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