|Year : 2020 | Volume
| Issue : 3 | Page : 281-283
Renal artery aneurysm
Rahul Lakshminarayanan, I Devarajan, Sabarish G Kumar, Sritharan Narayanan
Institute of Vascular Surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
|Date of Submission||08-Oct-2019|
|Date of Decision||02-Jan-2020|
|Date of Acceptance||05-Jan-2020|
|Date of Web Publication||12-Sep-2020|
Institute of Vascular Surgery, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Renal artery aneurysm (RAA) is a rare presentation, accounting for <1% of all splanchnic aneurysms. Renal aneurysms may present as hypertension, flank pain, hematuria, or with signs of rupture, but are often asymptomatic. We are hereby presenting one such case that we encountered in our clinical practice. A 67-year-old male diagnosed incidentally with left RAA 2.5 cm in size, without any local or systemic complications, underwent open repair with interposition vein graft repair and had an uneventful postoperative course.
Keywords: Aneurysm repair, interposition graft, renal artery aneurysm, RSV
|How to cite this article:|
Lakshminarayanan R, Devarajan I, Kumar SG, Narayanan S. Renal artery aneurysm. Indian J Vasc Endovasc Surg 2020;7:281-3
| Introduction|| |
Renal artery aneurysm (RAA) is a rare disease comprising < 1% of all splanchnic artery aneurysms. Conservative management has been described for these cases (kindly mentioned up to what size conservative treatment), and operative repair can be carried out with open repair (kindly improve phrasing operative repair and open surgery is almost the same thing) as well as endovascular therapy for suitable lesions.
We encountered a patient with RAA which was 2.5 cm in maximal diameter and proceeded with operative repair for the same. The case deserves mention in view of the rarity as well as the approach chosen in view of varied options available.
| Case Report|| |
A 67-year-old man presented with complaints of urinary retention. He did not have complaints of abdominal pain, giddiness, hematuria, or fever. He underwent an ultrasound abdomen, which showed an incidental finding of the left RAA 3.25 cm × 2.5 cm in diameter with bilaterally normal-sized kidneys. He underwent contrast-enhanced computerized tomogram of the abdomen which showed an aneurysm 2.5 cm × 2.5 cm in size, in the left renal artery between the first branch and secondary branch points [Figure 1]. He underwent diethylenetriaminepentaacetic acid scan to assess relative kidney function which showed left kidney having a 42% renal function.
|Figure 1: Computed tomography angiogram – three-dimensional reconstruction|
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He was evaluated and planned for open repair. The intraoperative plan was to assess the anatomy and decide regarding appropriate repair with the options ranging from primary anastomosis, patch repair, interposition graft placement (autologous/synthetic) to possible bench dissection and renal reimplantation in the right iliac fossa (most of the planning can be done these days with computed tomography/magnetic resonance imaging ANGIOS, only minor shift in plan could happen, kindly write clearly why so many options were planned).
He underwent a midline laparotomy with left colon mobilization. The left renal vein branches were ligated, and the vein was mobilized to visualize the aneurysm. The branches were delineated and controls taken [Figure 2]. The aneurysm sac was opened and the origins of the distal branches visualized and perfused with heparinized Ringer's lactate [Figure 3]. The excess sac was excised and patch surrounding distal branches with the aneurysm wall preserved [Figure 4] and [Figure 5]. Reversed great saphenous vein graft was harvested and an interposition graft was carried out with successful revascularization of the kidney [Figure 6] (kindly mention whether vein was taken before clamping and opening aneurysm, whether heparin given before clamping).
|Figure 6: Postrepair with reversed great saphenous vein interposition graft|
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| Discussion|| |
RAA is a rare entity, with incidence in the general population approaching 0.1%. The natural history of RAAs shows a slow increase in size between 0.06 and 0.6 cm per year. The risk of rupture is also low with no correlation demonstrated between morphology or calcification. A recent study also showed long-term follow-up for 88 aneurysms (2–3 cm) and 7 aneurysms (>3 cm) till 49 months, showing no complication or rupture (then why surgery was considered in this particular case kindly justify as size was ma × 2.5 cm × 2.5 cm).
The RAAs commonly present in the 6th decade with female predominance. Majority of the patients are asymptomatic at presentation, and hypertension could be the only presenting feature. Renal bruit and palpable abdominal mass are infrequent manifestations.
Most RAAs are saccular and affect arterial bifurcations. 10%–20% are bilateral (improve the phrasing). The average size varies between 1.3 cm and 3.8 cm. 18%–68% are associated with calcification and 8%–11% with hypertension. The types include true aneurysms (saccular and fusiform), pseudoaneurysms, dissecting aneurysms, and intrarenal aneurysms. The most common etiology involves atherosclerosis/degenerative, followed by fibromuscular dysplasia, trauma (blunt or iatrogenic), and dissection.
Indications for intervention include size >2 cm; women in childbearing age; symptomatic aneurysms with pain, hematuria, or hypertension; rupture; dissection and thromboembolism. The size criteria of 2 cm have been debated as to whether observation may be a more suitable approach as opposed to intervention, and as such controversy exists in this regard.
Intervention options include open surgical or endovascular options. Open repair includes-excision with primary angioplastic closure (kindly write optimally with proper surgical language) with or without branch reimplantation, patch repair, primary reanastomosis, interposition bypass grafting, aortorenal bypass, splanchno-renal bypass, and plication of small aneurysms. Moreover, additional option, especially for aneurysms involving the branch points or extending into the renal parenchyma, is ex vivo dissection and arterial repair with renal autoimplantation. For aneurysms for whom repair would not be feasible, nephrectomy is advised.
Endovascular options include stent placement, coil embolization, stent placement with coil embolization, and liquid embolization. Endovascular options depend on suitable anatomy and have the advantage of being as safe as open surgical repair with shorter operative times, lesser blood loss, and shorter postoperative hospital admission durations. The suitable anatomy for stent placement is if the aneurysm arises from the main renal artery. The suitable anatomy for coil placement is with a narrow neck for the aneurysm.
Technical success in endovascular therapy approaches 73%–100% with postoperative morbidity varying between 13% and 60% based on the study seen. The morbidity may include postoperative deterioration of glomerular filtration rate (GFR), thromboembolism, and access-related complications. Thirty percent reduction in GFR was reported in 12.5% of open surgical cases and 9.1% of endovascular repair cases. Freedom from reintervention at 12 and 24 months for open surgery was 82% and 82%, respectively. And for endovascular repair was 82% and 74%, respectively.
The open surgical reconstruction showed between 82% and 96% long-term patency in some studies with lesser numbers of reinterventions required for open surgical repair. Imaging studies also showed the durability of the repair was reliable. Appropriate case selection and choice of repair were essential to the successful outcome of open repair. Some studies showed better long-term patency with aneurysmorrhaphy that with autogenous vessel interposition graft (100% vs. 73%).
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]