Urgent interventional bilateral renal artery fenestration for giant pararenal abdominal aortic aneurysm with upper digestive tract obstruction

INTRODUCTION Renal artery aneurysms is relatively uncommon with reported incidence ranges from 0.3% to 1%. However, considering all visceral artery aneurysms the percentage of renal artery aneurysms is relatively high between 15-25%. The distal forms of renal artery aneurysms sometimes require "ex vivo" reconstruction and kidney autotransplantation. CASE REPORT A 75-year-old male presented with the right abdominal and back pain. He suffered from a long history of arterial hypertension and chronic renal failure over the last few months (urea blood = 19.8 mmol/l; creatinine = 198 mmol/l). Duplex ultrasonography showed abdominal aortic aneurysm. Subsequent translumbarangiography revealed juxtarenal abdominal aortic aneurysm associated with distal right renal artery aneurysm. The operation was performed under combined thoracic epidural analgesia and general anesthesia using transperitoneal approach. After the laparotomy, the ascending colon was mobilized and reflected medially followed by Kocher maneuver. The result was visualization of the anterior aspect of the right kidney, the collecting system, ureter as well as the right renal vein and artery with large saccular aneurysm located distally. After mobilization of the renal vessels and careful dissection of the ureter, the kidney was explanted. The operation was continued by two surgical teams. The first team performed abdominal aortic aneurysm resection and reconstruction with bifurcated Dacron graft. The second team performed ex vivo reparation of renal artery aneurysm. All time during the explantation, the kidney was perfused by Collins' solution. The saccular right renal artery aneurysm 4 cm in diameter was located at the kidney hilus at the first bifurcation. Three branches originated from the aneurysm. The aneurysm was resected completely. The longest and widest of three branches arising from the aneurysmal sac was end-to-end anastomized with 6 mm PTFE graft. After this intervention, one of shorter arteries was implanted into the long artery, and another one into PTFE graft. After 30 minutes of explanation, autotransplantation of the kidney into the right iliac fossa was performed. The right renal vein was implanted into the inferior vein cava, and PTFE graft into the right limb of Dacron graft. Immediately following the completion of both anastomoses, large volume of urine was evident. Finally, ureteneocystostomy was performed with previous insertion of double "J" catheter. In the immediate postoperative period, renal function was restored to normal, while postoperative angiography revealed all patent grafts. DISCUSSION The most common causes of renal artery aneurysms are arteriosclerosis, as in our case, and fibro-muscular dysplasia. Very often, renal artery aneurysms are asymptomatic and discovered only during angiography in patients with aneurysmal and occlusive aortic disease. Other cases include: arterial hypertension, groin pain and acute or chronic renal failure. Due to relatively small number of evaluated cases, the risk of aneurysmal rupture is not known. According to some authors, the overall rupture rate of renal artery aneurysm is 5%, however, the rupture risk becomes higher in young pregnant woman. Several standard surgical procedures are available for the repair of renal artery aneurysms. These include saphenous vein angioplasty, bypass grafting, as well as ex vivo reconstruction with reimplantation or autotransplantation. Furthermore, interventional embolization therapy, as well as endovascular treatment with ePTFE covered stent, or autologous vein-coverage stent graft, have been also reported to be successful. CONCLUSION The major indications for surgical treatment of renal artery aneurysms are to eliminate the source of thromboembolism which leads to fixed renal hypertension and kidney failure, as well as prevention of aneurysmal rupture.

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Hepatorenal Revascularization Enables Endovascular Aneurysm Repair on a Patient with Abdominal Aortic Aneurysm and an Ectopic Right Renal Artery

Annals of Vascular Surgery ◽

10.1016/j.avsg.2018.03.044 ◽

2018 ◽

Vol 52 ◽

pp. 316.e1-316.e5 ◽

Cited By ~ 2

Author(s):

Andreas M. Lazaris ◽

Konstantinos Moulakakis ◽

Georgios Mantas ◽

Katerina Poulou ◽

Evangelos Alexiou ◽

...

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Renal Artery ◽

Endovascular Aneurysm Repair ◽

Abdominal Aortic ◽

Aneurysm Repair

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Renal Artery Coverage During Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm

Annals of Vascular Surgery ◽

10.1016/j.avsg.2019.05.005 ◽

2020 ◽

Vol 62 ◽

pp. 63-69 ◽

Cited By ~ 1

Author(s):

Adam Tanious ◽

Laura T. Boitano ◽

Linda J. Wang ◽

Murray L. Shames ◽

Jason T. Lee ◽

...

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Renal Artery ◽

Endovascular Aneurysm Repair ◽

Ruptured Abdominal Aortic Aneurysm ◽

Abdominal Aortic ◽

Aneurysm Repair

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Fenestrated Plus Sandwiched-Reverse-Snorkel Technique for Endovascular Repair of a Pararenal Abdominal Aortic Aneurysm with Complex Renal Artery Anatomy

Annals of Vascular Surgery ◽

10.1016/j.avsg.2017.03.129 ◽

2017 ◽

Vol 41 ◽

pp. 11-12

Author(s):

Perry J. Xu ◽

Mina Boutrous ◽

Donald L. Jacobs

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Renal Artery ◽

Endovascular Repair ◽

Abdominal Aortic

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Laser Fenestration of Renal Artery in Fenestrated Endograft Repair of Abdominal Aortic Aneurysm

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2020.07.703 ◽

2020 ◽

Vol 231 (4) ◽

pp. S346-S347

Author(s):

Ali Rteil ◽

Scott Bendix ◽

Timothy James Nypaver ◽

Mitchell R. Weaver ◽

Loay S. Kabbani

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Renal Artery ◽

Abdominal Aortic ◽

Fenestrated Endograft

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Abdominal aortic aneurysm neck dilatation and sac remodeling in fenestrated compared to standard endovascular aortic repair

Vascular ◽

10.1177/17085381211052802 ◽

2021 ◽

pp. 170853812110528

Author(s):

Chong Li ◽

Katherine Teter ◽

Caron Rockman ◽

Karan Garg ◽

Neal Cayne ◽

...

Keyword(s):

Abdominal Aortic Aneurysm ◽

Aortic Aneurysm ◽

Renal Artery ◽

Aortic Rupture ◽

Endovascular Aortic Repair ◽

Aneurysm Neck ◽

Aortic Repair ◽

Aortic Neck ◽

Abdominal Aortic

Objective Contemporary commercially available endovascular devices for the treatment of abdominal aortic aneurysm (AAA) include standard endovascular aortic repair (sEVAR) or fenestrated EVAR (fEVAR) endografts. However, aortic neck dilatation (AND) can occur in nearly 25% of patients following EVAR, resulting in loss of proximal seal with risk of aortic rupture. AND has not been well characterized in fEVAR, and direct comparisons studying AND between fEVAR and sEVAR have not been performed. This study aims to analyze AND in the infrarenal and suprarenal aortic segments, including seal zone, and quantify sac regression following fEVAR implantation compared to sEVAR. Method A retrospective review of prospectively collected data on 20 consecutive fEVAR patients (Cook Zenith® Fenestrated) and 20 sEVAR (Cook Zenith®) patients was performed. Demographic data, anatomic characteristics, procedural details, and clinical outcome were analyzed. Pre-operative, post-operative (1 month), and longest follow-up CT scan at an average of 29.3 months for fEVAR and 29.8 months for sEVAR were analyzed using a dedicated 3D workstation (iNtuition, TeraRecon Inc, Foster City, California). Abdominal aortic aneurysm neck diameter was measured in 5 mm increments, ranging from 20 mm above to 20 mm below the lowest renal artery. Sub-analysis comparing the fEVAR to the sEVAR group at 12 months and at greater than 30 months was performed. Standard statistical analysis was done. Results Demographic characteristics did not differ significantly between the two cohorts. The fEVAR group had a larger mean aortic diameter at the lowest renal artery, shorter infrarenal aortic neck length, increased prevalence of nonparallel neck shape, and longer AAA length. On follow-up imaging, the suprarenal aortic segment dilated significantly more at all locations in the fEVAR cohort, whereas the infrarenal aortic neck segment dilated significantly less compared to the sEVAR group. Compared to the sEVAR cohort, the fEVAR patients demonstrated significantly greater positive sac remodeling as evident by more sac diameter regression, and elongation of distance measured from the celiac axis to the most cephalad margin of the sac. Device migration, endoleak occurrence, re-intervention rate, and mortalities were similar in both groups. Conclusion Compared to sEVAR, patients undergoing fEVAR had greater extent of suprarenal AND, consistent with a more diseased native proximal aorta. However, the infrarenal neck, which is shorter and also more diseased in fEVAR patients, appears more stable in the post-operative period as compared to sEVAR. Moreover, the fEVAR cohort had significantly greater sac shrinkage and improved aortic remodeling. The suprarenal seal zone in fEVAR may result in a previously undescribed increased level of protection against infrarenal neck dilatation. We hypothesize that the resultant decreased endotension conferred by better seal zone may be responsible for a more dramatic sac shrinkage in fEVAR.

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