Technical Note and Results in the Management of Anatomical Variants of Renal Vascularisation during Endovascular Aneurysm Repair
ABSTRACT The revascularisation of large (>3 mm) renal arteries emerging from the proximal sealing zone or off the aneurismal wall can be challenging during endovascular aortic aneurysm repair. In this article, we describe various endovascular techniques using custom-made endografts to treat these complex variant anatomies.
Nine patients deemed unfit for open repair with unusual renal vascularisation associated with aortic aneurysms were treated by endovascular means. After three-dimensional (3D) reconstructions on a dedicated workstation, custom-made devices were designed and manufactured. The revascularisation of multiple renal arteries and aberrant origins of renal arteries, associated or not with pelvic kidney or horseshoe kidney, was managed using fenestrated and branched endografts.
All target vessels were patent on computed tomography (CT) scan and contrast-enhanced ultrasound evaluation before discharge as well as on the 6-month follow-up. One patient presented a decrease of postoperative glomerular filtration rate over 30% but did not require dialysis. No sac enlargement was depicted, and no reintervention was performed during follow-up. Three type 2 endoleaks were diagnosed.
Endovascular treatment with fenestrated and branched endografts should be considered in challenging renal artery anatomies in patients unfit for open repair.
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ABSTRACT: The occurrence of an abdominal aortic aneurysm (AAA) with horseshoe kidney (HSK) is an uncommon but complex surgical problem. This report outlines three such cases, the particular issues encountered and how customized endovascular grafts were successfully used to overcome them. Case one shows an accessory renal artery arising from the left common iliac artery, case two shows a right accessory renal artery from the AAA sac and case three has the right renal artery coming off the distal abdominal aorta within the sac. Across three patients, each graft had a single custom fenestration, which preserved a total of three major vessels with no change in renal function. Customized endografts are a viable tool to preserve aberrant vessels and thus renal mass in AAA and HSK. Customized endografts require an extensive work-up and are currently expensive to fabricate. However they are rapidly evolving as a mainstream tool in vascular surgery and provide a solution in cases of aberrant visceral vasculature.Vascular 03/2013; 22(3). DOI:10.1177/1708538113480577 · 1.00 Impact Factor
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ABSTRACT: The association of congenital pelvic kidney with abdominal aortoiliac aneurysm is an extremely rare clinical finding. Previous reports have described various methods of aneurysm repair with successful preservation of the function of pelvic kidney. However, to our knowledge, reconstruction of more than two renal arteries has not been established. We report a case of abdominal aortic aneurysm complicated by congenital right pelvic kidney in a 72-year-old man. Computed tomography (CT) revealed an abdominal aortic aneurysm with a maximum diameter of 54 mm and a right common iliac aneurysm of 45 mm. In addition, he had a congenital right pelvic kidney and CT angiography identified three right pelvic renal arteries. The upper artery originated from the bifurcation of the terminal aorta and the lower two originated from the right common iliac artery. Three-dimensional CT was helpful for the accurate planning of the operation. Open surgical repair of the aortoiliac aneurysm with a Dacron bifurcated graft replacement was decided and reimplantation of all three right pelvic kidney arteries to the right limb of the graft was also performed. For renal preservation, the right pelvic kidney arteries were perfused with cold Ringer's lactate using a rapid infusion pump and coronary perfusion cannula. The patient's postoperative course was uneventful, and worsening of renal function was not observed. The perfusion of renal arteries with cold Ringer's solution was thought to be a simple and appropriate procedure for renal protection.Heart and Vessels 02/2014; DOI:10.1007/s00380-014-0483-x · 2.11 Impact Factor