Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 4  |  Page : 292-294

Open repair of an abdominal aortic aneurysm in a patient with congenital renal vascular anomalies


Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Web Publication11-Dec-2018

Correspondence Address:
Dr. Sreekumar Ramachandran
Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_48_18

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  Abstract 


Purpose: The renal vasculature is unique in such a way that each artery behaves as an end artery. The amount of renal damage that can occur by sacrificing these arteries are so unpredictable. The presence of aberrant or accessory renal arteries makes open repair of the abdominal aortic aneurysm (AAA) technically more challenging than conventional surgery. Here, we describe various techniques used to preserve the renal vasculature and prevent renal ischemia during surgery. Methods: We present a case of saccular AAA with low lying right kidney with an aberrant renal artery arising from neck and an accessory renal artery arising from the body of the aneurysm. We performed an open repair of the aneurysm, during which we did inter-renal clamping and renal perfusion with renoplegia solution using Pruitt-Inahara shunt. Conclusions: Interrenal clamping and administration of optimal renoplegia solution through shunt are very useful adjuncts to prevent renal ischemia during open repair of AAA with congenital renal vascular anomalies. Pruitt-Inahara Shunt, classically described in carotid endarterectomy, can be used in AAA surgeries for administering renoplegia.

Keywords: Abdominal aortic aneurysm, abdominal aortic aneurysm, aberrant the renal artery, accessory renal artery, congenital renal vascular anomalies, Pruitt-Inahara shunt, renoplegia


How to cite this article:
Kumar V, Pitchai S, Ramachandran S, Nair HR. Open repair of an abdominal aortic aneurysm in a patient with congenital renal vascular anomalies. Indian J Vasc Endovasc Surg 2018;5:292-4

How to cite this URL:
Kumar V, Pitchai S, Ramachandran S, Nair HR. Open repair of an abdominal aortic aneurysm in a patient with congenital renal vascular anomalies. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2019 Mar 18];5:292-4. Available from: http://www.indjvascsurg.org/text.asp?2018/5/4/292/247265




  Introduction Top


In 70% of cases, the kidney is supplied by a single renal artery that originates from the aorta.[1] The main renal artery branches out to four or five segmental arteries. Each segmental artery behaves like an end artery. Therefore, occlusion of one vessel may lead to infarction of the corresponding segment of the kidney. Congenital variations in renal vasculature have been found in 30% of cases, the most common being supernumerary or accessory renal arteries.[2] The term accessory and aberrant renal artery have been used interchangeably under various contexts.[3] The accessory renal artery is an artery that supplies blood to the kidney after entering through hilum either alone or accessory to the main renal artery. The aberrant renal artery is the one which supplies blood to the kidney without entering the hilum. We hereby present operative techniques used in the open repair of the abdominal aortic aneurysm (AAA) with aberrant and accessory renal artery.

Background

A 70-year-old male, a chronic smoker, with no comorbid conditions, presented with recurrent abdominal pain for the past 3 months. Computed tomography (CT) aortogram revealed a 7-cm saccular AAA with low lying right kidney. Furthermore, an aberrant renal artery and an accessory renal artery on the right side were found arising from the neck and body of the aneurysm, respectively [Figure 1]. Preoperative blood urea nitrogen was 10 mg/dl, the serum creatinine level was 0.83 mg/dl, and coronary angiogram was normal.
Figure 1: Preoperative computed tomography angiogram with three-dimensional reconstruction illustrating a saccular aortic aneurysm with left renal artery (top arrow) arising above the neck of the aneurysm. Right main renal artery (middle arrow), accessory right renal artery (bottom arrow), arising from the upper and lower part of the body of the aneurysm

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Procedure

The procedure was performed under general anesthesia. The transperitoneal approach was used. The left renal artery was arising from normal aorta above the aneurysm [Figure 2]a. Aortic clamp applied at the neck of aneurysm above aberrant below left renal artery and above the right renal artery. Aneurysm was opened, and then two Pruitt-Inahara shunts (Le Maître Vascular, Inc., Burlington, USA) were inserted into both renal Ostia and custom made renoplegia solution was delivered through the shunt [Figure 2]b. After completing proximal anastomosis implantation of aberrant and accessory renal artery was performed in that order to the 16-mm polyester tube graft by sequential clamping. Adequate urine output was maintained during the whole process of clamping and declamping. Renal implantation was completed in 30 min.
Figure 2: (a) Intraoperative photograph illustrating left renal artery (top right arrow) arising above the neck of the aneurysm. Right main renal artery (top left arrow), accessory right renal artery (bottom left arrow), arising from the upper and lower part of the body of aneurysm. (b) Intraoperative photograph illustrating administration of renoplegia through Pruitt-Inahara shunt inserted into right main renal artery (top left arrow), and accessory right renal artery ostium (bottom left arrow), after cut opening the aneurysm. Inset-Pruitt-Inahara Shunt

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The patient had a mild chest infection postoperatively for which he required prolonged ventilation. The postoperative renal function was normal, and CT revealed good arterial reconstruction [Figure 3].
Figure 3: (a) Intraoperative photograph illustrating completed anastomosis with reimplanted right main renal artery (top left arrow), accessory right renal artery (bottom left arrow), to main graft. Left renal artery (top right arrow) is well above the proximal anastomosis. (b) Postoperative computed tomography aortogram with three-dimensional reconstruction illustrating left renal artery (top arrow) arising above proximal anastomosis. Reimplanted Right main renal artery (middle arrow), accessory right renal artery (bottom arrow), arising from the upper and lower part of the body of the graft

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  Discussion Top


Therapeutic strategy for AAA is a matter of contention, especially in this era of endovascular intervention. The association of congenital renal vascular anomalies along with AAA further complicates the issue. Still, open repair is regarded as gold standard considering its durability, ease in postoperative follow-up with less requirement of contrast imaging and excellent long-term outcome.

During open AAA repair, small, non-bleeding accessory or other aortic branch vessels are conventionally ligated without trepidation and larger ones that back-bleed are reattached. In case of aberrant and accessory renal arteries, implantation is attempted much more rigorously because postoperative renal insufficiency is markedly associated with worse outcomes, including mortality.[4] The Society for Vascular Surgery Consensus statement recommends implantation of aberrant renal arteries of size ≥3 mm or those that supply one-third or more of the renal parenchyma, however, only low-quality evidence exists to support any of the above statements.[5]

The proximal clamp placement commonly used in AAA surgeries are infrarenal, suprarenal and supraceliac.[6] In our case, we used inter-renal clamping since right kidney was lying at a lower level due to the incomplete ascend that occurred during development. This plan of selective clamping was made successful by contrast tomography which we consider an indispensable part of the preoperative evaluation.

Various techniques have been described to prevent renal ischemia during aortic cross-clamping.[7] Here, we used Pruitt-Inahara shunt for delivering renoplegia solution. Pruitt-Inahara shunt was classically described in carotid endarterectomy to maintain cerebral circulation.[8] The balloon at the distal end of the shunt is inflated in such a way that it snuggly fits inside the artery. Thus, it was possible to avoid occlusion clamps and subsequent vessel trauma on the renal artery. Moreover, the balloon opened up the vessel lumen which eased the anastomosis. We performed renal artery reconstruction by sequentially shifting the clamp downwards, so that renal perfusion was maintained after subsequent anastomosis. Hence, it avoided possible embolic event to the kidney.

The solution which we custom made for renal perfusion is referred to as Renoplegia. The composition is 500 ml lactated ringer at 4° centigrade along with 1000 U of heparin, 12.5 mg mannitol, 6 mg dexamethasone, 25 mg sodium-bicarbonate and 30 mg of papaverine. Each component has its own function. Heparin prevented microthrombus propagation in renal vasculature, mannitol acted as a free radical scavenger, steroid decreased the inflammatory mediators related to renal ischemic injury,[9] sodium- bicarbonate neutralized the acidotic pH due to anaerobic metabolism in kidney and finally, papaverine provided renal arteriolar vasodilation.

Endovascular insertion of a branched or fenestrated stent-graft was a possible treatment option in this case. Long-term results of accessory renal artery coverage using stent grafts are available and are notassociated with any permanent renal dysfunction or worsening hypertension.[10] However in the index case, due to the limitation in the landing zone and associated financial constraints, we proceeded with open repair.


  Conclusions Top


The renal-related complication is the most common cause of morbidity following open repair of AAA with congenital renal vascular anomalies. Operative planning depends on the morphology of blood vessels whether they are single or multiple, originating from the neck or body of the aneurysm, of size more than or <3 mm, supplying a significant portion of kidney or not. Ideal clamp placement, intra-operative renal protective measures and early initiation of renal perfusion are the three crucial factors that decide the postoperative outcome. Interrenal clamping and administration of optimal Renoplegia solution through shunt are very useful adjuncts to prevent renal ischemia during the open repair of AAA with congenital renal vascular anomalies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bauer SB, Perlmutter AD, Retik AB. Anomalies of the upper urinary tract. In: Walsh PC, editor. Campbell's Urology. 6th ed. Philadelphia: W.B. Saunders; 1997. p. 1357-437.  Back to cited text no. 1
    
2.
Satyapal KS, Haffejee AA, Singh B, Ramsaroop L, Robbs JV, Kalideen JM, et al. Additional renal arteries: Incidence and morphometry. Surg Radiol Anat 2001;23:33-8.  Back to cited text no. 2
    
3.
Graves FT. The aberrant renal artery. J Anat 1956;90:553-8.  Back to cited text no. 3
    
4.
Hardy JD. Preservation of accessory arterial supply in abdominal aneurysm resection. Surg Gynecol Obstet 1966;123:1317-9.  Back to cited text no. 4
    
5.
Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: Executive summary. J Vasc Surg 2009;50:880-96.  Back to cited text no. 5
    
6.
Chong T, Nguyen L, Owens CD, Conte MS, Belkin M. Suprarenal aortic cross-clamp position: A reappraisal of its effects on outcomes for open abdominal aortic aneurysm repair. J Vasc Surg 2009;49:873-80.  Back to cited text no. 6
    
7.
Köksoy C, LeMaire SA, Curling PE, Raskin SA, Schmittling ZC, Conklin LD, et al. Renal perfusion during thoracoabdominal aortic operations: Cold crystalloid is superior to normothermic blood. Ann Thorac Surg 2002;73:730-8.  Back to cited text no. 7
    
8.
Hayes PD, Vainas T, Hartley S, Thompson MM, London NJ, Bell PR, et al. The Pruitt-Inahara shunt maintains mean middle cerebral artery velocities within 10% of preoperative values during carotid endarterectomy. J Vasc Surg 2000;32:299-306.  Back to cited text no. 8
    
9.
Baker RC, Armstrong MA, Young IS, McClean E, O'Rourke D, Campbell FC, et al. Methylprednisolone increases urinary nitrate concentrations and reduces subclinical renal injury during infrarenal aortic ischemia reperfusion. Ann Surg 2006;244:821-6.  Back to cited text no. 9
    
10.
Greenberg JI, Dorsey C, Dalman RL, Lee JT, Harris EJ, Hernandez-Boussard T, et al. Long-term results after accessory renal artery coverage during endovascular aortic aneurysm repair. J Vasc Surg 2012;56:291-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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