Хирургическое лечение вазоренальная гипертензия при

ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1•2016

46

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 ar-

tery 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 tech-

nology 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 pros-

thesis. Endarterectomy from the mouth of the left 

renal artery. Prosthetics right artery. The second 

stage is made splenotomiya right. Subclavian, axil-

lary 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 ef-

fectiveness 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 com-

paring the blood pressure before and after the op-

eration. 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 pa-

tients 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 pres-

sure 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 sur-

gical 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 

SURGICAL TREATMENT OF RENOVASCULAR HYPERTENSION 

WITH BILATERAL RENAL ARTERY STENOSIS

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 representa-

tion 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. Sub-

clavian, axillary alloshunt

 Figure 4

Angiogram. Syndrome 

Denereya-Leriche. A criti-

cal stenosis of both renal 

arteries

BULLETIN OF SURGERY IN KAZAKHSTAN № 1•2016

47

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 sur-

gical treatment in patients 

with VRH depending on 

the duration of hyperten-

sion

blood pressure (P <0.05) - 147

±110 mmHg and dia-

stolic 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 “satisfac-

tory” - in 20 patients. Unsatisfactory results of the 

operation were observed in 3 patients (8.3%).

The analysis results of the operations depend-

ing on the nature of surgical intervention and etiol-

ogy found that the results in patients with athero-

sclerosis better than with Aortoarteritis (Table 2).

After analyzing the results of surgical treatment, 

depending on the length of her previous hyperten-

sion, it can be concluded: the smaller the dura-

tion 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 antihy-

pertensive 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 py-

elonephritis. Chronic renal failure I of a degree. 

Acute postoperative renal failure, anuria stage. 

Produced thoraco Fresne-lumbotomy left. Aorto-

birenalnoe alloprotezirovanie bifurcation. Resection 

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

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

SURGICAL TREATMENT OF RENOVASCULAR HYPERTENSION 

WITH BILATERAL RENAL ARTERY STENOSIS

Figure 6

Schematic representation 

of the steps (I - II) opera-

tion. The first stage of the 

operation performed: 

Transluminal balloon an-

gioplasty a.subclavia sin., 

A. axilaris sin., a.lumbalis 

sinistrae on both sides of 

the vertebral and ca-

rotid arteries of the right 

to good effect, the second 

stage, after 3 months, the 

operation was planned - 

both balloon angioplasty 

of the renal arteries

Figure 5

Schematic representa-

tion of both transluminal 

balloon angioplasty of the 

renal arteries

ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1•2016

48

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; antibi-

otic 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 de-

teriorated - 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 pe-

riod, 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 nec-

essary 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 sys-

tolic 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 re-

sults of operations of these patients were also un-

satisfactory.

Patient K., 65 years old, to operate with a diag-

nosis 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 ap-

proaches 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 ath-

erosclerosis and aortoarteritis.

As the analysis of long-term results of conser-

vative treatment, for five years died 3 (20%) pa-

tients, 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 

SURGICAL TREATMENT OF RENOVASCULAR HYPERTENSION 

WITH BILATERAL RENAL ARTERY STENOSIS

Figure 7

Angiogram. Aortoarterit. 

Renovascular hyperten-

sion. 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

BULLETIN OF SURGERY IN KAZAKHSTAN № 1•2016

49

SURGICAL TREATMENT OF RENOVASCULAR HYPERTENSION 

WITH BILATERAL RENAL ARTERY STENOSIS

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.

References

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

in the absence of experience or ability to radiolo-

gists 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 with-

out the use of additional strain relief and the plastic 

material.

The operation was carried out from the median 

laparotomy. Laparotomy is convenient for simulta-

neous correction of two renal arteries. The main 

advantage of the opportunity to perform the recon-

struction of the access not only to the renal arter-

ies, 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 steno-

sis. 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 op-

erating 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 inter-

vention 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.

ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 1•2016

50

ОТДАЛЕННЫЕ РЕЗУЛЬТАТЫ ИМПЛАНТАЦИИ 

КСЕНОПЕРИКАРДИАЛЬНОГО КОНДУИТА С 

КЛАПАНОМ ИЗ ГЛИССОНОВОЙ КАПСУЛЫ 

ПЕЧЕНИ

УДК 616.369-616.141

III. ХИРУРГИЯ

Аннотация

Изучены отдаленные результаты имплантации  ксеноперикардиального кондуита со створками из глиссоновой 

капсулы печени   у 30 пациентов в различные сроки (от 1 года до 9 лет).

Выживаемость пациентов в отдаленные сроки после имплантации трехстворчатого ксеноперикардиального 

кондуита с клапаном из глиссоновой капсулы печени к 1 году составила 100%, а к 6 годам – 93,6%. Свобода от 

дисфункции кондуита через 3 года после имплантации составила 98,2%, а к седьмому году наблюдения – 84,6% 

и не изменялась в дальнейшем.

Наш собственный опыт свидетельствует о том, что ксеноперикардиальные клапансодержащие кондуиты по 

сравнению аллографтами являются более предпочтительными для коррекции сложных врожденных пороков 

сердца.

Ключевые слова: 

Ксеноперикардиальный 

кондуит, глиссонова капсула 

печени.

1

Болатбекулы Ж.Б., 

2

Абзалиев К.Б., 

1

Сарсенбаева Г.И., 

1

Тойбаева А.К.

1

Научный центр педиатрии и детской хирургии, 

2

Казахский Медицинский Университет Непрерывного образования, Алматы

1

Болатбек±лы Ж.Б., 

2

Абзалиев К.Б., 

1

Сарсенбаева Г.И., 

1

Тойбаева А.К.

1

Педиатрия жєне бала хирургиясы ѓылыми орталыѓы, 

2

?аза? Медициналы? ‡здіксіз Білім беру Университеті, Алматы

1

Bolatbekuly J.B., 

2

Abzaliev K.B., 

1

Sarsenbaeva G.I., 

1

Toybaeva A.K.

1

Scientific Center of Pediatrics and Pediatric Surgery, 

2

Kazakh Medical University of Continuing Education, Almaty

Ањдатпа

Т‰рлі кезењдердегі (1 жылдан 9 жылѓа дейінгі) 30 нау?ас?а бауырдыњ глиссонды капшы?тарынан жасалынѓан 

?а?па?шалармен ксеноперикардиалды кондуитті импланттаудаѓы ±за? мерзімді нєтижелер ?арастырылѓан.

Бауырдыњ глиссонды капшы?тарынан жасалынѓан ?а?па?шалармен ‰шашпалы ксеноперикардиалды кондуитті им-

планттаудан кейінгі нау?астардыњ ±за? мерзімдегі ?міршењдігі 1 жылда 100%, 6 жылда -93,6% ?±рады. Имплантта-

удан кейінгі 3 жыл мерзімінде кондуиттіњ єрекетсіздігінен арылу 98,2%, ал 7 жыл ба?ылау кезењінде - 84,6% ?±рап, 

ары ?арай ?згерістер бай?алмады.

Біздіњ жеке тєжірибеміз туа біткен ж‰рек а?ауларын т‰зету ‰шін аллографтармен салыстырѓанда ксенокардиалды 

?а?па?шалы кондуиттердіњ оњтайлыра? болып табылатындыѓын к?рсетеді.

Summary

We studied the long-term results of implantation of xenopericardial conduit with cusps of Glisson capsule of the liver in 

30 patients in different periods (from 1 to 9 years).

The survival rate of patients in the remote period after implantation of the tricuspid valve xenopericardial conduit of the 

Glisson capsule of the liver to 1 year was 100%, and to 6 years - 93.6%. Freedom from dysfunction conduit 3 years after 

implantation was 98.2%, and the seventh year of observation - 84.6% and did not change in the future.

Our own experience shows that xenopericardial with valve conduits compared allografts are more preferable for the 

correction of complex congenital heart defects.

Т‰йін с?здер

К

сеноперикардиальді кондуит, 

бауырдыњ глиссонды ‰лпершегі.

жүктеу/скачать 11,89 Mb.

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