Open repair of atherosclerotic renal artery disease is most commonly made through a midline xiphoid to pubis abdominal incision. The patient is positioned with the operating table flexed. Extending the proximal incision 1 to 2 cm to one side of the xiphoid is required to obtain full exposure of the upper abdominal aorta and renal arteries (Fig. 1A). A fixed mechanical retraction system is advantageous, especially when combined aortorenal reconstruction is performed. Extended flank incisions coursing from the contralateral semilunar line and bisecting the ipsilateral costal margin and pelvic crest are useful for combined visceral–renal artery reconstruction and ex vivo branch renal artery repair. When performed
from an extended left flank incision, supraceliac exposure of the aorta is facilitated. In this instance, the ipsilateral flank is elevated on rolled sheets and the left arm is padded and positioned posteriorly. A left visceral mobilization provides access to the renal vasculature, the celiac axis, the superior mesenteric artery, and the supraceliac aorta. If required, the aortic crura can be divided, allowing for extrapleural aortic dissection to the T₁₀ level of the descending thoracic aorta for proximal control and reconstruction.

When a midline abdominal incision is performed, the posterior peritoneum overlying the aorta is incised longitudinally (Fig. 1B). The ligament of Treitz is mobilized with care to identify visceral collaterals, which may course with the inferior mesenteric vein at this level (Fig. 1B). The duodenum is reflected to the patient’s right to expose the renal vein, which is mobilized from the vena cava origin to the renal hilum (Fig. 2A). By so doing, the inferior border of the pancreas is also mobilized in an avascular plane, allowing exposure of the left renal hilum. Depending on the course of the left renal artery, the gonadal, adrenal, and lumbar renal branches of the left renal vein may be divided to retract the vein either superiorly or inferiorly (Fig. 2B). The proximal portion of the right renal artery can be exposed by this same approach. The entire retrocaval portion of the right renal artery can be exposed by ligating one or more pairs of lumbar veins (Fig. 2C).

When distal exposure of the renal artery is required or unilateral branch renal artery repair is planned, unilateral flank incision may be preferred. The right renal artery exposure is achieved by mobilization of the hepatic flexure of the colon combined with mobilization of the duodenum with an extensive Kocher maneuver (Fig. 3). An avascular plane is entered anterior to the kidney, sweeping the duodenum medially (Fig. 4A). The vena cava is identified and the origin of the right renal vein is noted. The right renal artery usually courses posterior to the vein, which may be retracted either superiorly or inferiorly to provide the best exposure. Supernumerary renal arteries occur on both the right and left in 15% to 20% of patients. All arteries coursing anterior to the vena cava should be considered supernumerary or polar renal arteries to the right kidney and carefully preserved (Fig. 4B).

Aortic exposure proximal to the renal arteries is facilitated by partial division of the diaphragmatic crura. This maneuver allows exposure of the aorta proximal to origin of the superior mesenteric artery. Exposure and control of the aorta at this level is required during transaortic thromboendarterectomy.

Regardless of the material chosen for aortorenal bypass, proximal aortorenal anastomosis is performed first. A segment of in-frarenal aorta proximal to the inferior mesenteric artery is controlled and an aortotomy created along the anterolateral aspect of the aorta. It is important to excise
an ellipse of aorta with the length of the aortotomy at least three times the diameter of the renal artery conduit. Several applications of a 4.8-mm aortic punch can be used to create this ellipse. The proximal anastomosis is performed with a continuous 6-0 polypropylene suture (Fig. 5).

In the past, the distal graft to renal artery anastomoses was frequently created in an end-to-side fashion; however, distal end-to-end anastomosis is preferred. In this case, both conduit and renal artery are spatulated widely (two to three times the diameter of the renal artery) and the anastomosis accomplished with a continuous 7-0 polypropylene suture. Prior to the completion of the anastomosis, the graft is flushed of air and debris and blood flow reestablished to the kidney. In most instances, the warm renal ischemia time is 20 minutes or less.

Transaortic thromboendarterectomy is particularly useful in patients with multiple renal arteries that demonstrate orificial atherosclerotic stenosis. Prior to undertaking thromboendarterectomy, the extent of atherosclerotic disease should be clearly defined. All visible and palpable renal artery atheroma should end within 1 to 1.5 cm of the aortic origin.

Thromboendarterectomy requires more extensive aortic exposure than aortorenal bypass (Fig. 6). The aorta proximal to the superior mesenteric artery should be exposed for control at this level (Fig. 6B). As discussed previously, this is facilitated by partial division of the diaphragmatic crura. The superior mesenteric artery origin is exposed and controlled with an elastic loop. After preliminary control of each renal artery and after proximal and distal aortic control, the aorta is opened longitudinally to the base of the superior mesenteric artery (Fig. 6A). First a sleeve endarterectomy of the aorta is performed. The correct endarterectomy plane is best defined at the site of the most advanced atherosclerotic disease. The aortic atheroma is divided sharply at the proximal and distal end points flush with the residual adventitia. Distal tacking sutures may be applied if necessary. Following sleeve endarterectomy of the aorta, an eversion type of endarterectomy of each renal artery is performed. The renal artery is everted into the aorta to allow the distal end point of the endarterectomy to be visualized (Fig. 6B). The aortic arteriotomy is then closed primarily with a continuous 5-0 polypropylene suture.

As with thromboendarterectomy at all anatomic sites, this procedure is contraindicated by the presence of degenerative aneurysmal change of the aortic wall and aortic atheroma complicated by transmural calcification. This later condition is defined by gentle palpation of the aorta. Transmural calcification may feel like fine-grade sandpaper on palpation. When thromboendarterectomy is performed in this setting, multiple defects may be created within the adventitia, which are apparent only after blood flow is restored.

After extensive mobilization of the renal artery, there may be sufficient redundancy of the vessel to allow for aortic reimplantation. As with aortorenal bypass, the procedure requires that an ellipse of the aorta be taken and that the renal artery be spatulated two to three times its diameter (Fig. 7B,C). Renal artery reimplantation has particular application to children and adolescents with hypoplastic orificial lesions. The technique obviates concerns regarding renal artery conduit in these age groups.

Splanchnorenal bypass has received increased use as an alternative method for renal revascularization. It is essential that the celiac axis and its branches be free of hemodynamically significant disease prior to reconstruction. In addition, significant compression during respiration by arcuate ligament must be excluded.