Bilateral renal artery aneurysms: in-situ and extracorporeal repair.

Renal artery aneurysms are uncommon, but when they do occur they are frequently associated with hypertension which may be amenable to surgery. Complex arterial abnormalities which formerly would have been treated by nephrectomy may now be reconstructed with preservation of the kidney. This is illustrated by a patient with renovascular hypertension and bilateral renal artery aneurysms, in whom arteriography and renal vein renin ratios were used as a guide to surgery performed in two stages. An in-situ repair was performed on one side. On the other side, where the aneurysm involved the three main branches of the renal artery, an extracorporeal repair was performed using continuous cold perfusion, substitution of the pathological segment with the patient's internal iliac artery, and autotransplantation to the iliac fossa. Both kidneys were retained and the hypertension was cured.     

Technical tips for endovascular repair of common iliac artery aneurysms

Isolated common iliac artery aneurysms are rare, comprising <2% of all aneurysm disease. These aneurysms present as either isolated disease, .03% of the population, or, in conjunction with abdominal aortic aneurysm, in approximately 20% to 25% of such cases. Common iliac artery aneurysms are defined as any localized dilatation of the common iliac artery >1.5 cm in diameter. Elective repair for isolated common iliac artery aneurysms is generally not undertaken for aneurysms <3 cm in diameter unless they are part of an abdominal aortic aneurysm repair. Most common iliac artery aneurysms are found incidentally during abdominal/pelvic diagnostic imaging studies or at the time of pelvic or abdominal surgery. As with abdominal aortic aneurysms, endovascular repair of common iliac artery aneurysms follows techniques similar to those used for endovascular repair of abdominal aortic aneurysm. Management includes aneurysm exclusion with an endograft, which seals at sites within the proximal and distal common iliac artery and may involve coil occlusion of the hypogastric artery with extension of the reconstruction into the proximal external iliac artery, or use a "bell-bottom" endograft limb placed at the common iliac bifurcation. Technical tips for successful outcome are described here, and all US Food and Drug Administration approved endografts have been used for repair. There were no statistically significant differences in outcomes that correlated with device or repair techniques used for management of common iliac artery aneurysms. Mid-term 54-month outcome has been excellent, with no common iliac artery ruptures or aneurysm-related deaths and the need for secondary interventions was gratifyingly small.     

Renal artery aneurysms.

Renal artery aneurysms, previously considered to be rare, have been diagnosed more frequently in recent years mainly due to the extensive use of angiography. Fifty-six patients with 67 aneurysms were evaluated, 5 of these were dissecting aneurysms. Most cases were manifestations of medial hyperplasia or atherosclerosis of the renal arteries. Symptomatology is not pathognomonic. Expanding aneurysm, intractable hypertension, hematuria, and renal infarction represent the most common indications for surgical repair. Reconstruction and repair of these aneurysms, with preservation of the kidney, is the preferred treatment. Surgery was performed on 17 patients (30%): 14 patients had primary repair, while 3 patients underwent nephrectomy for associated carcinoma and end-stage kidney disease. Temporary occlusion of the renal artery with hypothermic perfusion allows surgical repair safely to both patient and kidney. Autotransplantation into the ipsilateral iliac fossa was employed for dissecting aneurysms after resection and repair of the diseased segment. Nine of 12 hypertensive patients required no treatment for hypertension following aneurysmal repair, while 3 patients had improved control.     

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.     

Repair of Bilateral Common Iliac Artery Aneurysms Coexisting with a Pelvic Horseshoe Kidney

This report describes the treatment of bilateral common iliac artery aneurysms in a patient with a pelvic horseshoe kidney. Anomalous renal arteries arising from the aorta, the common iliac arteries, and the left hypogastric artery were identified precisely by selective angiography. These multiple renal artery anomalies and the presence of a large pelvic horseshoe kidney complicated the surgical treatment of the aneurysms. The repair of the aneurysms was successfully accomplished by staged retroperitoneal procedures. This technique allowed excellent visualization of the iliac aneurysms and preservation of all renal arteries with intact renal function.     

A case of rectal obstruction caused by bilateral internal iliac artery aneurysms

In this article, we report a rare case of rectal obstruction caused by bilateral internal iliac artery aneurysms that required open surgical repair. A 73-year-old man was admitted to our hospital complaining of abdominal pain and persistent constipation for >1 month. Computed tomography demonstrated bilateral internal iliac artery aneurysms, 5.0 and 7.0 cm each in diameter, which occupied the intrapelvic space. An urgent surgery was performed to reduce the volume of the aneurysms and release the obstructed rectum. The postoperative course was uneventful, in which he had good evacuation. Aneurysms in the iliac region can be a good indication for the use of newly developed endovascular devices; however, open surgery should be considered without delay to avoid ileus or subileus symptoms when the aneurysms cause space-occupying complications.     

Aneurysms of the renal artery: surgical management with special reference to extracorporeal surgery and autotransplantation

27 patients underwent surgical arterial reconstruction for renal artery aneurysms. Hypertension was present in 21 cases. The indication for surgery was the prevention of hemorrhagic rupture in association with hypertension. Extracorporeal surgery was performed 13 times for complex aneurysms involving several branches of the renal artery. Simple autotransplantation was performed 3 times for aneurysms located on the main renal artery. In situ surgery was performed on 11 patients (5 aneurysmectomy-arteriorrhaphies and 7 bypass operations). Results on high blood pressure showed that 10 of the 14 hypertensive patients operated by extracorporeal surgery and/or autotransplantation were cured. 1 delayed nephrectomy was performed in this group and 1 death was observed. 39 of the 46 peripheral anastomoses were patent postoperatively. All patients treated with aneurysmectomy-arteriorrhaphy were cured. In patients treated with bypass operations, 3 thromboses of the bypass and 2 failures on hypertension were observed. Aneurysmectomy and simple arterioplasty are preferred for simple renal artery aneurysms. For complex lesions involving several branches and of an intrarenal location, extracorporeal surgery and autotransplantation represent an effective treatment on hypertension and preservation of kidney function.     

Management of isolated common iliac artery aneurysms

Purpose: Since isolated common iliac artery aneurysms are rare and there is no consensus regarding some aspects of their management, we reviewed our recorded experience with common iliac artery aneurysms from 1977 through 1993. Methods: We were able to identify 25 patients having a total of 33 common iliac artery aneurysms on the basis of information maintained by our medical records staff, old surgical logs and a departmental registry that was implemented in 1989. Follow-up data were collected from outpatient charts and by telephone contact. New imaging studies were obtained for 14 patients who either underwent common iliac artery aneurysm repair without aortic replacement (aortic ultrasound scans, n = 7) or had no surgical treatment whatsoever (computerized tomography of the abdomen and pelvis, n = 7). Results: All 25 patients were men (mean age, 71 years). Eighteen patients (72%) had elective (n = 14) or urgent (n = 4) operations to repair common iliac artery aneurysms with mean diameters of 3.8 cm and 5.8 cm, respectively. There was one postoperative death (5.5%) in conjunction with complementary renal revascularization in a patient with preoperative renal insufficiency. During a mean follow-up period of 50 months, two (29%) of the seven patients who had not received bifurcation grafts at the time of their common iliac artery aneurysm procedures had developed infrarenal aortic aneurysms. Seven (28%) of the original 25 patients were observed without intervention for common iliac artery aneurysms measuring 2–2.5 cm in diameter. No common iliac artery aneurysm enlargement or new aortic aneurysms have been documented in any of these patients at a mean follow-up interval of 57 months. Conclusions: In our limited experience, the risk for spontaneous rupture appears to be concentrated among common iliac artery aneurysms exceeding 5 cm in diameter, while those that are less than 3 cm in diameter may fail even to enlarge under observation. Therefore, common iliac artery aneurysms measuring ≥3 cm in size probably warrant surgical treatment, at which time simultaneous aortic replacement also should be a serious consideration.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Renal perfusion with the Biomedicus pump during resection of an abdominal aortic aneurysm.

Renal artery perfusion is usually unnecessary during resection of an abdominal aortic aneurysm, because most of these aneurysms are situated below the renal arteries. The authors report the interesting case of a patient with a solitary functioning kidney, who had undergone previous bypass grafting from the right iliac artery to the right renal artery and in whom the kidney was perfused with the Biomedicus pump during the repair of an abdominal aortic aneurysm. This technique may be useful in special situations in which any period of renal ischemia might be hazardous to renal function.     

Renal artery aneurysm. Treatment by ex-vivo reconstruction and autotransplantation: three cases and literature review

Renal artery aneurysms (RAAs) is a rare clinical entity: the prevalence is approximately 0.01%-1% in the general population. Complex aneurysms of the first ramification of the main renal artery often require nephrectomy for adequate excision. From December 2002 to July 2007, we treated 3 patients with complex RAA. All the patients were treated with ex vivo reconstruction of the renal artery followed by autotransplantation of the kidney into the ipsilateral iliac fossa. Observation is suggested for asymptomatic complex renal artery aneurysms measuring less than 2 cm in diameter. Surgical treatment by aneurysmectomy and reconstruction in vivo or ex vivo technique is indicated for RAA causing renovascular hypertension, dissection, embolization, local expansion and for those in women of childbearing age with a potential for pregnancy, or asymptomatic more than 2 cm in diameter. Ex vivo repair and renal autotransplantation is a safe and effective treatment for the management of complex renal artery aneurysms.     

Renal artery stenosis and aneurysms associated with neurofibromatosis

Renal artery lesions associated with neurofibromatosis may involve stenosis and aneurysm formation at all levels of the renal artery to the intraparenchymal branches, and usually are associated with hypertension. A 13-year-old boy with type I neurofibromatosis and severe hypertension presented with multiple aneurysms and multiple stenotic lesions in the renal artery and segmental arteries. The patient underwent ex-vivo renal artery repair with autologous hypogastric artery and autotransplantation to the iliac fossa and was clinically improved. The characteristic histologic findings are presented. A review of the recent literature comparing different treatment modalities for renovascular hypertension in children with neurofibromatosis suggests that surgery remains the best treatment alternative.     

Endovascular repair of abdominal aortic aneurysm with pelvic transplant kidney with antegrade deployment of iliac limb

A 63-year-old woman presented with a symptomatic aneurysm and a pelvic transplant kidney on the side of an external iliac artery occlusion. A commercially available bifurcated endograft was introduced through the common iliac artery contralateral to the kidney. The external iliac artery occlusion required antegrade delivery of an iliac limb through the contralateral endograft gate and cannulation of the common iliac artery to allow for deployment proximal to the transplant kidney artery. This technique was successful and remains so six months postoperatively. Endovascular repair of aneurysms proximal to pelvic transplant kidneys remains the preferred method of repair. However, inadequate access vessels may require antegrade delivery of endograft components which is facilitated by advances in endograft design.     

Extraparenchymal Renal Artery Aneurysms: Is Hypertension an Indication for Revascularization Surgery?

We report here the surgical management of extraparenchymal renal artery aneurysms associated with hypertension and the results of this treatment. From January 1978 through December 1999, 19 consecutive patients with 23 extraparenchymal renal artery aneurysms underwent surgery with renal revascularization techniques. Of these 19 patients, 89.5% had systemic hypertension, and 12 of 16 patients had associated renovascular hypertension. Twenty of the aneurysms were patent, one was chronically thrombosed, and one patient presented with acute thrombosis of abdominal aortic and bilateral renal aneurysms; 11 of the 20 patent cases had significant stenosis in the preoperative arteriography. Seventeen aneurysms (74%) were located on the main trunk of the renal artery. Response of hypertension and renal function were examined. Surgical technique patency was evaluated by life-table methods. Our basic surgical indication for extraparenchymal renal artery aneurysms in this series was renovascular hypertension. Nonrenal hypertension alone does not indicate surgery. We consider the saphenous vein to be the graft of choice for renal revascularization.     

Repair of bilateral iliac artery aneurysms associated with a congenital pelvic kidney

The association of iliac artery aneurysms with a congenital pelvic kidney is extremely rare. Although multiple techniques are well described for renal preservation with renal ectopia in the setting of aortic reconstruction, few reports exist describing techniques for renal preservation in the setting of bilateral iliac artery aneurysms. A case is presented of a middle-aged man with a 6-cm right common iliac artery aneurysm and a 3-cm left common iliac artery aneurysm and a right pelvic kidney. A double-proximal-clamp technique and temporary shunting to the pelvic kidney were used during the aneurysm repair. The technical aspects of this procedure are presented as well as a brief discussion of the various options for renal preservation with renal ectopia when repairing complex aneurysmal disease.     

Aortic reconstruction in patients with functioning renal allografts

Patients with functioning renal allografts requiring aortic reconstruction pose a considerable challenge to the vascular surgeon. A variety of strategies for renal allograft preservation during intervention have been described including hypothermia, indwelling shunts, cold renal perfusion, axillofemoral bypass, and endovascular stent-grafting. Reported here are two cases of successful aortic reconstruction utilizing standard open surgical techniques designed simply to minimize warm renal ischemia. The first case was that of a 55 year-old patient with a functional renal allograft originating from the right external iliac artery, who presented acutely with large symptomatic aortic and bilateral iliac artery aneurysms. He was treated with aorto-right femoral/left iliac bypass grafting. The right femoral anastomosis was performed first so that warm renal ischemia was limited to the 34 min required to perform the proximal end-to-end aortic anastomosis. The second case was that of a 44-year-old patient also with a transplanted kidney originating from the right external iliac artery. He presented with worsening hypertension, decreasing renal function, claudication, and severe aortoiliac occlusive disease. He was treated with aorto-left femoral bypass grafting via a retroperitoneal approach, followed by femorofemoral crossover bypass for retrograde perfusion of the kidney (total warm ischemia time 20 min). Both patients recovered uneventfully without a decrement in renal function and remain well on follow-up. It is concluded that standard open surgery without adjunctive shunts or bypasses remains a viable treatment option for these patients, provided warm renal ischemia can be minimized.     

Renal artery aneurysm: a report of 28 cases

Renal artery aneurysms are being increasingly encountered due to the wider use of angiography. From 1972 to 1992, 28 patients with renal artery aneurysm were identified in the present study, including 18 women and 10 men, with a mean age of 58 years. The aneurysms were discovered incidentally in 39% of patients during evaluation for hypertension in 39%, and during investigation of abdominal pain in 22%. Only 7% of patients had symptoms directly attributable to the aneurysm. Aneurysm size varied from 0.5 cm to 8 cm in diameter, with a mean of 2.1 cm. The main renal artery was involved in 52% of cases, and primary branches in 44%; the remainder were intraparenchymal. There was a slight right-sided predominance in this series. The etiology of the aneurysms included atherosclerosis (75%), fibromuscular disease (21%), and Ehlers-Danlos syndrome (4%). Surgical therapy was undertaken in 10 patients (36%). Procedures performed included aortorenal bypass in four patients, aneurysm excision and renal artery repair in three, partial nephrectomy in one, and total nephrectomy in two. Although the natural history of renal artery macroaneurysms is not known with certainly, potential complications include embolization and rupture. The authors' indications for surgery include: (a) symptomatic or enlarging aneurysms; (b) renal embolization; (c) aneurysms in pregnant females or those considering pregnancy; (d) renovascular hypertension; (e) aneurysms >2.5 cm. Most symptom-free aneurysms <2.5 cm in diameter can be safely treated expectantly.     

Endovascular repair of a ruptured internal iliac arterial aneurysm with a novel application of the aorto-uni-iliac converter device

Internal iliac artery aneurysms are rarely discovered by examination and may consequently present with rupture in a patient without an established diagnosis. Ruptured internal iliac aneurysms harbor a high risk of morbidity and mortality. Although open repair is possible, endovascular repair may be an option in some patients. We present a case of a ruptured internal iliac artery aneurysm with an adjoining ipsilateral common iliac artery aneurysm repaired with a novel use of an aorto-uni-iliac device.     

Management isolierter Iliakalaneurysmen

Isolated aneurysms of the iliac artery are a rare finding. The pathology is usually found in patients with atherosclerosis and the lesions are generally asymptomatic. Due to silent disease progression approximately every third patient suffers from rupture which is associated with a substantial mortality rate. In the clinical practice, computed tomography (CT) angiography represents the diagnostic tool of choice, especially due to the anatomical position (e.g. internal iliac aneurysm). Surgical repair in asymptomatic patients is indicated if the diameter exceeds 3 cm and is performed analogue to abdominal aortic aneurysms to prevent rupture or embolism. Surgery can be undertaken by conventional open (interposition, bypass and ligation) or endovascular (bell-bottom technique, iliac side branch technology or embolization) means. In suitable patients endovascular repair represents the preferred treatment strategy, particularly in high-risk patients. Follow-up should be performed with duplex ultrasound and/or CT angiography after both open and endovascular repair.     

Surgical treatment of isolated iliac artery aneurysm with ureteral obstruction and/or renal failure

Three patients with isolated iliac artery aneurysm with ureteral obstruction and/or renal failure are presented. One patient had a stenotic lesion of the right ureter caused by direct compression of common and internal iliac artery aneurysms. Resection of the aneurysms and graft replacement were successfully performed. The other patients, who had hydroureteronephrosis and renal failure caused by entrapment of the ureters in perianeurysmal fibrosis, were treated surgically by ureterolysis, resection with graft replacement of the common iliac artery aneurysms, and endoaneurysmorraphy of the internal iliac artery aneurysms. One has had a good postoperative course, whereas the other died from a rare complication of rectosigmoid colon perforation caused by direct compression by the graft.