IP045. Management of Abdominal Aortic Aneurysms With Atypical Renal Artery Anatomy

Abstract

Renal artery anomalies occur at a rate of 1% to 2%, and with a growing number of renal transplants performed annually, we are more frequently faced with particular challenges to abdominal aortic aneurysm repair. We describe here adjuncts used to manage such anatomic variants. This is a retrospective review of a prospectively collected database of all abdominal aortic aneurysms repaired in a single academic vascular surgery practice. Patients with renal transplants, congenital single/pelvic kidneys arising from the distal abdominal aorta or iliac arteries, and horseshoe kidneys were included in the review. Over an 8-year period, 18 patients were identified (prior renal transplant, n = 9; horseshoe kidney, n = 3; congenital single/pelvic kidney, n = 6). All prior transplant patients were treated with endovascular repair, with four requiring aortouniiliac extension to the external iliac artery contralateral to the renal transplant for aneurysm exclusion (with retrograde flow via cross femoral bypass providing renal perfusion). Additionally, three transplant patients required carotid artery access for device deployment due to severe iliofemoral occlusive disease or origin of renal transplant off of the internal iliac artery. Two horseshoe kidney patients underwent open aneurysm repair with direct reimplantation of accessory renal arteries, while one underwent standard endovascular repair with exclusion of an isthmus branch. While there was no renal dysfunction noted, the patient did have a prolonged course of abdominal pain postoperatively due to infarct of the devascularized renal segment. Of the congenital single/pelvic kidney cohort, two underwent open repair with renal reimplantation, two underwent standard endovascular repair, one was treated with aortouniiliac and cross-femoral bypass, and one was treated in a staged fashion with initial ileorenal bypass and subsequent fenestrated endovascular repair. Intravascular ultrasound imaging was used to minimize contrast use in patients with chronic renal insufficiency (creatinine >1.2 mg/dL, n = 6). Over a mean follow-up of 41.7 months (range, 1-110 months), there were no aortic related deaths or reinterventions, no decline in renal function (measured by serum creatinine and glomerular filtration rate), and 100% patency of the preserved renal arteries. Atypical renal anatomy provides unique challenges to abdominal aortic aneurysm repair. The use of technical adjuncts can make repair of such aneurysms safe with good long-term outcomes that do not impair renal function.