Advanced renovascular hypertension and renal insufficiency: Trends in medical comorbidity and surgical approach from 1970 to 1993

Purpose: The primary aims of this study were to delineate trends in medical comorbidity and surgical approach in patients with renal atherosclerosis and azotemia. Methods: We reviewed 1643 patients undergoing renovascular surgery between 1970 and 1993. We focused on those with the most advanced kidney disease (serum creatinine >2 mg/dl) (n=402). Attention was focused specifically on trends in sex, age, medical risk factors, surgical technique (bypass vs endarterectomy), and outcome including eventual need for long-term dialysis. Results: From 1970 to 1980, 652 patients underwent renovascular surgery, with 98 (15%) having a serum creatinine >2 mg/dl. From 1980 to 1993, the percentage of patients with renal insufficiency increased to 31% (304 of 991) (p<0.001). Gender distribution did not change, but median age rose from 63.5 years in the first decade to 68.0 in the past 13 years. A remarkable increase in all serious medical risk factors also occurred (first vs second decade). Another significant trend was a shift toward bilateral simultaneous transaortic endarterectomy (18% from 1980 to 1985 vs 53% from 1986 to 1993; p<0.01), which simplified and achieved complete renal revascularization, especially in patients having multiple renal artery stenoses and those needing aortic grafting for occlusive or aneurysmal disease (56% from 1970 to 1980 vs 75% from 1980 to 1993). Patients at low risk (0 to 1 comorbid medical conditions) had a 30-day mortality rate of 5.6% compared with patients at high risk (2 to 3 comorbid conditions) (15.5%) (p=0.016). The eventual need for long-term dialysis remained low (9%) for patients with a preoperative serum creatinine of 2 to 2.9 mg/dl compared with those with a serum creatinine greater than 3 mg/dl (35%, p<0.01). Conclusions: In the past 20 years, there has been a remarkable increase in the medical comorbidity and extent of aortic disease in patients undergoing surgical revascularization for advanced renovascular hypertension and renal insufficiency. However, the surgical approach can be simplified and expedited by bilateral transaortic endarterectomy, and the risk of late dialysis can be reduced significantly by operating before the serum creatinine exceeds 3 mg/dl.