial atherosclerotic renal artery
tudes to and indications for management of renovascular disease. lesions and medial fibroplasia of the main renal artery. Suboptimal
Today, open surgical repair is commonly reserved for (1) patients results have been achieved with hypoplastic (i.e., developmental)
who have severe hypertension despite optimal medical therapy, (2) lesions, fibrodysplasia of the intimal and perimedial variety, ostial
patients in whom percutaneous transluminal renal artery angio- atherosclerotic renal artery lesions, and renal artery occlusions.
plasty (PTRA) fails or who have disease patterns that are not For ostial renal artery atherosclerosis, some surgeons have advo-
amenable to PTRA, and (3) patients who have renovascular dis- cated PTRA with primary endoluminal stenting in an effort to
ease associated with excretory renal insufficiency (i.e., ischemic improve results; however, the results of PTRA and primary stent-
nephropathy).1 ing in this setting have been inferior to those of open operative
The experience of our center (Wake Forest University School of repair. Consequently, in the majority of cases of ostial atheroscle-
Medicine) in the management of more than 850 patients over a rosis in combination with renal insufficiency, we advise operative
16-year period indicates that atherosclerotic renovascular disease intervention for good-risk patients.
frequently exists in combination with diffuse extrarenal athero- These recommendations are not absolute. Decisions regarding
sclerosis and renal insufficiency. In one study, bilateral atheroscle- therapy for renovascular disease must be individualized. Factors
rotic renal artery lesions were present in two thirds of patients, and contributing to the choice of treatment include the expected mor-
complete renal artery occlusion was present in more than one bidity and mortality of operative repair and the presence of pre-
third.2 Although practitioners frequently cite selected data to sup- dictors of death and dialysis dependence at follow-up. In this
port a particular management scheme in this setting, the question regard, severe left ventricular dysfunction with clinical congestive
of what constitutes optimal management of atherosclerotic reno- heart failure, diabetes mellitus, and uncorrectable azotemia have
vascular disease responsible for either hypertension or renal insuf- all been shown to be significant and independent predictors of
ficiency is still unanswerable.To date, there have been no prospec- reduced dialysis-free survival.2,3
tive, randomized trials that compare the best medical manage-
ment with PTRA and with open surgical repair.
Operative Planning
Preoperative Evaluation SURGICAL STRATEGY
Evaluation and diagnosis of renovascular hypertension and reno- Our use of open surgical methods to treat atherosclerotic reno-
vascular renal insufficiency (i.e., ischemic nephropathy) are discussed vascular disease is based on several guiding principles [see Table 1].
in more detail elsewhere, as are general issues related to the We consider severe hypertension a prerequisite for open operative
question of medical versus surgical therapy. management and do not perform prophylactic renal artery repair
INDICATIONS FOR INTERVENTION
The recognition of both the progressive nature of the athero- Table 1—Recommended Principles for
sclerotic renovascular lesions seen in combination with severe Contemporary Surgical Management of
hypertension and the deterioration of renal function seen in select- Renovascular Disease10
ed patients who are managed medically lends support to the idea
that renal artery intervention is indicated when either renovascu- Renal artery repair is done on an empirical, but not prophylactic, basis
lar hypertension or ischemic nephropathy is present. In our view, Complete renal artery repair is done in one operation when feasible;
bilateral ex vivo reconstruction may be staged
renal artery intervention is appropriate in patients with severe Direct aortorenal methods of reconstruction are preferred
hypertension and, specifically, in all patients who have severe hy- Nephrectomy is reserved for nonreconstructable disease in a
pertension in combination with excretory renal insufficiency (i.e., nonfunctioning kidney
ischemic nephropathy). Open operative management is preferred Combined aortic reconstruction is limited to clinically significant
disease
for children and young adults and for patients with bilateral reno-
Intraoperative duplex sonography is performed to assess technical
vascular disease, especially if renal artery occlusion is present.2 success
PTRA [see 6:16 Endovascular Procedures for Renovascular

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 2
a b
c
Figure 1 Aortorenal bypass.8 Technique for end-to-side (a, b) and end-to-end (c) aortorenal bypass
grafting. The length of arteriotomy is at least three times the diameter of the artery to prevent recur-
rent anastomotic stenosis. For the anastomosis, 6-0 or 7-0 monofilament polypropylene sutures are
used in continuous fashion, under loupe magnification. If the apex sutures are placed too deeply or
with excess advancement, stenosis can be created, posing a risk of late graft thrombosis.
Operative Technique
in patients who are not hypertensive. Although we employ renal
vein renin assays to guide management of unilateral lesions in many Various open surgical techniques are used to correct athero-
cases, we typically perform empirical renal artery repair without sclerotic renovascular disease; however, no single repair technique
functional studies when the hypertension is severe or uncontrolled is optimal for all renovascular lesions. The best approach to renal
and when renal artery disease is bilateral or involves a solitary kid- artery reconstruction in any given case depends on patient char-
ney. We attempt to correct all hemodynamically significant reno- acteristics, the pattern of renal artery disease, and the presence or
vascular disease in a single operation; we perform staged repair only absence of associated aortic lesions that may have to be corrected
in cases in which the disease necessitates bilateral ex vivo recon- simultaneously. The open procedures most commonly performed
struction. Because the lower limit of renal function retrieval is not to treat renovascular disease are (1) aortorenal bypass, (2) renal
known but improved renal function is known to be the strongest artery thromboendarterectomy, and (3) renal artery reimplanta-
predictor of dialysis-free survival, we reserve nephrectomy for tion. In general, aortorenal bypass is the most versatile of these
patients who have an unreconstructable lesion in a renal artery sup- procedures.Transaortic thromboendarterectomy may be especial-
plying a nonfunctioning kidney (i.e., a kidney providing less than ly useful when ostial atherosclerosis ends within 1 cm of the origin
10% glomerular filtration on renography).4 In the majority of open of the renal artery and involves multiple renal arteries. Renal
operative repairs, we employ direct aortorenal reconstruction artery reimplantation is often particularly appropriate for the cor-
methods; we seldom use indirect (splanchnorenal) methods, rection of renovascular disease in children and adolescents, in that
because celiac axis stenosis is present in 40% to 50% of patients concerns regarding graft material are eliminated.
and bilateral repair is required in more than 50%.2 Regardless of With all of these reconstruction techniques, multiple small
the method of reconstruction employed, we perform intraoperative doses of mannitol are administered intravenously during perirenal
renal duplex sonography as a completion study to look for any aortic and renal artery dissection. Mannitol is given both before
technical errors in the repair that might lead to restenosis or occlu- and after periods of warm renal ischemia up to a total dose of 1
sion. Failed renal artery repair has been associated with a signifi- g/kg. During cross-clamping of the aorta and the renal artery, the
cant and independent risk of eventual dependence on dialysis.5 patient is given heparin, 100 U/kg, to establish systemic anticoag-

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 3
ulation. When a purely autogenous reconstruction is performed, eter of the smallest conduit, and the ends of the conduit should be
antibiotics are unnecessary; however, when a prosthetic graft is widely spatulated to guard against late suture line stenosis. The
employed, administration of a first-generation cephalosporin is proximal anastomosis is usually made with a continuous 6-0
begun 2 hours before operation and continued for 24 hours. monofilament polypropylene suture, and the distal anastomosis is
created with a continuous 7-0 or 8-0 monofilament polypropylene
AORTORENAL BYPASS
suture.
Aortorenal bypass [see Figure 1] may be performed with either
THROMBOENDARTERECTOMY
an autogenous conduit or a prosthetic graft. If an entirely autoge-
nous repair is possible, we prefer to use a reversed segment of the Thromboendarterectomy of the renal arteries and the perirenal
greater saphenous vein as the conduit. If the saphenous vein is too aorta may be performed via either a transrenal or a transaortic
narrow (i.e., < 4 mm in diameter) or of inadequate quality, a 6 approach. When the renal artery atheroma extends 1 cm or less
mm thin-walled polytetrafluoroethylene (PTFE) graft is used from the ostium and involves both or multiple renal arteries, the
instead. In either case, the infrarenal aorta is dissected and transaortic technique [see Figure 2] is especially useful. With both
clamped proximally and distally, and a longitudinal elliptical open- endarterectomy techniques, extensive aortic exposure is required.
ing is created anterolaterally in the aortic wall (e.g., with two or The aorta proximal to the origin of the superior mesenteric artery
three applications of a 5.2 mm aortic punch). If required, a local (SMA) is exposed and controlled. This exposure is facilitated by
endarterectomy at the site of the anastomosis may be performed partially dividing the aortic crura and controlling the SMA with a
through this opening. Silastic loop.
The proximal and distal anastomoses are then created. Currently, the majority of aortorenal endarterectomies are per-
Although end-to-side distal renal artery anastomoses were com- formed through a longitudinal aortotomy extending from a point
monly performed at one time, current aortorenal bypass tech- 2 to 3 cm below the renal arteries to the base of the SMA. A sleeve
niques typically employ end-to-end distal renal artery anasto- of aortic atheroma is created, then divided sharply at the base of
moses. For both the proximal and the distal anastomosis, the the SMA proximally and well below the most inferior renal artery
length of the arteriotomy should be at least three times the diam- distally. After the aortic endarterectomy is completed, an eversion-
a b
Left
Renal
Artery
SMA
SMA
IMA
Figure 2 Thromboendarterectomy.8 Exposure for a longitudinal transaortic endarterectomy is
obtained via the standard transperitoneal approach. The duodenum is mobilized from the aorta later-
ally in the standard fashion; alternatively, for more complete exposure, the ascending colon and the
small bowel are mobilized. (a) Dotted line shows the location of the aortotomy. (b) The plaque is
transected proximally and distally, the renal arteries are everted, and the atherosclerotic plaque is
removed from each renal ostium. The aortotomy is typically closed with a continuous 4-0 or 5-0
polypropylene suture. (IMA—inferior mesenteric artery)

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 4
a b c
d
Figure 3 Renal artery reimplantation.9 (a)
When the renal artery is redundant and the
disease involves the orifice of the renal artery,
it is usually possible to reimplant the vessel at
a lower level. Dotted lines indicate the location
of the aortotomy and the point where the renal
artery is divided. (b) An elliptical opening is
created in the aortic wall, and a local
endarterectomy is done as required. (c) A
monofilament suture is placed in the aortic
wall. (d) The native renal artery is ligated,
proximally spatulated, and reimplanted.
type endarterectomy is performed for each of the renal arteries. Although this technique has only limited applicability to the
The surgical assistant retracts the anterior lip of the aortic wall and treatment of atherosclerotic renovascular disease in adults, it may
inverts the renal artery into the aorta, and the operating surgeon be particularly useful for this purpose in children and young ado-
retracts the renal artery atheroma while gently pushing the lescents, who often have congenital or developmental lesions that
remaining renal artery away with a dissector. In this manner, the involve the renal artery orifice. The main advantage of reimplan-
end point of the endarterectomy can easily be visualized to con- tation is that it obviates concerns regarding the durability of the
firm that the endarterectomy is complete.The endarterectomy site renal artery conduit.
is then irrigated with heparinized saline, and the longitudinal aor-
SPLANCHNORENAL BYPASS
totomy is closed with a continuous 4-0 or 5-0 monofilament
polypropylene suture. Indirect, or splanchnorenal, bypass [see Figure 4] is an uncom-
Both transrenal and transaortic thromboendarterectomy are mon procedure at our center. In large part, its relative rarity is a
contraindicated if aneurysmal degeneration of the perirenal aorta reflection of the frequent presence of simultaneous disease of the
is present or if there is transmural calcification at the site of celiac axis and the frequent need for bilateral renal artery recon-
endarterectomy. struction in combination with aortic repair. In addition, we believe
that this approach does not yield long-term patency equivalent to
RENAL ARTERY REIMPLANTATION
that provided by direct aortorenal reconstruction. Consequently,
In the course of renal artery exposure, the vessel is dissected these indirect bypass techniques are reserved for a selected sub-
from its aortic origin to its primary bifurcation. On occasion, after group of high-risk patients.
complete dissection, the vessel is found to have sufficient redun- Hepatorenal bypass is most frequently performed through a
dancy to allow tension-free reimplantation into the infrarenal right subcostal incision, splenorenal bypass through a left sub-
aorta [see Figure 3]. As in a renal artery bypass [see Aortorenal costal incision. In either procedure, the patient is positioned with
Bypass, above], an elliptical section of the aortic wall is resected, a roll beneath the ipsilateral flank, with the operating table flexed
and a widely spatulated aortorenal anastomosis is fashioned. and the ipsilateral arm padded and tucked to the side.The incision

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 5
may be extended to the contralateral semilunar line and into the function in 60% of occluded renal arteries that underwent opera-
ipsilateral flank as necessary for exposure. In a hepatorenal bypass, tive repair.4
a greater saphenous vein graft is usually employed, originating
INTRAOPERATIVE RENAL DUPLEX ULTRASONOGRAPHY
from the common hepatic artery and coursing posterior to the
portal triad and anterior to the vena cava before the end-to-end The surgeon’s technique plays a dominant role in determining
renal artery anastomosis [see Figure 4]. A splenorenal bypass may patency after renal artery reconstruction. To look for technical
be created either in a similar fashion (i.e., with a greater saphenous errors at the time of operation, we employ intraoperative renal
vein graft) or by anastomosing the transected splenic artery direct- duplex ultrasonography. A 10.0/5.0 mHz compact linear array
ly to the left renal artery [see Figure 5]. If the latter approach is probe with Doppler color-flow capability is placed within a sterile
taken, the collateral circulation to the spleen is sufficient to main- sheath that has a latex tip containing sterile gel.The operative field
tain splenic viability. is flooded with warm saline solution, and B-scan images are
obtained from the sites of aortic control and of renal artery repair.
NEPHRECTOMY All defects noted on the B-scan images are then examined in both
In patients with renovascular renal insufficiency or ischemic longitudinal and transverse projections. Doppler samples are
nephropathy, an incremental increase in excretory renal function obtained proximal and distal to the lesions to determine their
after operation is the dominant determinant of dialysis-free sur- hemodynamic significance.6 In 249 consecutive renal artery
vival. As noted [see Operative Planning, Surgical Strategy, above], repairs with anatomic follow-up, 10% had a focal increase in peak
we reserve nephrectomy for patients in whom an unrecon- systolic velocities consistent with residual stenosis.2 Each defect
structable renal artery is supplying a nonfunctioning kidney.When was revised immediately, and in each case, a significant defect was
the renal artery is occluded, reconstruction is performed if the dis- found. At 12 months after operation, primary patency of the renal
tal renal artery is normal at the time of surgical exploration. Past reconstruction was observed in 97% of repairs.This product-limit
recommendations regarding the management of renal artery oc- estimate of patency is stable up to 8 years after operation.
clusion have emphasized kidney length, distal renal artery recon-
stitution, and the appearance of a nephrogram during angiography
Outcome Evaluation
as criteria for determining whether reconstruction is indicated.
Our practice, however, has been to perform renal artery recon- Surgical repair of atherosclerotic renovascular disease can be
struction whenever a normal distal renal artery is demonstrated. accomplished with a high rate of success and sustained long-term
In a study employing this strategy, we reported retrieval of renal patency. With proper patient selection, the majority of patients
a b
c
Figure 4 Hepatorenal bypass.9 (a) Shown is exposure of the
common hepatic artery and the proximal gastroduodenal artery
in the hepatoduodenal ligament in preparation for hepatorenal
bypass (typically through a right subcostal skin incision). (b,c)
The reconstruction is completed by placing a greater saphenous
vein interposition graft between the side of the hepatic artery
and the distal end of the transected right renal artery.

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 6
Splenic Artery
a b
Left Renal
Artery
Figure 5 Splenorenal bypass.9 (a) Shown is exposure of the left renal
hilum in preparation for splenorenal bypass (typically obtained through
a left subcostal incision). The pancreas has been mobilized along its
inferior margin and retracted superiorly. (b) The transected splenic
artery is anastomosed to the transected left renal artery in an end-to-
end manner. A splenectomy is not routinely performed.
demonstrate beneficial blood pressure response and renal function perioperative mortality demonstrated significant and independent
response, albeit with perioperative mortality and morbidity that associations with advanced age and clinical congestive heart fail-
vary according to the complexity of the procedure. ure. The estimated primary patency rate for all 720 renal artery
In a 2002 report, we reviewed our center’s experience with 500 reconstructions was 97% at 8 years’ follow-up.
consecutive patients who underwent open surgical repair for treat-
ment of atherosclerotic renovascular disease between January HYPERTENSION RESPONSE
1987 and December 1999.2 These patients included 254 women Early blood pressure response was estimated on the basis of
and 246 men, with a mean age of 65 ± 9 years. Each patient had ambulatory blood pressure values and medication requirements
severe hypertension.The mean preoperative blood pressure for the determined at least 1 month after operative repair. Among surgi-
group was 200 ± 35/104 ± 21 mm Hg. Most of the patients had cal survivors, 12% were considered cured, 73% were considered
diffuse extrarenal atherosclerosis. A total of 81% had at least one
improved, and 15% were considered failed [see Table 3].
manifestation of cardiac disease; 34% had a history of significant
cerebrovascular disease; and 78% were considered to have at least RENAL FUNCTION RESPONSE
mild renal insufficiency, as evidenced by a serum creatinine con-
centration of 1.3 mg/dl or greater. Ischemic nephropathy was seen A significant change in excretory renal function was defined
in 244 patients (49%), including 40 patients who were dependent as a change of at least 20% in the estimated glomerular filtration
on dialysis before operation. rate (EGFR), measured at least 3 weeks after repair. Of patients
Angiographic evaluation demonstrated the presence of bilater-
al renal artery disease in 60% of these atherosclerotic patients.The
renal artery lesion was considered ostial in 97% of cases, and 16% Table 2 Summary of Operative Management of
of renal arteries were completely occluded. A total of 720 renal Atherosclerotic Renovascular Disease2
artery reconstructions were performed [see Table 2]. Aortorenal by-
pass was performed in two thirds of the repairs, and two thirds of Total renal reconstructions 720
these bypasses were done with venous grafts.Thromboendarterec- Aortorenal bypass 384
tomy was performed in almost one third of the cases. Renal artery Venous graft 204
reimplantation was performed in 56 instances, splanchnorenal by- PTFE graft 159
pass in only 13 instances. Although there were 124 renal artery oc- Dacron graft 21
clusions, only 56 of these were treated by means of nephrectomy. Reimplantation 56
Twenty-three patients (4.6%) died in the hospital or within 30 Thromboendarterectomy 267
days of renal reconstruction. Mortality varied significantly with Splanchnorenal bypass 13
the magnitude of procedure. Mortality after isolated renal artery Total nephrectomies 56
repair was substantially lower than mortality after combined aor-
tic and bilateral renal artery repair (0.8% versus 6.9%). Moreover, Total kidneys operated on 776

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 7
100
Table 3 Results of Operative Treatment of
Atherosclerotic Renovascular Disease among 90
472 Surgical Survivors2
80
Result Rate (%)
70
Dialysis-Free Survival (%)
Perioperative mortality 4.6
Hypertension response 60
Cured 12
Improved 73 50
Failed 15
Renal function response* 40
Improved 58
Unchanged 35 30
Worsened 7
20
*For 220 patients with preoperative serum creatinine concentrations ≥ 1.8 mg/dl; a
significant change is defined as a ≥ 20% change in EGFR.
10
0
with preoperative ischemic nephropathy, 58% showed improve- 0 20 40 60 80 100 120 140
ments in renal function, including 30 patients removed from
dialysis dependence [see Table 3]. In contrast to previous reports Follow-up (months)
that suggested the existence of a lower limit of renal dysfunction EGFR EGFR EGFR
beyond which recovery could not be observed, the percentage of Improved Unchanged Worsened
patients who showed improvement rose with increasing preop- Figure 7 Illustrated are product-limit estimates of time to death
erative serum creatinine concentration. Overall, 75% of dialysis- or dialysis, stratified according to postoperative renal function
dependent patients were permanently removed from dialysis response for patients with a preoperative EGFR of 25 ml/min/m2.
after renal artery repair. In addition, the site of disease and the The interaction between preoperative EGFR and renal function
extent of repair were found to influence increases in the EGFR. response for dialysis-free survival was significant and independent.2
100 Although each subgroup of patients who underwent operation
demonstrated some improvement in renal function, the greatest
90 incremental increase in the EGFR was observed in those who
underwent bilateral renal reconstruction for significant bilateral
80 disease.3,7
RELATIONSHIP OF HYPERTENSION RESPONSE AND RENAL
70
Dialysis-Free Survival (%)
FUNCTION RESPONSE TO DIALYSIS-FREE SURVIVAL
60 At a mean follow-up of 56 months, 171 patient deaths had
occurred.When outcomes were considered in terms of the blood
50 pressure response to operative intervention, only hypertension
cured was found to be significantly and independently associat-
40
ed with survival or dialysis dependence: patients whose hyper-
tension was cured experienced improved dialysis-free survival
30
[see Figure 6]. In contrast, all outcome categories for the renal
function response influenced both survival and eventual dialysis
20
dependence. Patients with improved renal function experienced
a significant increase in dialysis-free survival [see Figure 7].2 For
patients whose renal function remained unchanged after oper-
10
ation, however, the risk of eventual dialysis dependence and
death was equivalent to that of patients whose renal function
0
worsened after surgery. Whereas renal function that is un-
0 20 40 60 80 100 120 140 160
changed after intervention is frequently described as “stabilized”
N=472 N=376 N=271 N=184 N=113 N=67 N=30 N=8
or “preserved,” our experience suggests that patients with ische-
Follow-up (months) mic nephropathy and atherosclerotic renovascular disease whose
renal function is unchanged postoperatively remain at increased
Cured Improved Failed
risk for eventual dialysis dependence and death.Whether similar
Figure 6 Illustrated are product-limit estimates of time to death associations exist for patients treated by means of catheter-based
or dialysis, stratified according to blood pressure response to oper- methods is unknown, but the question certainly merits future
ation for atherosclerotic renovascular disease.2 study.

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6 VASCULAR SYSTEM 22 OPEN PROCEDURES FOR RENOVASCULAR DISEASE — 8
References
1. Dean RH, Benjamin ME, Hansen KJ: Surgical man- tion. J Vasc Surg 29:140, 1999 8. Benjamin ME, Dean RH: Techniques in renal
agement of renovascular hypertension. Curr Probl artery reconstruction: part I. Ann Vasc Surg
5. Hansen KJ, Deitch JS, Oskin TC, et al: Renal artery
Surg 34:209, 1997 10:306, 1996
repair: consequence of operative failures. Ann Surg
2. Cherr GS, Hansen KJ, Craven TE, et al: Surgical 227:678, 1998 9. Benjamin ME, Dean RH: Techniques in renal
management of atherosclerotic renovascular disease.
J Vasc Surg 35:236, 2002 6. Hansen KJ, Reavis SW, Dean RH: Duplex scanning artery reconstruction: part II. Ann Vasc Surg
in renovascular disease. Geriatr Nephrol Urol 6:89, 10:409, 1996
3. Hansen KJ, Cherr GS, Craven TE, et al: Manage-
ment of ischemic nephropathy: dialysis-free survival 1996 10. Hansen KJ,Wong JM: Aortorenal bypass for renovas-
after surgical repair. J Vasc Surg 32:472, 2000 7. Dean RH,Tribble RW, Hansen KJ, et al: Evolution of cular hypertension in adults. Current Therapy in Vas-
4. Oskin TC, Hansen KJ, Deitch JS, et al: Chronic renal renal insufficiency in ischemic nephropathy. Ann cular Surgery, 4th ed. Ernst CB, Stanley JC, Eds.
artery occlusion: nephrectomy versus revasculariza- Surg 213:446, 1991 Harcourt Health Sciences, St Louis, 2000, p 735
Recommended Reading
Deitch JS, Hansen KJ, Craven TE, et al: Renal artery re- study. J Vasc Surg 36:443, 2002 sonography: main renal artery versus hilar analysis. J Vasc
pair in African-Americans. J Vasc Surg 26:465, 1997 Hansen KJ, Tribble RW, Reavis SW, et al: Renal duplex Surg 32:462, 2000
Edwards MS, Hansen KJ, Craven TE, et al: Relationships sonography: evaluation of clinical utility. J Vasc Surg
between renovascular disease, blood pressure, and renal 12:227, 1990
function in the elderly: a population-based study. Am J Hunt JC, Strong CG: Renovascular hypertension: mecha-
Kidney Dis 41:990, 2003 nisms, natural history and treatment. Am J Cardiol Acknowledgment
Hansen KJ, Edwards MS, Craven TE, et al: Prevalence of 32:562, 1973
renovascular disease in the elderly: a population-based Motew SJ, Cherr GS, Craven TE, et al: Renal duplex Figures 1 through 4 Alice Y. Chen.