title: Delayed hepato-spleno-renal bypass for renal salvage following malposition of an infrarenal aortic stent-graft.
abstract: OBJECTIVE
  To report a salvage maneuver for accidental coverage of both renal arteries during endovascular aneurysm repair (EVAR) of an infrarenal aortic aneurysm (AAA) and survey our surgical colleagues in the UK for their use of this bypass procedure.
  
  
  METHODS
  A 74-year-old woman who had an EVAR complicated by renal failure secondary to malposition of the stent-graft underwent successful delayed renal revascularization with hepatorenal and splenorenal bypasses. This case prompted a literature review and preparation of an online 6-part questionnaire regarding the incidence and management of renal impairment following EVAR. The survey invitation was sent to all listed members of the Vascular Society of Great Britain and Ireland.
  
  
  RESULTS
  Responses from 68 (10.5%) of the 650 vascular surgeons invited to participate in the survey were analyzed. The combined experience of those who completed the survey was >1500 EVAR procedures per annum. Forty percent (27/68) of the respondents had experienced a case of bilateral renal artery occlusion during EVAR. Two thirds (67%, 18/27) of these surgeons stated a preference for revascularizing the kidneys endovascularly, 7 surgeons would convert to open repair, 1 surgeon favored iliorenal bypass, and another suggested splenorenal bypass. Following intervention, 15 (56%) of 27 surgeons achieved revascularization that resulted in a return to baseline serum creatinine, 7 (26%) achieved partial recovery of the patient's serum creatinine, 3 (11%) had a patient on permanent dialysis, and 2 (7%) had patients who died (after open repair and endovascular procedure, respectively).
  
  
  CONCLUSIONS
  Bilateral renal artery occlusion caused by malposition of a stent-graft is probably underreported. If revascularization of the kidneys by endovascular techniques fails, there is no consensus as to the optimal approach. Delayed revascularization should be considered if the kidneys show concentration of imaging contrast. Hepato-spleno-renal bypass, which has not heretofore been indicated for renal salvage post EVAR, can provide a good functional result in this situation.
authors.affiliation: Department of Vascular Surgery, Hammersmith Hospitals, London, UK.
authors.forename: Maher
authors.initials: M
authors.lastname: Hamish
authors.forename: George
authors.initials: G
authors.lastname: Geroulakos
authors.forename: Dominic A
authors.initials: DA
authors.lastname: Hughes
authors.forename: Steve
authors.initials: S
authors.lastname: Moser
authors.forename: Amanda
authors.initials: A
authors.lastname: Shepherd
authors.forename: Alan D
authors.initials: AD
authors.lastname: Salama
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D003404:Creatinine / Q000097:blood; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D011859:Radiography; D012077:Renal Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D012078:Renal Artery Obstruction / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006435:Renal Dialysis; D051437:Renal Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D016879:Salvage Therapy; D012501:Saphenous Vein / Q000637:transplantation; D013157:Splenic Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D015607:Stents; D011795:Surveys and Questionnaires; D017131:Thrombectomy; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom
chemical_list: D003404:Creatinine