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.

Real Renal Function After Renal Autotransplantation Through the Analysis of Solitary Kidney Autotransplantation Cases

Introduction

Previous studies of the safety of renal autotransplantation (RAT) have been limited by a lack of evidence. Because of the influence of the opposite kidney, it is difficult to evaluate actual renal function. This study evaluated the actual results of RAT by collecting only cases involving a solitary kidney.

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.     

Laparoscopic Nephrectomy,Ex Vivo Repair,and Autotransplantation for a Renal Artery Aneurysm: Report of a Case

A 57-year-old woman was hospitalized with a left renal artery aneurysm (RAA). The aneurysm measured 35 mm in diameter and was located at the renal artery bifurcation. We performed a laparoscopic nephrectomy using a retroperitoneal approach and performed an ex vivo repair of the renal artery. The reconstructed kidney was then autotransplanted at the left iliac fossa. The patient's postoperative course was uneventful. A laparoscopic nephrectomy and ex vivo repair are both considered to be effective for treating complex RAA.     

Renal function after elective infrarenal aortic aneurysm repair in patients with pelvic kidneys

Pelvic kidneys complicate aortic reconstructions because of increased risk of renal ischemia. Strategies for protection include shunting, cooling, and reliance on collaterals. A review identified two congenital pelvic kidney (not solitary) and five transplanted kidney patients who underwent elective abdominal aortic aneurysm repair. For congenital pelvic kidneys, topical cooling was used in one patient while no preservation was performed for the other patient. Three transplanted kidney patients were shunted, and one had endovascular repair. Postoperative creatinine values were compared to preoperative values. The two congenital pelvic kidney patients had no significant elevation of creatinine postoperatively. The transplanted kidney patient who underwent endovascular repair had no increase in creatinine postoperatively. All transplanted kidney patients who had open repair had significant but transient increase in creatinine postoperatively. Three patients who were shunted intraoperatively had normalization of creatinine. The patient who had persistent elevation of creatinine at discharge was not shunted. Aortorenal shunting or endovascular repair in transplanted pelvic kidney patients maintains renal function. For patients with congenital pelvic kidneys and adequate collaterals, cooling and collateral perfusion is usually sufficient. Though experience is limited, endovascular repair is likely to be superior to open repair in minimizing renal ischemia.     

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.     

Robot-assisted renal artery aneurysm repair with a saphenous vein Y-graft interposition

Background

Renal artery aneurysms (RAA) treatment includes both surgical repair and endovascular techniques, mostly depending on the location of aneurysm [1]. For complex RAA located at renal artery bifurcation or distally, open surgical repair represents the gold standard of treatment [2]. However, the transperitoneal open access to the renal artery requires a wide laparotomy—hence the attempt to be minimally invasive with the first reports of laparoscopic approach [3, 4]. Even if it represents a possibility, laparoscopy has not yet gained widespread acceptance for the technical difficulties in performing vascular anastomosis. We herein describe the repair of a complex RAA using the Da Vinci Surgical System.

Methods

A 41-year-old woman had an accidentally discovered saccular aneurysm of the right renal artery with a maximum diameter of 20 mm, with one in and four out. A laparoscopic robot-assisted approach was planned. Intraoperatively, we confirm the strategy to group the four output branches in two different patches. Thus, a Y-shaped autologous saphenous graft was prepared and introduced through a trocar. For the three anastomoses, a polytetrafluoroethylene running suture was preferred.

Results

The total operation time was 350 min, and the estimated surgical blood loss was about 200 ml. Warm ischemia time was 58 min for the posterior branch and 24 min for the second declamping. The patient resumed a regular diet on postoperative day 2, and the hospital stay lasted 4 days. No intraoperative or postoperative morbidity was noted. A CT scan performed 2 months later revealed the patency of all the reconstructed branches.

Conclusions

The experience of our group counts five other renal aneurysm repair performed with a robot-assisted technique [5]. The presence of five different arterial branches involved in the reconstruction makes this procedure difficult. Robot-assisted laparoscopic technique represents a valid alternative to open surgery in complex cases.     

Traumatic renal artery occlusion in a patient with a solitary kidney: case report of treatment with endovascular stent and review of the literature

Renal artery occlusion after blunt trauma is a rare occurrence, and the optimal treatment for this condition has not been established. To our knowledge, endovascular repair for blunt renal artery occlusion in a solitary kidney has not been described in the literature. This case report describes a 42-year-old woman with a solitary left kidney presenting with total occlusion of the left renal artery after a significant crush injury. She was successfully treated by percutaneous placement of an endovascular stent. Postprocedure, the patient developed acute renal failure requiring temporary dialysis. At follow-up 4 months later, the patient has normal urinary output and a normal creatinine.     

复杂性肾动脉瘤诊治

目的 探讨复杂性肾动脉瘤(RAA)的特点及诊治方法.方法 1999年3月至2008年9月收治复杂性RAA患者5例.女4例,男1例.平均年龄35(20～54)岁.腰痛伴血尿2例、腹痛伴休克i例、高血压1例、查体发现1例.RAA直径平均3.5(0.5～9.0)cm.单侧3例、双侧2例.5例均经数字减影血管造影确诊.保守治疗1例、肾动脉栓塞后肾切除1例、超选择性肾动脉栓塞1例、覆膜支架介入治疗1例、肾分支动脉结扎1例.结果 1例孤立肾多发动脉瘤破裂出血者保守治疗5 d死亡;1例肾上极1.5 cm动脉瘤,超选择性肾动脉栓塞后随访10个月未见复发;1例直径9.0 cm肾动脉瘤经肾动脉栓塞后行肾切除,随访12个月未见复发;1例肾内3.0 cm动脉瘤行覆膜支架介入治疗,随访12个月未见复发;1例右肾2.5 cm动脉瘤行右肾分支动脉结扎,10个月后发现左肾1.3 cm动脉瘤.随访24个月左肾RAA无变化,右肾RAA无复发.结论 直径＜2 cmRAA可密切观察,复杂性RAA治疗应根据患者一般状况、症状,动脉瘤大小、数目、部位、肾功能、有无并发症等选择手术或介入治疗.     

Ruptured renal artery aneurysm in a pregnant uninephric patient: successful ex vivo repair and autotransplantation

Renal artery aneurysm rupture during pregnancy is a rare event, with only 22 cases recorded in the literature. Maternal and fetal mortality rates have been high, and renal salvage with in situ repair of the renal artery has been documented in only three cases. We present here a case report of renal artery aneurysm rupture in a pregnant patient with congenital absence of the contralateral kidney, which was treated successfully with ex vivo renal artery reconstruction and autotransplantation. The literature on renal artery aneurysm rupture in pregnancy is reviewed and technical aspects of renal artery reconstruction and autotransplantation are presented.     

离体肾动脉瘤切除和自体肾移植术治疗复杂肾动脉瘤

目的 探讨手助腹腔镜法活体取肾、离体肾动脉瘤切除、肾动脉重建和自体肾移植技术治疗复杂性肾动脉瘤的安全性和可行性.方法 2006年10月收治1例42岁复杂性肾动脉瘤男性患者.术前彩超、CT及DSA检查显示左肾动脉瘤3.4 cm×4.3 cm×4.5cm大小,瘤内有部分血栓形成,位于左肾动脉主干分叉部,累及5支分支动脉,邻近肾门.患者有高血压病史,药物控制不佳.术中采用手助腹腔镜法活体取肾成功后,立即对离体肾脏采用4℃肾脏保存液灌注,低温保护肾脏.体外进行肾动脉瘤切除:切取自体右髂内动脉体外行肾动脉重建,最后将肾脏异位移植至右侧髂窝.结果 患者手术成功,围手术期未出现并发症.术后.肾功能正常:彩超复查显示右侧髂窝移植肾动脉及其分支血流通畅无狭窄,肾静脉血流通畅,输尿管无狭窄.术后13个月随访,血压恢复正常,肾功能正常.结论 离体肾动脉瘤切除和自体.肾移植术治疗复杂性肾动脉瘤微创、安全、可行.     

离体肾动脉瘤修补、肾动脉重建和自体肾移植治疗复杂性孤肾肾动脉瘤一例并文献复习

目的探讨离体肾动脉瘤修补、肾动脉重建和自体肾移植技术治疗复杂性孤肾肾动脉瘤的安全性和可行性。方法CT血管造影（CTA）确诊复杂性孤肾肾动脉瘤1例,病变位于肾动脉主干分叉部,累及节段分支动脉,深入肾门内。肾脏暂时性离体后,在低温和肾脏灌注液灌注保护肾脏的前提下,体外进行肾动脉瘤修补和自体大隐静脉肾动脉重建,然后将肾脏异位移植到右侧髂窝。结果手术成功,围手术期无严重并发症发生。术后血肌酐暂时性升高至约200μmol／L,半个月后逐渐恢复正常;术后2周复查CTA示右髂窝移植肾动脉及其分支血流通畅无狭窄,肾静脉回流通畅,输尿管无狭窄。结论该方法治疗复杂性孤肾肾动脉瘤安全可行,并为以后类似的复杂性肾脏疾病的处理提供了可行方法。     

A case of ex vivo renal artery reconstruction and autotransplantation for renal artery aneurysm

A 74-year male patient was admitted to our department with a left renal artery aneurysm (RAA). It was detected by a computed tomography (CT) scan while performing an examination for hypertension. The diameter of the aneurysm was 25 mm. There was no evidence of calcification. Selective left renal angiography and a 3-dimensional (3D)-CT image revealed a saccular renal aneurysm in the left main renal artery. Because of the risk of rupture, autotransplantation of the left kidney to the left iliac fossa was performed after resecting the aneurysm and reconstructing the left artery under bench surgery. Postoperative 3D-CT revealed no stenosis. This ex-vivo technique and autotransplantation into ipsilateral iliac fossa are both effective and safe for the treatment of RAA.     

Laparoscopic nephrectomy, ex vivo excision and autotransplantation for complex renal tumors

Purpose:

In many patients partial nephrectomy is the preferred alternative to radical nephrectomy for upper urinary tract cancers. We describe the use of laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation to expand the realm of minimally invasive, nephron sparing surgery to the most complex renal tumors.

Materials and Methods:

In our cohort undergoing renal surgery 2 patients had a solitary kidney with renal tumors not considered amenable to in situ partial nephrectomy. After transperitoneal laparoscopic nephrectomy ex vivo tumor excision and renorrhaphy were performed. The kidney was transplanted to the ipsilateral iliac vessels through the Gibson extraction incision.

Results:

Indications for surgery were high grade urothelial carcinoma within a caliceal diverticulum and a central 5 cm renal cell carcinoma. Mean nephrectomy, cold ischemic and transplantation times were 4.5, 2 and 3.7 hours, respectively. No intraoperative or postoperative complications were noted. Hospitalization was 12 and 6 days, respectively. At 20 and 12 months of followup each patient remained off dialysis without evidence of recurrence.

Conclusions:

Despite experience with conventional nephron sparing surgery some cases may be more appropriate for ex vivo excision and reconstruction. In these situations the minimally invasive approach provides a kidney suitable for renal autotransplantation, while simultaneously decreasing patient morbidity. This novel approach to complex renal tumors is feasible when one applies principles of laparoscopic donor nephrectomy and possesses experience with renal transplantation.     

Renal cell carcinoma with renal artery aneurysm treated by extracorporeal surgery and autotransplantation--a report of 2 cases]

We experienced two cases of renal cell carcinoma with renal artery aneurysm in the contralateral kidney. These cases have not been reported in the literatures which we have so far explored. In our cases, firstly tumor was resected, and then extracorporeal surgery and autotransplantation were performed on the renal artery aneurysm of the opposite side. Their postoperative courses were uneventful. Only a few instances of extracorporeal surgery and autotransplantation for renal artery aneurysm in a solitary kidney have been reported in the literature. However, no report of a case treated by extracorporeal surgery and autotransplantation for renal artery aneurysm in the contralateral kidney after surgical treatment of renal cell carcinoma has been made. Regarding the treatment of renal artery aneurysm, extracorporeal surgery and autotransplantation appeared satisfactory in our experience. It was a safe and assured surgical procedure. We recommend extracorporeal surgery and autotransplantation for renal artery aneurysm when management in situ is considered difficult.     

Induction of cold ischemia in patients with solitary kidney using retrograde intrarenal cooling: 2-year functional outcomes

Purpose

Renal hypothermia is commonly utilized during nephron sparing surgery to minimize ischemic tissue damage. We propose a method to induce renal hypothermia using continuous retrograde irrigation of iced saline via dual-lumen ureteral catheter. We will report results in an ex vivo porcine model followed by clinical outcomes in a series of patients with solitary kidney undergoing robotic-assisted laparoscopic partial nephrectomy (RALPN).

Materials and methods

First, we performed temperature measurements during retrograde renal cooling in a porcine model before investigating the technique in humans. In porcine experiments, renal cortical temperature measurements (n = 270) were recorded during retrograde infusion of ice-cold saline via a 10-Fr dual-lumen ureteral catheter placed in ureter. Subsequently, a series of patients (n = 10) undergoing RALPN with a solitary kidney had concomitant intra-operative retrograde renal cooling. A 10-Fr dual-lumen ureteral catheter was placed at initiation of anesthesia and cold saline initiated prior to renal artery clamping.

Results

Porcine cortical temperature reached the target temperature (≤20 °C) within an average of 203 s of retrograde irrigation. In the clinical series, patients’ mean preoperative creatinine was 1.16 mg/dL (GFR = 60). At a median follow-up of 10 months (range 1–27 months), postoperative creatinine was 1.50 mg/dL (GFR = 41.28). Average clamp time was 19.4 min. All patients had negative surgical margins.

Conclusions

Retrograde irrigation is a technically feasible method to induce cold ischemia, which may provide an additional protective effect of renal function in patients who have a solitary kidney undergoing surgery via a minimally invasive approach.     

Erste Erfahrungen mit dem AZUR® Peripheral HydroCoil® Embolisationssystem

Background

This article reports on preliminary clinical experiences with the AZUR® Peripheral HydroCoil® Embolization System (Terumo®, Somerset, NJ) with regards to safety and successful target vessel occlusion in central and peripheral artery disease.

Material and methods

From January 2011 to December 2012 a total of 12 occlusion procedures were performed with the AZUR® Peripheral HydroCoil® Embolization System in 11 enrolled patients. The median age of the patients was 74 years (range 63–81 years) and the median follow-up was 7.6 months (range 0.6–14.5 months).

Indications

A total of six internal iliac artery (AII) aneurysms, one ruptured para-anastomotic aneurysm (target vessel AII), one type Ia endoleak (EL) after endovascular repair (target vessel renal artery), one type Ib EL in conjunction with an AII aneurysm (Fig. 1) (target vessel AII) and one patient with bleeding from the anterior tibial artery. Two accessory renal arteries were coiled to prevent type II EL during endovascular repair.

Results

Technical success was achieved in 100?% (12 out of 12) of the procedures performed and no endoleaks were observed. Hospital mortality was 9?% (1 out of11). During follow-up, there was no need for reinterventions but one patient died of gastrointestinal bleeding 2 years postoperatively which was unrelated to the study procedure.

Conclusion

The AZUR® Peripheral HydroCoil® Embolization System is a safe and effective tool to occlude central and peripheral arteries. Procedure-related complications as well as reinterventions are rare.     

Renal autotransplantation combined with direct pyelocystostomy for a doubled renal artery aneurysm of a stone forming kidney

A 35-yr-old female patient presented with recurrent left-sided calcium oxalate nephrolithiasis in combination with equilateral doubled renal artery aneurysm. Approximately two-thirds of the cumulative renal function were scintigraphically calculated in favour of the affected kidney. After a left-sided nephrectomy, "workbench surgery" with resection of both aneurysms was performed. The renal artery was reconstructed with contralateral internal-iliac artery graft. To allow passage of renal calculi, the kidney was transplanted in the right iliac fossa combined with a wide pyelocystostomy. The patient recovered uneventfully and presented with good physical health and regular serum creatinine 1 yr postoperatively.     

Renal artery aneurysm: ex vivo repair and autotransplantation: case report and review of the literature

The incidence of renal artery aneurysm is unknown, its natural history is unclear and unpredictable, and the clinical symptoms are of little or no value in diagnosis. The risk of rupture is high in pregnant women, as in splenic artery aneurysms and in aneurysms greater than 2 cm in size. Digital subtraction angiography is the best diagnostic test. When an aneurysm is identified, surgery is the best treatment option to avoid hypertension or rupture of the aneurysm. Because of advances in organ preservation, nephrectomy, ex vivo repair, and autotransplantation is a safe and successful procedure. We report the case of a 2-cm-wide neck aneurysm that was treated by nephrectomy, ex vivo repair, and auto-transplantation.     

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.