Autotransplantation of solitary kidney with renal artery aneurysm treated with laparoscopic nephrectomy and ex vivo repair: a case report

Introduction

Renal artery aneurysms (RAA) are extremely rare clinical entities with associated morbidities including hypertension and rupture. Although most RAA can be treated with in vivo repair or endovascular techniques, these may not be possible in patients with complex RAA beyond the renal artery bifurcation. We report a case of RAA in a patient with a solitary kidney that we treated successfully by extracorporeal repair and autotransplantation and the 2-years follow-up.

Case Report

A 64-year-old woman with a history of right nephrectomy for renal cell carcinoma presented with RAA found on routine computed tomography (CT). Preoperative workup demonstrated a 2.2 × 2.1 × 3-cm aneurysm in the distal left renal artery that was not amendable to in vivo or endovascular repair. The patient underwent a laparoscopic-assisted left nephrectomy, ex vivo renal artery aneurysm repair, and autotransplantation. She did well postoperatively and in clinic follow-up was found to have a creatinine of 1.2 mg/dL at the end of 2 years and stable blood pressure control.

Discussion

This patient with RAA in her solitary kidney was successfully treated with laparoscopic-assisted nephrectomy, ex vivo repair, and autotransplantation. Her creatinine was stable postoperatively despite absence of a second 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.     

Hand-assisted laparoscopic live donor nephrectomy in a patient with renal artery aneurysm

Among the transplantation teams there is an increasing interest in laparoscopic live donor nephrectomy. For technical reasons, the use of the left kidney is recommended. However, considering the shortage of organ donors, it is likely that right-side laparoscopic live donor nephrectomy will need to be considered in selected donors, even those with vascular anomalies. Here we report the first case of right-side live donor laparoscopic nephrectomy in a patient with a renal artery aneurysm. Arteriography showed a 3-cm saccular aneurysm of the main right renal artery located at the bifurcation of the secondary branches and associated with an inferior polar artery coming directly from the aorta. The patient was placed in the lumbotomy position. An 8-cm midline incision was made above the umbilicus to insert the HandPort system (Smith & Nephew S.A., 72019 Le Mans Cedex2, France). Four additional trocars were introduced. Dissection of the renal artery was carried out beyond the level of relieving the aneurysm behind the vena cava. The main and polar arteries were clipped, and the renal vein was stapled. The kidney was removed through the HandPort and perfused cold ex vivo. The warm ischemia time for the kidney was 1 min, and the total operative time was 280 min. Vascular abnomalies were corrected ex vivo. The postoperative course of the donor was uneventful. At 6 months after transplantation, the graft function was normal. The hand-assisted approach is of particular value on the right side where the dissection must be carried out behind the vena cava. The HandPort may save few precious minutes over the sac extraction technique of the standard laparoscopic procedure.     

Ruptured renal artery aneurysm during pregnancy

A 38-year-old woman (gravida 4, para 1) underwent arteriography at 19 weeks' gestation after two exploratory laparotomies had failed to identify a source of retroperitoneal and intra-abdominal hemorrhage. The arteriogram demonstrated a large right renal artery aneurysm (RAA) and a very small left RAA. Emergency repair of the aneurysm was attempted but was impossible, so a right nephrectomy was performed. The fetus had died prior to arteriography and a cesarean section was performed concomitantly. The postoperative course was unremarkable. RAAs are rare and usually asymptomatic, but pregnancy is associated with a higher risk of rupture. Prior to 1970, reported rupture occurred most often on the left side, during the third trimester, and was associated with a 92% maternal mortality and a 100% fetal mortality rate. Since 1970, published reports have not shown a left-sided predominance, and survival after this catastrophic event has greatly improved, even though preoperative diagnosis is still rare. The possibility of a ruptured RAA should be considered in pregnant women with evidence of retroperitoneal hemorrhage. Arterial repair should be attempted but has not been feasible in most cases. This case was unusual because it occurred during the second trimester of pregnancy. Recent cases and technical considerations regarding repair are discussed.Presented at the Fourteenth Annual Meeting of the Southern California Vascular Surgical Society, September 15–17, 1995, La Jolla, Calif.     

Branch renal artery repair with cold perfusion protection

PURPOSE: This retrospective review describes the use and clinical outcome of cold perfusion protection during branch renal artery (RA) repair in 77 consecutive patients. METHODS: From July 1987 through November 2006, 874 patients had open operative RA repair to 1312 kidneys. Seventy-seven patients (62 women, 15 men; mean age, 44 +/- 17 years) had branch RA reconstruction using ex vivo or in situ cold perfusion protection for 78 kidneys. Demographic data and surgical technique were examined. Blood pressure response and renal function were estimated. Patency of repair was determined by angiography and renal duplex ultrasound (RDUS) imaging. Primary RA patency was estimated by life-table methods. RESULTS: Seventy-eight RAs were repaired using ex vivo (49 kidneys) or in situ (29 kidneys) cold perfusion protection. Bilateral RA repair was performed in eight patients, with 13 repairs to solitary kidneys. RA disease included aneurysm (RAA) in 50, fibromuscular dysplasia (FMD) in 37, atherosclerosis in 5, and arteritis in 2; 16 patients had both FMD and RAA. Hypertension was present in 93.5% (mean blood pressure, 184 +/- 35/107 +/- 19 mm Hg; mean of 1.9 +/- 1.1 drugs). RA repair included bypass using saphenous vein in 69, hypogastric artery in 3, polytetrafluoroethylene (PTFE) in 2, composite vein/PTFE in 2, cephalic vein in 1, or aneurysmorrhaphy in 1. The eight bilateral RA repairs were staged. One patient required bilateral cold perfusion protection. One planned nephrectomy was performed at the time of contralateral ex vivo reconstruction. No primary nephrectomies were required for intended reconstruction. Each RA reconstruction required branch dissection and reconstruction (mean of 2.8 +/- 1.6 branches were repaired). Mean cold ischemia time was 125 +/- 40 minutes. Each kidney was reconstructed in an orthotopic fashion. Five early failures of repair required three nephrectomies and one operative revision. Based on postoperative angiography or RDUS, or both, primary patency of RA repair at 12 months was 85% +/- 5%; assisted primary patency was 93% +/- 4%. Among patients with preoperative hypertension, 15% were cured, 65% were improved, and 20% were considered failed. Early renal function was improved in 35%, unchanged in 48%, and worse in 17%. Four patients had perioperative acute tubular necrosis. No patient progressed to dialysis-dependence. CONCLUSION: Both ex vivo and in situ cold perfusion protection extend the safe renal ischemia time for complex branch RA repair and avoid the need for nephrectomy.     

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.     

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.     

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.     

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.     

Renal Artery Aneurysm Secondary to Fibromuscular Dysplasia in a Young Patient

An 8-year-old male was found on routine physical examination to have a blood pressure of 220/110. Renal angiography demonstrated bilateral renal artery stenosis and an aneurysm of the distal left renal artery with branch involvement. At operation, the left renal artery stenosis and aneurysm was repaired by ex vivo arterial reconstruction and autotransplantation of the kidney. Pathologic evaluation of the resected aneurysm confirmed the diagnosis of fibromuscular dysplasia. Fibromuscular dysplasia is the most common cause of renal artery stenosis in children over 1 year of age and can in rare cases be associated with the development of renal artery aneurysms. In complex cases of renal artery stenosis with involvement of renal artery branches, ex vivo repair and orthotopic autotransplantation is an excellent approach for surgical management.Presented at the Twenty-second Annual Meeting of the Southern California Vascular Surgery Society, La Jolla, CA, April 30-May 2, 2004.     

LAPAROSCOPIC REPAIR OF RENAL ARTERY ANEURYSM

PURPOSE: We describe technical considerations of the laparoscopic repair of a renal artery aneurysm. MATERIALS AND METHODS: A 57-year-old woman presented with a 3 cm. aneurysm of the distal left main renal artery at its bifurcation. Using a purely laparoscopic 4-port transperitoneal technique the aneurysm was completely mobilized from its location behind the renal vein. Its 3 feeding vessels were controlled individually with bulldog clamps. The aneurysm sac was bivalved and precisely trimmed to conform with the diameter of the main renal artery. Vascular reconstruction was performed with running freehand laparoscopic suturing and intracorporeal knot tying using 4-zero polypropylene suture. RESULTS: Warm ischemia time was 31 minutes, total operative time was 4.2 hours, blood loss was 100 cc and hospital stay was 2 days. Postoperatively renal scan showed improved perfusion and renal arteriography confirmed adequate repair of the aneurysm. CONCLUSIONS: Laparoscopic repair of the renal artery aneurysm is feasible. To our knowledge we present the initial clinical report of laparoscopic renovascular surgery in the literature.     

Surgical management of renal artery aneurysms

PURPOSE: This retrospective review describes the surgical management and clinical outcome for renal artery aneurysms (RAAs) in 62 consecutive patients. METHODS: From January 1987 through July 2003, 804 patients had operative renal artery (RA) repair involving 1206 kidneys at our center. A subgroup of 62 patients (42 women, 20 men; mean age 46 +/- 18 years) received repair of 72 RAAs. Demographic data, comorbidity, and surgical technique were examined. Blood pressure and renal function response were determined. Patency of repair was evaluated by renal duplex sonography. Primary patency and patient survival were estimated by life-table methods. Tests of association were performed using chi(2) and the Student t tests. RESULTS: Seventy-two RAs were repaired for RAA with a mean diameter of 2.6 cm (range, 1.3 to 5.5 cm). Bilateral RAAs were present in 21 patients. Associated conditions included fibromuscular dysplasia, atherosclerosis, and arteritis in 54%, 35%, and 7%, respectively. Hypertension was present in 89% (mean blood pressure, 171 +/- 35/95 +/- 19 mm Hg; mean medications, 2.2 +/- 1.2 drugs) and renal insufficiency was present in 8% (mean serum creatinine, 1.9 +/- 0.6 mg/dL). RAA repair included bypass (67%), aneurysmorrhaphy (15%), or a combination (17%). One planned nephrectomy (1%) was performed for un-reconstructable disease. Branch RA reconstruction in 78% used ex vivo cold perfusion in 50%, in situ cold perfusion in 29%, and warm in situ repair in 21%. Of 9 bilateral RAA repairs, 7 (78%) were staged and 2 (22%) were simultaneous. Combined aortic reconstruction was required in 6 (10%) patients. Perioperative death occurred in 1 patient (1.6%), and significant morbidity was observed in 8 patients (12%). Hypertension was considered improved in 54%, cured in 21%, and unchanged in 25% at mean follow-up of 48 months (range, 1-156 months). Among patients with renal insufficiency, renal function was improved in 3 (60%), unchanged in 1 (20%), and declined in 1 (20%). Follow-up patency (mean, 33 months; range, 1-118 months) was determined for 64 (91%) RA reconstructions. Product-limit estimate of primary patency at 48 months was 96%. Product-limit estimate of survival was 91% at 120 months. CONCLUSION: RAAs were repaired with low morbidity and mortality. Complex branch RAA repair using cold perfusion preservation and ex vivo techniques resulted in no unplanned nephrectomy, with an estimated primary patency of 96% at 48 months. Beneficial blood pressure response was observed in the majority of hypertensive patients. These results support selective surgical management of RAA.     

肾动脉瘤14例诊治报告

为探讨肾动脉瘤(RAA)的特点和诊治方法,回顾性分析2015年6月-2019年10月我院收治的14例RAA患者的临床资料.14例患者中,男8例,女6例;年龄40～77岁,平均59.1岁;左肾RAA 6例,右肾RAA 7例,双肾RAA 1例;体检发现8例,表现为腰腹部疼痛5例,表现为血压骤升1例;2例RAA破裂,1例表现...     

Two cases of bilateral renal cell carcinoma in patients with Von Hipple-Lindau disease

Von Hipple-Lindau (VHL) disease is a rare familial cancer syndrome that is dominantly inherited and pre-disposes affected individuals to developing various tumors, including hemangioblastoma of the retina and central nervous system, and multicentric renal cell carcinoma. We report two cases of VHL disease with bilateral renal cell carcinoma. Case 1: A 53-year-old woman was referred to our hospital because of bilateral kidney tumor incidentally found. We performed left laparoscopic radical nephrectomy and laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for the right kidney. Case 2: A 43-year-old woman was referred to our hospital because of left kidney tumor incidentally found. Because the suspectious lesion in the right kidney was very small, we decided to follow it up with no treatment. We performed laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for left kidney.     

Ex vivo repair of a large renal artery aneurysm and associated arteriovenous fistula

The development of a renal artery to vein arteriovenous fistula due to a large extraparenchymal renal artery aneurysm is uncommon. Previous surgical experience with this entity is limited. Based on the existing surgical literature, nephrectomy has been the treatment of choice. We report preservation of the kidney by surgical correction of this entity using ex vivo "bench" repair in a middle-aged female with fibromuscular dysplasia of the renal artery. The technique, results, and recommendations for surgical management are discussed.     

Spontaneous rupture of a left renal artery aneurysm: a case report

Rupture of a renal artery aneurysm is an acute surgical event associated with high mortality. We report a case of retroperitoneal hemorrhage from a spontaneously ruptured renal artery aneurysm. A 73-year-old woman complained of left flank and abdominal pain. She consulted our department and left retroperitoneal hemorrhage was recognized by abdominal computerized tomography. Selective left renal arteriography revealed a saccular aneurysm arising from the ventral branch of the renal artery, and did not show extravasation of contrast material from the aneurysm. Since it was difficult to remove the aneurysm with preservation of the involved renal unit, we performed left nephrectomy.     

Renovascular reconstruction of grafts with renal artery variations in living kidney transplantation

INTRODUCTION: The shortage of grafts in living kidney transplantation has forced the use of marginal grafts with arterial disease or grafts with multiple renal arteries (MRA). We reviewed the outcomes of transplants using allografts with MRA procured by open donor nephrectomy and report two cases requiring vascular reconstruction. PATIENTS AND METHODS: We reviewed 31 cases where renovascular reconstruction of an MRA graft was performed. A ex vivo pantaloon (side-to-side) anastomosis to create a common channel was performed in 24 cases including two cases of renal artery aneurysms in the grafts, where vascular reconstruction was performed in the same fashion after resection of the aneurysm. In four cases, an accessory artery was anastomosed sequentially after revasculization of the main artery. In three cases of grafts with multiple renal arteries, multiple anastomoses were done in situ after various ex vivo renovascular reconstructions. RESULTS: Twenty one MRA grafts including grafts with a renal aneurysm are functioning well for a mean follow-up 135 months. The graft survival rate was 71.0% at 5 years after transplantation and 67.7% at 10 years. The donors whose grafts had a renal aneurysm were also well and normotensive with normal renal function at present. Ten grafts failed mainly due to chronic allograft nephropathy. CONCLUSION: MRA grafts procured by open nephrectomy, including those with renal artery aneurysms, were engrafted successfully by applying appropriate renovascular surgery. The use of those grafts was safe for both the recipient and the donor.     

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.

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.     

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.