Renal autotransplantation for complex renal arterial disease: a case report

A renal artery aneurysm in a stenotic renal artery is a rare clinical entity with an incidence of 0.015% to 1% in patients with renovascular hypertension. Interventional stent placement is the first line of treatment for simple aneurysms of the proximal renal artery. However, renal autotransplantation has been used as an alternative treatment for complex lesions and for lesions originating from the distal renal artery. We present a patient with a renal artery aneurysm, renal artery stenosis of the segmental branches of the left kidney, and occlusion of the right renal artery. The surgical strategy included renal explantation, ex vivo renal preservation, ex vivo reconstruction of the 2 renal artery branches, and renal heterotopic autotransplantation. We conclude that renal autotransplantation is a safe and effective surgical procedure for patients with complex renal arterial disease.     

Ex Vivo Repair and Renal Autotransplantation for Complex Renal Artery Aneurysms in a Solitary Kidney

Renal artery aneurysm (RAA) is a rare clinical entity with an incidence of 0.015-1%. Indications for interventional or surgical repair of RAAs are expanding aneurysms, diameter >2.5 cm, intractable renovascular hypertension, dissecting RAA, hematuria, and renal infarction after distal embolization. Interventional insertion of a stent graft as well as aortorenal bypass implantation are both low-risk procedures in simple aneurysms of the proximal renal artery. However, complex distal renal aneurysms involving several renal artery branches require not only an excellent result of vascular reconstruction, but also a surgical technique offering maximal protection for the kidney during the ischemic period. Here, we present a case of a solitary kidney with two consecutive RAAs of segmental renal artery branches (type 2 RAA). A surgical strategy including renal explantation, ex vivo renal preservation, ex vivo reconstruction of the renal artery, and renal heterotopic autotransplantation was successfully applied. The technique of ex vivo repair is a safe and effective surgical procedure in this clinical setting.     

Ischemic nephropathy. Epidemiology and clinical implications.

Renal dysfunction secondary to stenosis of the renal arteries is an entity that is underdiagnosed but becoming increasingly recognized. This condition probably accounts for a large number of patients in dialysis programs. Hypertension is not an essential component of this disease. Progression of renal artery stenosis with deterioration of renal function is the natural course. This progression can be reversed with surgical or percutaneous revascularization of the ischemic kidneys with a high degree of success in preserving or restoring kidney function.     

Renal malperfusion: spontaneous renal artery dissection and with aortic dissection

Renal malperfusion associated with renal artery dissection can present as either an isolated disease process or in the setting of branch vessel stenosis complicating aortic dissection. Isolated renal artery dissection is a rare disorder, the clinical presentation of which often presents both diagnostic and therapeutic challenges. The true incidence and natural history of this phenomenon also remain unclear. Multiple approaches to management have been described. Medical therapy typically consists of anticoagulation and blood pressure management and is reserved for cases with well-controlled symptoms and blood pressure and preserved, stable renal function. Historically, surgical reconstruction with in situ or more complex ex vivo reconstruction has been described for the treatment of uncontrolled hypertension with preservation of renal perfusion. Nephrectomy, either partial or total, for control of hypertension, is reserved for cases where parenchymal injury necessitates this radical intervention. Recently, endovascular stenting of the renal artery has shown excellent and durable results and is now considered to be the first-line intervention for renal artery dissection. Renal malperfusion associated with complicated aortic dissection is a different entity and one that is consistently an independent predictor of poor prognosis. The pathogenesis of malperfusion can be dynamic, static, or a combination. In addition, renal hypoperfusion may occur with or without extension of the intimal flap into the renal artery itself. Traditional open surgical interventions to treat aortic dissection with malperfusion have a very high perioperative mortality rate. Endovascular fenestration and stenting of both the thoracic aortic and it’s branch vessels have significantly improved clinical outcomes in complicated aortic dissections relative to open surgical fenestration. Although a significant body of long-term data has yet to be accumulated, endovascular stent grafting has the added advantage over fenestration that it may affect aortic remodeling and prevent the very morbid complication of aneurysmal degeneration.     

Endovascular management of recurrent stenosis following left renal vein transposition for the treatment of Nutcracker syndrome

Nutcracker syndrome is an entity resulting from left renal vein compression by the superior mesenteric artery and the aorta, leading to symptoms of left flank pain and hematuria. Conventional treatment has been surgical, commonly through transposition of the left renal vein to a more caudal location on the inferior vena cava. Additionally, endovascular approaches, primarily via renal vein stenting, have been described for treatment of this syndrome. We report the case of a patient with Nutcracker syndrome who underwent successful left renal vein transposition but then developed recurrent symptoms 10 months postoperatively and was successfully treated with angioplasty and stenting.     

Robot‐assisted laparoscopic renal artery aneurysm repair with selective arterial clamping

Renal artery aneurysms represent a rare clinical entity, and most are managed with endovascular techniques when treatment is indicated. Laparoscopic and robot‐assisted repair of renal artery aneurysms has been described; however, few reports exist in the literature. We describe our experience with the surgical management of a 1.6‐cm right‐sided renal artery aneurysms in a 35‐year‐old man who presented with flank pain. Using the DaVinci Si surgical platform (Intuitive, Sunnyvale, CA, USA), the aneurysm was resected and the renal artery was reconstructed. Segmental branches of the renal artery were dissected and selectively clamped during resection, allowing for regional rather than global renal ischemia. Operative time was 240 min, with an estimated blood loss of 200 cc. Warm ischemia time was only regional, for a duration of 44 min. Follow‐up functional analysis showed preserved renal function in the right kidney. We describe our technique and show the technical feasibility of robot‐assisted renal artery aneurysm repair. Furthermore, use of the DaVinci Si system facilitates segmental artery dissection, and allows for selective clamping during reconstruction. This avoids global renal ischemia and optimizes functional preservation.     

Wandel der Indikationen zur chirurgischen Nierenarterienrevaskularisation

Background

Although evidence regarding the optimal treatment of renovascular disease appears uncertain, the rate of percutaneous renal artery revascularization has rapidly increased since 1990.

Purpose

To evaluate a change in the indications for surgical renovascular reconstruction.

Patients and methods

The inpatient database of the Teaching Hospital of Stuttgart (from January 1997 to December 2002: Vascular Unit Database (Excel); from January 2003 to July 2008: Hospital-Information-System (KIS) i.s.h.med/SAP Healthcare) was analyzed to identify patients undergoing surgical renal artery revascularization. During the study period, 164 patients had renal artery surgery.

Results

Sixty-five percent of the renal revascularizations were done simultaneously with aortoiliac reconstructions. Comparing the two periods 1997–2002 and 2003–07/2008, there was an increase in simultaneous renal and aortoiliac reconstructions from 53% to 83%, but the number of patients decreased by 35%. The overall in-hospital mortality was 4.9%.

Conclusions

Atherosclerosis with renal artery stenosis is increasing in an aging population. Because of an increasing rate of percutaneous endovascular renovascular repair, surgical revascularization is decreasing, although evidence regarding the optimal treatment of atherosclerotic renal artery stenosis is uncertain. Until now there has been no statistical power regarding which intervention provides the best clinical outcome. It seems that renal artery stenting has replaced surgical revascularization of the renal arteries; the only remaining bastion for surgical renal artery reconstruction is simultaneous renal and aortoiliac revascularizations. With a decreasing number of patients receiving renovascular surgery, there will not be enough trained surgeons in the future, or surgery on the renal arteries will have to be done only in high-volume hospitals.     

Pheochromocytoma coexisting with renal artery lesions

PURPOSE: Physiologically significant renal artery lesions in the presence of a pheochromocytoma comprise a confounding factor which may impact on the hypertension cure following excision of the pheochromocytoma. We present 10 cases of these dual lesions and review the literature on this entity. MATERIALS AND METHODS: From 1952 to 1999, 269 patients were diagnosed with pheochromocytoma at our institution. Hospital charts of these patients were reviewed retrospectively to identify those with coexisting renal artery stenosis. A Medline search was performed to review the available literature. RESULTS: Of the 269 patients with pheochromocytoma 10 (3. 7%) had coexisting renal artery lesions, including renal artery stenosis in 8, renal artery aneurysm in 1 and postangiographic dissection occlusion in 1. Pheochromocytoma was adrenal in 8 cases and ectopic in 2. Of the patients 9 have been treated to date by adrenalectomy in 4, nephroadrenalectomy in 3, adrenalectomy plus lysis of renal artery adhesions in 1 and adrenalectomy plus renal autotransplantation with bench repair in 1. Both lesions were diagnosed preoperatively in 9 cases and a hypovascular adrenal lesion was missed preoperatively in 1. A review of literature revealed a total of 87 cases of coexisting pheochromocytoma and renal artery lesions. CONCLUSIONS: There are multiple mechanisms that can lead to renal artery stenosis and pheochromocytoma. A high index of suspicion is necessary to enable both entities to be diagnosed preoperatively and allow proper planning of surgical therapy. Incomplete diagnosis may lead to persistent hypertension postoperatively.     

Post-transplant renal artery stenosis: a cause of anuria. Report of 2 cases corrected by revascularization

We report 2 cases of severe hypertension and acute onset of anuria after renal transplantation in which angiography revealed renal artery stenosis. After renal artery reconstructive surgery renal function returned to normal and the hypertension improved. A high index of suspicion is needed to make the diagnosis. Only by heightened awareness of this important entity will patients with post-transplantation anuria secondary to renal artery stenosis be identified. Such patients may benefit from renal artery revascularization to reverse this type of renal failure.     

Anastomotic line renal artery stenosis after transplantation

We report on 5 patients with renal artery stenosis after renal transplantation. Renal arteriography showed the stenosis to be localized at the line of arterial anastomosis. The patients presented with refractory hypertension, with or without renal failure, 10 days to 13 months after transplantation. Percutaneous transluminal balloon angioplasty in 4 patients failed in 3 and produced temporary improvement in 1. Resection of the stenosis resulted in dramatic improvement of the clinical state in all 5 patients. Histological examination of the resected stenotic segment revealed a nodular fibrotic lesion at the anastomotic line in all cases, and was associated with extensive calcification in 3. Anastomotic line stenosis should be recognized as a specific entity causing transplant renal artery stenosis. The pathological changes observed explain the failure of transluminal angioplasty and suggest that surgical repair is the treatment of choice. Possible factors in the etiology of anastomotic line stenosis are discussed.     

Case Report: Treatment of Renal Artery Aneurysms by Ex Vivo Renal Artery Aneurysm Repair and Transplantation

Background

Renal artery aneurysms are increasingly being detected incidentally during diagnostic imaging using magnetic resonance imaging, computed tomography, or angiography performed for evaluation of other diseases. Our understanding of their natural history and surgical management has evolved significantly during the past two decades.

Renal autotransplantation in children: a successful treatment for renovascular hypertension

Renovascular hypertension in children is not a common disease. With improved surgical technique the incidence of nephrectomy has decreased and renovascular reconstruction is currently the preferred method to manage this entity. Between 1977 and 1988, 21 patients with renovascular hypertension were treated at our hospital: 7 patients 6 to 16 years old underwent renal autotransplantation. Of the children 4 had unilateral and 3 had bilateral disease requiring bilateral autotransplantation. Autotransplantation was performed by anastomosis of each renal artery end-to-side to the common iliac artery. The renal veins were anastomosed end-to-side to the common iliac veins. The ureters were left intact in all but 1 patient who required a bench operation. Of the 4 patients who had a unilateral procedure 3 are cured and 1 is improved with a normal blood pressure on a small dose of antihypertensive medication. The 3 patients with bilateral autotransplants are cured. These results, with normalization of the blood pressure in 86% of the patients and improvement in blood pressure in 14% with a patency rate of 87%, are similar to other reported reconstructive modalities in children.     

Renal Artery Aneurysms

A renal artery aneurysm is defined as a dilated segment of renal artery that exceeds twice the diameter of a normal renal artery. Although rare, the diagnosis and incidence of this entity have been steadily increasing due to the routine use of cross-sectional imaging. In certain cases, renal artery aneurysms may be clinically important and potentially lethal. However, knowledge of their occurrence, their natural history, and their prognosis with or without treatment is still limited. This article aims to review the recent literature concerning renal artery aneurysms, with special consideration given to physiopathology, indications for treatment, different technical options, post-procedure complications and treatment outcomes.     

The simultaneous occurrence of renal artery stenosis and an aldosteronoma in a patient with hypertension

The simultaneous occurrence of renovascular hypertension and an adrenocortical adenoma is a rare entity. The case of a 64-year-old woman who underwent an aortorenal bypass graft for renovascular hypertension requiring a multidrug antihypertensive regimen is presented. Persistently elevated blood pressures in the postoperative period prompted further workup for other causes of hypertension. Laboratory evaluation showed hyperaldosteronism and hyporeninemia despite enalapril administration. Abdominal computerized tomography (CT) revealed a left adrenal mass which, on surgical removal, was found to be a cortical adenoma. Subsequently, her antihypertensive therapy has been reduced to a single agent. Previous authors have described only four patients with malignant hypertension who had the rare clinical combination of renal artery stenosis and an aldosteronoma. This case reemphasizes the critical need for a thorough search for other surgically correctable lesions in those patients who remain severely hypertensive after the "definitive" operation.     

Surgical correction of renovascular hypertension

The role of surgical revascularization in the management of patients with renal artery disease has changed in recent years. This has occurred owing to the advent of transluminal angioplasty as an effective method of treatment for certain patients, improved results of surgical revascularization in older patients with atherosclerosis, an enhanced appreciation of advanced atherosclerotic renal artery disease as a correctable cause of renal failure, and the development of more effective surgical techniques for patients with severe aortic atherosclerosis and branch renal artery disease. Surgical revascularization is at present the treatment of choice for patients with branch renal artery disease, ostial atherosclerotic renal artery disease, a renal artery aneurysm, and patients in whom renal angioplasty has been unsuccessful. Excellent clinical results continue to be achieved with surgical revascularization in properly selected patients.     

Surgical treatment of juxtarenal aortic occlusion

From 1974 to 1976, four patients with juxtarenal aortic occlusion were operated upon with no surgical mortality. Thromboendarterectomy (TEA) of the aorta with renal revascularization was performed in one patient, and TEA with grafting in three. Intraoperative renal protection was particularly important, since suprarenal aortic clamping was often required in these cases. Possible renal embolism developed in one patient postoperatively. In order to prevent renal embolism and to minimize ischemic insult to the kidney, the value of the following procedures was stressed; (a) irrigation of aortic lumen with saline after TEA under suprarenal aortic clamping with renal arteries kept occluded, and (b) re-application of aortic clamp below the renal arteries after irrigation. Since the most distal level of occlusive process was the common femoral artery in our series, the patient with this desease entity should be treated more actively.     

Intra-cardiac extension of a Wilms’ tumor

Background

Wilms? tumor, or renal nephroblastoma, is the commonest malignant renal tumor in children and young adults. Intravascular and intracardiac extension of this tumor is a very rare and challenging clinical entity.

Case presentation

The case is reported of a 6-year-old boy diagnosed with nephroblastoma, in whom the tumor involved the inferior vena cava and the right atrium. The successful multimodal surgical management consisted of combined, synchronous surgical resection of both renal and intracardiac tumors. The boy had an uneventful postoperative course and recovery, followed by relapse-free living.

Conclusion

Intra-cardiac extension of Wilm’s tumor poses a surgical challenge where the favorable outcome is provided only by the combined and well-coordinated, skilled multidisciplinary care of pediatric surgeons and pediatric cardiac surgeons.

     

Dunbar syndrome: apropos of a case (review of the literature)

The authors report a case of the uncommon and still discussed "coeliac artery compression syndrome". On the basis of the literature's review and of their own observation they conclude that Dunbar's Syndrome is a real clinical entity. The section of the arcuate ligament and the subadventitial removal of the pericoeliac tissue, or, whenever indicated, an aorto-coeliac by-pass, seems to be the "gold standard" in the surgical treatment.     

Splenic Artery Pseudoaneurysm Masquerading as a Pancreatic Cyst—A Diagnostic Challenge

Splenic artery pseudoaneurysm is a rare entity. Clinical diagnosis is challenging because presentation is often varied. It can range from an incidental finding to hemodynamic collapse from sudden rupture and bleeding. The most common cause of this condition is pancreatitis. We report an unusual case of a young man not known to have pancreatitis who presented with hematemesis with normal esophagogastroduodenoscopy. Imaging modalities did not lead to a definitive diagnosis, and he underwent emergency laparotomy with surgical ligation of splenic artery pseudoaneurysm for hemodynamic instability, without a definitive preoperative diagnosis.Key words: Splenic artery pseudoaneurysmSplenic artery pseudoaneurysm (SAP) is a rare entity. Fewer than 200 cases of SAP have been reported in the literature.¹ Clinical diagnosis remains challenging because presentation is often varied. It can range from an incidental finding to hemodynamic collapse from sudden rupture and bleeding.² Therefore, a high index of suspicion is required. The most common cause of SAP is chronic pancreatitis.¹ We report an unusual case of a young man not known to have pancreatitis who presented with hematemesis and hemodynamic instability not amenable to endoscopic hemostasis. He underwent emergency laparotomy and surgical ligation of SAP.     

Treatment of acute renal artery occlusion after percutaneous transluminal angioplasty

Four patients with occlusive complications after percutaneous transluminal renal artery angioplasty (PTA) have been treated from July 1, 1984, to March 14, 1988. During this interval such renal artery angioplasties were performed in 44 patients. Two resulted in complete main renal artery occlusion, one angioplasty resulted in occlusion of a stenotic renal artery bypass graft, and one renal PTA resulted in segmental branch renal artery narrowing, which was thought to represent a dissection. The latter segmental renal artery narrowing was treated expectantly with good long-term results. One of the main renal artery occlusions was treated by radiologic means by reentry and repeat transluminal dilation. The other two acute complete occlusions, one of an autogenous artery and the other of an aortorenal bypass graft, were treated by aortorenal or ileorenal bypass grafting, respectively. The overall incidence of main renal artery occlusion (including the bypass graft occlusion) after PTA requiring operative intervention was 4.5% (2/44). Revascularization was accomplished after 6 and 8 hours of renal ischemia time for the two surgical procedures. Despite this, the bypass grafts done emergently remain patent, and the involved kidneys appear to be functional. The incidence of main renal artery occlusion after PTA is not as low as would be apparent from a review of the literature. It is proposed that main renal artery occlusion after PTA can be treated successfully by surgical and interventional radiologic techniques because of the presence of protective renal collateral circulation whose formation was stimulated by the renal artery lesion that prompted PTA.