|Year : 2019 | Volume
| Issue : 3 | Page : 201-203
A case of renal artery and multiple splenic artery aneurysms managed by heterotopic renal autotransplantation with splenectomy and proximal splenorenal shunt
Bokka Sri Harsha1, Ramanitharan Manikandan1, Lalgudi Narayanan Dorairajan1, Biju Pottakkat2, Sreevathsa K3
1 Department of Urology and Renal Transplantation, JIPMER, Puducherry, India
2 Department of Surgical Gastroenterology, JIPMER, Puducherry, India
3 Department of Cardiothoracic and Vascular Surgery, JIPMER, Puducherry, India
|Date of Web Publication||29-Aug-2019|
Dr. Bokka Sri Harsha
Department of Urology and Renal Transplantation, JIPMER, Puducherry
Source of Support: None, Conflict of Interest: None
A 30-year-old female was incidentally detected to have multiple splenic artery aneurysms and a large left renal artery aneurysm along with portal hypertension and splenomegaly during her prenatal workup. She was successfully managed by splenectomy, proximal splenorenal shunt, excision of left renal artery aneurysm, bench reconstruction of the left renal artery with saphenous vein graft, and renal autotransplantation in the right iliac fossa.
Keywords: Aneurysm, autotransplantation, heterotopic, proximal splenorenal shunt
|How to cite this article:|
Harsha BS, Manikandan R, Dorairajan LN, Pottakkat B, Sreevathsa. A case of renal artery and multiple splenic artery aneurysms managed by heterotopic renal autotransplantation with splenectomy and proximal splenorenal shunt. Indian J Vasc Endovasc Surg 2019;6:201-3
|How to cite this URL:|
Harsha BS, Manikandan R, Dorairajan LN, Pottakkat B, Sreevathsa. A case of renal artery and multiple splenic artery aneurysms managed by heterotopic renal autotransplantation with splenectomy and proximal splenorenal shunt. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Feb 19];6:201-3. Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/201/265773
| Introduction|| |
Surgical repair of a renal artery aneurysm is commonly recommended for symptomatic aneurysms, rapidly expanding aneurysms, or those >1.5 cm in diameter. In addition, because of an increased risk of rupture during pregnancy, women of childbearing age should have renal artery aneurysms repaired regardless of size. Potential benefits of this technique include adequate surgical exposure, a bloodless surgical field, and hypothermic protection of the kidney against ischemia. Furthermore, it is a useful last resort in preventing kidney loss in highly selected circumstances and when conventional methods have failed.
| Case Report|| |
A 30-year-old female was evaluated for thrombocytopenia in the antenatal period and was found to have splenomegaly with multiple splenic artery aneurysms all along its course, portal vein collaterals, and large esophageal varices. Incidentally, she was found to have a left renal artery aneurysm and was referred to our department for its management. Workup from our side on computed tomography [Figure 1]a and digital subtraction angiography [Figure 1]b revealed a large (4 cm) left renal artery aneurysm situated <1 cm from segmentation of the main renal artery. There were no aneurysmal changes elsewhere. Due to multiple large splenic artery aneurysms, splenectomy with splenorenal shunt was considered the appropriate management strategy. The portal hypertension was diagnosed to be due to noncirrhotic in etiology. The workup for hepatitis B and C antigens was negative, and serum transaminases were within the normal range. In view of risk factors for aneurysm rupture, after informed consent, her pregnancy was medically terminated at 8 weeks of gestational period, and she was taken up for a surgery which involved retrieval of the left kidney, bench excision of aneurysm which resulted in a kidney with practically two renal arteries (which were perhaps, the segmental arteries) [Figure 2]a and [Figure 2]b, reconstruction of seemingly larger segmental artery by end-to-end anastomosis with reversed saphenous vein graft, end-to-side anastomosis of smaller segmental artery with the graft, [Figure 2]c autotransplantation of the kidney in the right iliac fossa with end-to-side anastomosis of saphenous vein graft with the external iliac artery, renal vein with external iliac vein, and extravesical ureteroneocystostomy. Surgical Gastroenterology team performed splenectomy with proximal splenorenal shunt, while bench reconstruction of the renal artery was going on. Platelet count in the postoperative period improved significantly and portal venous pressure normalized subsequently. Histopathology of aneurysm revealed myxoid degeneration with medial calcification and elastic degeneration. Postoperative Doppler study of autotransplanted kidney at 6 months demonstrated good color flow across the hilum [Figure 2]d.
|Figure 1: (a) Computed tomography three-dimensional reconstructed image showing multiple aneurysms along the left splenic artery and an aneurysm over the left renal artery, (b) digital subtraction angiography showing a large left renal artery aneurysm just at the bifurcation into segmental arteries|
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|Figure 2: (a) Intraoperative picture showing aneurysm in distended state, (b) intraoperative picture showing the aneurysm in collapsed state, and its vicinity to bifurcation of renal artery into segmental arteries, (c) bench reconstruction showing anastomosed larger segmental artery to saphenous vein graft in end-to-end and smaller segmental renal artery to saphenous vein in end-to-side manner, (d) Postoperative Doppler showing good color flow in the autotransplanted kidney|
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| Discussion|| |
The most important indication for surgical repair of a renal artery aneurysm appears to be the presence of concurrent hypertension and female gender, with size a relative but secondary consideration. James Hardy performed the first renal autotransplant in 1963 to repair a high ureteral injury sustained during aortic surgery. Renal autotransplantation and extracorporeal repair for various indications such as fibromuscular disease, renovascular disease, tumors, and ureteral injuries were reported in probably one of the largest series by Flatmark in 1989. In a recent series of nine patients with refractory renovascular hypertension published by Shelke et al., the authors concluded that autotransplantation can be a successful treatment of severe right ventricular hypertrophy and should be considered in patients with renal arterial disease unfavorable for percutaneous intervention. Of late, renal autotransplantation in the setting of radiotherapy-induced renal artery stenosis causing renovascular hypertension has also been described.
While heterotopic transplantation is a commonly reported entity, orthotopic autotransplantation of the kidney can also be performed in selected cases. One such case is reported by Zhang et al. where a patient with midaortic syndrome that failed to respond to bilateral renal artery stenting was treated with aortic bypass and orthotopic right renal autotransplantation with good outcome. The most common indication for renal autotransplantation is to allow extracorporeal repair of complex branch renal artery lesions as described by Novick et al. in their series of 108 cases where the procedure was performed in 54 of them for complex renovascular conditions, a successful clinical outcome was achieved in 52 of them.
Splenic artery aneurysm is the most common of all the visceral artery aneurysms. Serum amyloid A (SAA) is defined by a pathologic dilatation of the splenic artery to >1 cm in diameter. The true prevalence remains unknown because 95% of individuals remain asymptomatic until the aneurysm ruptures.,,
Approximately 95% of SAA rupture occurs during pregnancy, most commonly during the third trimester. If a woman has an existing SAA, the risk of rupture during pregnancy is 20%–50%. Although the rupture of an SAA during pregnancy is a rare event, it carries a high risk of maternal and fetal mortality. The mortality in the general population when an SAA rupture is 25%. In pregnant women, this rate increases to a 75% maternal mortality rate and a 95% fetal mortality rate.
| Conclusion|| |
Renal autotransplantation is a safe, effective yet, challenging procedure for the treatment of rare urologic and renal vascular conditions where in situ repair is difficult and risky. Furthermore, it is reasonable in conditions where the salvage of the concerned kidney is strongly recommended like in our case where the patient is young and has good life expectancy.
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]