Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 260-262

Ex vivo Repair of renal artery branch aneurysm in fibromuscular dysplasia


Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission05-Jan-2022
Date of Acceptance22-Jan-2022
Date of Web Publication21-Aug-2022

Correspondence Address:
Shivanesan Pitchai
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_2_22

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  Abstract 


Renal artery aneurysm is a rare disorder with an incidence of < 1%. We describe a case of fibromuscular dysplasia with right renal artery branch aneurysm, who had uncontrolled renovascular hypertension. The patient was successfully managed with ex vivo repair and reconstruction of the renal artery using reverse saphenous vein graft, followed by autotransplantation of the right kidney. Although surgically demanding, the technique is feasible and yielded good results.

Keywords: Ex vivo repair, fibromuscular dysplasia, renal artery aneurysm


How to cite this article:
Sun N, Pandey AK, Manchikanti S, Pitchai S. Ex vivo Repair of renal artery branch aneurysm in fibromuscular dysplasia. Indian J Vasc Endovasc Surg 2022;9:260-2

How to cite this URL:
Sun N, Pandey AK, Manchikanti S, Pitchai S. Ex vivo Repair of renal artery branch aneurysm in fibromuscular dysplasia. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Sep 25];9:260-2. Available from: https://www.indjvascsurg.org/text.asp?2022/9/3/260/354071




  Introduction Top


Renal artery aneurysm is a rare disorder, with an incidence of <1% and most patients detected on evaluation for hypertension.[1],[2],[3],[4] Endovascular procedures have been described, but only a few patients fulfill the anatomical criteria suitable for intervention.[5] We present a case of fibromuscular dysplasia with right renal artery branch aneurysm, who underwent ex vivo repair and autotransplantation of the right kidney.


  Case Report Top


A 36-year-old man, painter by occupation, was diagnosed with renovascular hypertension, uncontrolled with four antihypertensives. He had no complaints of abdominal pain and hematuria and had normal urine output. On examination, he had a pulse rate of 80 beats/min and blood pressure (BP) of 150/90 mmHg. Per abdomen examination was not significant, and no bruit was present. His vasculitic workup was within normal limits.

His computed tomography (CT) angiogram revealed the mid-segment of the right renal artery to be tortuous, with multifocal stenosis and aneurysmal dilatation, extending up to the segmental artery supplying the right upper pole. The maximum size of aneurysm measured 23 mm × 18 mm [Figure 1]a.
Figure 1: (a) Reconstructed computed tomography angiogram image showing right renal artery aneurysm, extending into the segmental branch. Tight stenosis (yellow arrow) is seen just proximal to the aneurysm. (b) Intraoperative image showing the renal artery aneurysm (black arrow) below the looped renal vein

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Intervention radiology was consulted for possibility of endovascular management but was not amenable, due to involvement of the segmental artery. Hence, he was planned for open surgical correction of the aneurysm and stenosis, after informed consent.

Using midline laparotomy, the right kidney was exposed and the suprarenal vein was ligated to mobilize the right renal vein. Renal artery was dissected up to its origin from the aorta [Figure 1]b. Ureter was dissected and preserved. Left great saphenous vein (GSV) was harvested. Heparin 1 mg/kg was given. Renal vein was divided with a cuff of inferior vena cava (IVC) and clamped. Renal artery was divided at its origin, and stump was overrun. Kidney was perfused with cold crystalloid solution enriched with histidine-tryptophan-ketoglutarate (Custodiol; Dr. Franz-Kohler Chemie GmbH, Bensheim, Germany) by using an Inahara-Pruitt shunt, until the effluent was clear. Kidney was then explanted to the abdominal wall and kept in ice slush. The ureter was kept intact and was clamped [Figure 2]. Aneurysmal segments were resected. Renal hilum was dissected and four segmental arteries were identified [Figure 3]a. GSV was anastomosed end to end with the normal segments of segmental arteries [Figure 3]b. The upper and lower segmental arteries were piggybacked to the GSV attached to the central segmental artery graft [Figure 3]c. The graft was perfused with Custodiol, and anastomotic sites were checked. Kidney was reimplanted orthotopically and the venous graft was anastomosed to the infrarenal aorta [Figure 4]. Renal vein was reanastomosed to IVC. Postanastomosis, good pulsations were present in the graft, renal vein was dilated, and kidney became pink. Total cold ischemia time was 3 h 30 min. Heparin was reversed with protamine. Hemostasis was checked, a drain was placed, and closure was completed. He was shifted to the intensive care unit with minimal inotropic supports.
Figure 2: Explanted kidney kept in ice slush, with the aneurysmal segment (yellow arrow), renal vein (black arrow), and intact ureter (arrowhead)

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Figure 3: Steps of renal artery reconstruction (*: intact ureter, yellow arrow: renal vein) (a) Renal hilum with four arrowheads showing segmental arteries, (b) Great saphenous vein (GSV) anastomosed end to end with the four segmental arteries, (c) GSV grafts piggybacked to central single graft

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Figure 4: The kidney reimplanted orthotopically and venous graft anastomosed to the infrarenal aorta (yellow arrow)

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Postoperatively, he had hematuria that gradually reduced over the next 2–3 days. His drain was removed on postoperative day 6. He always maintained a good urine output, and BP was managed with two antihypertensives. Before discharge, a Doppler was done which showed good flow in the main graft, with a peak systolic velocity of 60 cm/s, and good interrenal flow. Histopathology confirmed fibromuscular dysplasia. At 1 year of follow-up, he was doing well, on two antihypertensives, with normal renal function and renal Doppler showed good flow in the graft.


  Discussion Top


Renal artery aneurysms are rare, with fibromuscular dysplasia, atherosclerosis, and arteritis being commonly reported causes.[1],[6],[7] Most cases are detected on evaluation for renovascular hypertension, while some patients present with hematuria, acute kidney injury, and rarely rupture.[6],[7] It has been hypothesized that the cause of hypertension is a twist or kink of the renal artery, limited renal blood flow due to turbulence, or emboli causing renal ischemia.[8]

Imaging with ultrasound, CT angiography, and magnetic resonance angiography are used to evaluate the aneurysm extent, size, location, and the presence of renal artery stenosis. Most case series and case reports have a cutoff size of >2 cm for intervention, however, the recent guidelines advise a size of >3 cm in asymptomatic individuals for intervention.[9] Other indications include women of childbearing age, uncontrolled hypertension, and renal artery stenosis.[9]

Rundback et al. classified renal artery aneurysms into three types – types 1 and 3 being well suited for endovascular management and type 2 for open surgical management.[10] While aneurysm of the main branch can be addressed by endovascular procedures, renal artery branches pose a difficulty in achieving adequate coverage, as well as the higher risk of renal embolization resulting in ischemia and worsening hypertension. Our patient is a type 2 aneurysm involving the main and branch vessel, along with the presence of renal artery stenosis, and was hence taken up for surgical management.

Aneurysmectomy is the most commonly described surgical method for the treatment of renal artery aneurysms.[1] Ex vivo repair is an approach using renal transplant technique of ligating the renal vessels and the use of cold preservation methods. Ex vivo repair provides a clean field, adequate space for dissection, and ability to reach the distal small branches for anastomosis and control.[7] Although in situ repair of renal artery aneurysms has also been described, the surgical field is smaller, making dissection difficult, especially in the presence of inflamed tissues.[7]

Low perioperative morbidity and mortality have been reported with ex vivo repair, with complications mostly related to graft thrombosis, segmental ischemia due to emboli, or diminished renal function.[6] Duprey et al. reported zero mortality in the immediate postoperative period, with 9-day average duration of hospital stay and minimal complication rate.[7] The primary patency rate at 8years was 88%. At 9years, 43% of patients with hypertension were cured and 18% improved with a significant reduction of antihypertensives.[7]

Ex vivo repair and autotransplantation of the kidney is a feasible, though surgically demanding, management of renal artery branch aneurysms in patients with fibromuscular dysplasia, with low morbidity and high success rate.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Orion KC, Abularrage CJ. Renal artery aneurysms: Movement toward endovascular repair. Semin Vasc Surg 2013;26:226-32.  Back to cited text no. 1
    
2.
González J, Esteban M, Andrés G, Linares E, Martínez-Salamanca JI. Renal artery aneurysms. Curr Urol Rep 2014;15:376.  Back to cited text no. 2
    
3.
Hupp T, Allenberg JR, Post K, Roeren T, Meier M, Clorius JH. Renal artery aneurysm: Surgical indications and results. Eur J Vasc Surg 1992;6:477-86.  Back to cited text no. 3
    
4.
Henriksson C, Bjorkerud S, Nilson AE, Pettersson S. Natural history of renal artery aneurysm elucidated by repeated angiography and pathoanatomic studies. Eur Urol 1985;11:244-8.  Back to cited text no. 4
    
5.
Cura M, Elmerhi F, Bugnogne A, Palacios R, Suri R, Dalsaso T. Renal aneurysms and pseudoaneurysms. Clin Imaging 2011;35:29-41.  Back to cited text no. 5
    
6.
English WP, Pearce JD, Craven TE, Wilson DB, Edwards MS, Ayerdi J, et al. Surgical management of renal artery aneurysms. J Vasc Surg 2004;40:53-60.  Back to cited text no. 6
    
7.
Duprey A, Chavent B, Meyer-Bisch V, Varin T, Albertini JN, Favre JP, et al. Editor's choice Ex vivo renal artery repair with kidney autotransplantation for renal artery branch aneurysms: Long-term results of sixty-seven procedures. Eur J Vasc Endovasc Surg 2016;51:872-9.  Back to cited text no. 7
    
8.
Lumsden AB, Salam TA, Walton KG. Renal artery aneurysm: A report of 28 cases. Cardiovasc Surg 1996;4:185-9.  Back to cited text no. 8
    
9.
Chaer RA, Abularrage CJ, Coleman DM, Eslami MH, Kashyap VS, Rockman C, et al. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. J Vasc Surg 2020;72:3S-39S.  Back to cited text no. 9
    
10.
Rundback JH, Rizvi A, Rozenblit GN, Poplausky M, Maddineni S, Crea G, et al. Percutaneous stent-graft management of renal artery aneurysms. J Vasc Interv Radiol 2000;11:1189-93.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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