|Year : 2022 | Volume
| Issue : 3 | Page : 260-262
Ex vivo Repair of renal artery branch aneurysm in fibromuscular dysplasia
Neelamjingbha Sun, Ashutosh Kumar Pandey, Sriram Manchikanti, Shivanesan Pitchai
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
|Date of Submission||05-Jan-2022|
|Date of Acceptance||22-Jan-2022|
|Date of Web Publication||21-Aug-2022|
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
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 Oct 1];9:260-2. Available from: https://www.indjvascsurg.org/text.asp?2022/9/3/260/354071
| Introduction|| |
Renal artery aneurysm is a rare disorder, with an incidence of <1% and most patients detected on evaluation for hypertension.,,, Endovascular procedures have been described, but only a few patients fulfill the anatomical criteria suitable for intervention. 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|| |
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|| |
Renal artery aneurysms are rare, with fibromuscular dysplasia, atherosclerosis, and arteritis being commonly reported causes.,, Most cases are detected on evaluation for renovascular hypertension, while some patients present with hematuria, acute kidney injury, and rarely rupture., 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.
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. Other indications include women of childbearing age, uncontrolled hypertension, and renal artery stenosis.
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. 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. 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. 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.
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. Duprey et al. reported zero mortality in the immediate postoperative period, with 9-day average duration of hospital stay and minimal complication rate. 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.
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
Conflicts of interest
There are no conflicts of interest.
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