Renal Aneurysm Research Articles

Techniques and Strategies for the Endovascular Treatment of Renal Artery Aneurysm

ABSTRACT Background Renal artery aneurysms are rare and constitute a challenge to endovascular treatment. Our objective was to describe and analyze the techniques and strategies for the endovascular treatment of renal artery aneurysms verifying short and medium-term results in a consecutive series of cases. Methods Retrospective study of procedures performed from January 2010 to December 2013, analyzing technical and therapeutic success, morbidity and mortality, the rate of endoleaks and reinterventions. Results In a total of six patients treated, mean age was 41 ± 5 years and all patients were female. The majority of the patients had type 2 saccular aneurysms (83.3%). Remodeling techniques using stent and coils were used in four cases; embolization of renal polar branch was used in one case and treatment with a Multilayer® endoprosthesis in another case. Technical and therapeutic success rates were 100% and 83.3%, respectively. In one patient there was upper renal pole ischemia, which progressed to uncontrollable hematuria and pain, requiring nephrectomy. There were no deaths or occlusion of the native renal artery and its branches during the 1-year follow-up. Conclusions Endovascular treatment of renal artery aneurysm proved to be a feasible alternative to conventional surgery with low morbidity. A detailed study of renal vasculature and aneurysm location determines the choice of the endovascular technique to be used. Type II renal artery aneurysm was the most frequent morphology observed and may be successfully treated by remodeling techniques using stents and coils.

Management of Synchronous Renal Cell Carcinoma and Abdominal Aortic Aneurysm as a Single Staged Operation

Simultaneous occurrence of abdominal aortic aneurysm and renal cell carcinoma is a rare entity. Benefits of single stage operations have to be weighed against staged operations. There is no consensus on the best management approach for patients with simultaneous aortic aneurysm and malignancy. Various possibilities have been considered, namely, to repair the aneurysm and treat the malignancy later, to resect the malignancy and repair the aneurysm later, to undertake both procedures simultaneously, and in some cases to treat the malignancy and manage the aneurysm conservatively. Aortic aneurysm repair is a prophylactic procedure and is worthwhile where the lifetime risk of rupture exceeds the risk from treatment. The prognosis of cancer is therefore central to the decision making process. The perceived increase risk of aortic aneurysm rupture following cancer surgery, the significant delay in the treatment of cancer if aneurysm is treated first, and the risk of graft infection are the other important considerations in the management of concomitant aortic aneurysm and cancer. In staged operations, malignancy or abdominal aortic aneurysm (AAA) first have to be decided depending on stage of cancer, risk of aneurysm rupture, graft infection and other comorbid features. We rarely encounter a situation where abdominal aortic aneurysm and abdominal malignancy, in particular renal cell carcinoma (RCC) occurs concomitantly and treated as single staged operation. Patient underwent bypass graft followed by partial nephrectomy through a midline laparotomy. Patient had uneventful post operative recovery except for chylous leak, not subsiding with conservative treatment followed by blockage of lymphatic fistula with computerized tomography (CT) guided fibrin glue application. Chylous ascites has to be treated as early as possible since it increases the possibility of graft infection. In this case, we discuss various possibility to approach a case of synchronous malignancy, and chylous ascites management through ‘CT guided fibrin glue application’ for a favourable outcome.

Incidence of postembolization syndrome after complete renal angioinfarction: a single-institution experience over four years

Objective. Renal angioinfarction (RAI) has been used for various indications in the management of renal tumors. While historically used for palliation of local symptoms (pain or hematuria), this technique has theoretical use in facilitating radical nephrectomy by allowing early ligation of the renal vein, decreasing blood loss and creating edema in resection planes. A common impediment to embolization is the development of postembolization syndrome (PES), which has been reported to have an incidence as high as 89%. This study reports the authors' experience with RAI as a safe palliative and adjunctive procedure over 4 years. Material and methods. From 2008 to 2011, 113 patients underwent complete RAI at Washington Hospital Center for palliative or adjunctive therapy by an interventional radiologist. Procedures were performed in a radiology suite using mild sedation with vascular access obtained by femoral artery puncture. RAI was performed by subsegmental injection of polyvinyl alcohol particles. Results. All 113 patients underwent successful RAI with confirmation of total arterial flow ablation via postprocedure arteriogram: 38 underwent embolization for preoperative adjunctive therapy, 34 for palliation of renal mass, 36 for trauma/hemorrhage and five for symptomatic renal artery pseudoaneurysm after partial nephrectomy. PES occurred in 33 out of 75 patients (44.0%), with symptomatic PES in only two patients (2.6%). No major complications (>Clavien grade III) occurred. Thirty-eight patients were excluded from analysis as they underwent radical nephrectomy within 24 h, preventing accurate assessment of PES. Conclusions. RAI is a safe and reliable procedure for palliation of renal masses, as an adjunctive procedure for radical nephrectomy, and for conservative management of renal hemorrhage or aneurysm. PES occurs in relatively few patients, with no major complications, and should not impede clinical consideration of this procedure.

An Unusual Case of Fibromuscular Dysplasia with Bilateral Renal Macroaneurysms: Three-year Outcome After Endovascular Treatment

Fibromuscular dysplasia (FMD) is an idiopathic, segmental, non-inflammatory and non-atherosclerotic disease that affects arterial walls, leading to stenosis of small and medium-sized arteries. FMD mostly involves renal and intracranial arteries and only in few patients is associated with macroaneurysms (RAAs). We present the case of a 45-years old woman with recent history of grade 2 hypertension that suffered of subarachnoid haemorrhage due to rupture of a basilar artery aneurysm. The cerebral aneurysm was immediately treated by coil embolization and an abdominal angio-CT scan was performed to investigate the presence of renovascular hypertension. The exam showed the presence of FMD of the renal arteries associated with presence of bilateral RAAs. Due to the high risk of rupture, the bigger aneurysm (2,5 cm diameter) present on the left artery was immediately treated by coil embolization. The fusiform aneurysm, present on the right renal artery, was instead treated one year later by using two flow diverter stents. After three years, an angiographic study showed that both cerebral and renal aneurysms were excluded from the blood flow without evidence of arterial restenosis.

Renal Artery Mycotic Aneurysm in a Drug Abuser

Renal Artery Mycotic Aneurysm in a Drug Abuser

Superselective renal artery embolization in the treatment of renal hemorrhage

Renal hemorrhage is a potentially life-threatening event that may follow trauma, operation, biopsy, and sudden spontaneous rupture of renal tumors or aneurysms. Superselective renal artery embolization (SRAE) is a well-established method for such cases. To assess the effectiveness of SRAE in the treatment of renal hemorrhage at our institute. We respectively reviewed the medical records of patients who underwent SRAE for renal hemorrhage from January 2005 to June 2012. Data on patients' characteristics, indications, requirement of pre-embolization blood transfusion, angiographic finding, location of bleeding site, embolization agents, post-embolization transfusion requirement, complications and the outcome were recorded. A total of 46 patients, aged 26-73 years, underwent SRAE because of hemorrhage after percutaneous nephrolithotomy (n = 25), partial nephrectomy (n = 6), renal biopsy (n = 2), trauma (n = 2), rupture of angiomyolipoma (n = 4), renal aneurysm (n = 1), and renal ateriovenous malformations (n = 6). A total of 41 patients (80.8 %) underwent successful embolization. Treatment failed in 5 patients with hemorrhage caused by percutaneous nephrolithotomy. Of these, four patients underwent a secondly superselective embolization and had a successful outcome. The remaining one was managed by conservative therapy with repeated blood transfusions. No patient required nephrectomy to save the life of the patient. No serious procedure-related complications occurred. SRAE is an effective and minimal invasive method for the control of renal hemorrhage. Our experience strongly recommended the first-line use of SRAE for severe renal hemorrhage.

Computed Tomography Angiography in the Diagnosis of ANCA-Associated Small- and Medium-Vessel Vasculitis

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that typically occurs without detectable antineutrophil cytoplasmic antibody. It leads to aneurysm formation by affecting muscular arteries, usually those of medium size but also occasionally those of small size. Kidney involvement is common, leading to reduced glomerular filtration rate, hypertension, rupture of renal arterial aneurysms causing perinephric hematomas, and renal infarctions in those with severe vasculitis. Similar to PAN, microscopic polyangiitis (MPA) leads to aneurysm formation; however, MPA usually is associated with antineutrophil cytoplasmic antibody, and glomerulonephritis is a more common feature of MPA. Although kidney biopsy may show classic vascular changes in both PAN and MPA, this procedure is not without risk of significant bleeding due to aneurysm rupture. We present 2 cases of renal aneurysms that were diagnosed as MPA using computed tomography angiography (CTA), allowing implementation of appropriate immunosuppressive therapy. Follow-up CTA after treatment showed resolution of all previously observed abnormalities. CTA is a useful alternative to kidney biopsy in establishing both the extent of disease in renal aneurysms and allowing for tracking of disease progression and response to therapy.

A Case of Polyarteritis Nodosa with Small Intestinal Perforation and Renal Aneurysm Rupture

A Case of Polyarteritis Nodosa with Small Intestinal Perforation and Renal Aneurysm Rupture

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

Renal artery aneurysms (RAA) treatment includes both surgical repair and endovascular techniques, mostly depending on the location of aneurysm. For complex RAA located at renal artery bifurcation or distally, open surgical repair represents the gold standard of treatment. 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. 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. 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. 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. The experience of our group counts five other renal aneurysm repair performed with a robot-assisted technique. 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.

Spontaneous perirenal hematoma due to multiple renal artery aneurysms in a patient with presumed polyarteritis nodosa

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that involves the renal and visceral arteries.1 PAN typically presents with systemic symptoms and signs such as fatigue, weight loss, weakness, fever, arthralgia, skin lesions, hypertension, renal insufficiency, neurologic dysfunction and abdominal pain.2 Despite the common involvement of the kidney, spontaneous perirenal hemorrhage from a renal vasculitic aneurysm is a rare complication. A 72-year-old man was admitted to the hospital with complaints of dyspnea and generalized edema that had persisted for 2 weeks. Physical examination revealed coarse and decreased breath sounds with moist rales. His serum potassium and creatinine level were 9.5 mEq/L and 10.6 mg/ dL, respectively. Viral makers and autoantibodies, including anti-neutrophil cytoplasmic antibodies, were negative. His erythrocyte sedimentation rate was 18 mm/h and high sensitive C-reactive protein was 21.4 mg/L. We performed emergency hemodialysis via femoral vein catheterization under the impression of acute kidney injury and uncontrollable potassium levels. After emergency dialysis, the patient’s condition slowly improved. On the 15th hospital day, he complained of a sudden onset of right flank pain accompanied by a hypotensive episode. Abdominal computed tomography showed massive perirenal hematoma around the right kidney (Panel A: arrow). Renal angiography showed multiple aneurysmal dilatations of the interlobar arteries of the right kidney, and we performed coil embolization (Panel B: arrows; Panel C). Polyarteritis nodosa was diagnosed according to the radiologic findings of aneurysmal dilatation of the interlobar arteries of the right kidney. Images in vascular medicine

Laparoscopic Nephrectomy, Ex Vivo Angioplasty, and Renal Autotransplant for a Renal Artery Aneurysm: A Case Report

We describe in this report the case of a renal aneurysm in a 42-year-old woman. The aneurysm measured 27 mm in diameter, and was sited at the first bifurcation of the renal artery. We performed laparoscopic nephrectomy, ex vivo angioplasty and renal autotransplant to avoid ischemic damage to the kidney during reconstruction. The patient recovered and was discharged from the hospital without any complications. Hence, we suggest these treatments can be effectively done in patients with complex renal aneurysms.

'String of beads' or 'bunch of grapes': A case report of renal artery fibromuscular dysplasia

Introduction: Fibromuscular dysplasia (FMD), a disease of unknown etiology leading to renovascular hypertension (RVH) usually affects medium and large arteries of young females. Case Report: We report the case of 29­ year­old man in whom fibromuscular dysplasia presented as ‘Bunch of Grapes’ instead of its telltale sign of ‘String of Beads’. To our knowledge it is the first case of renal artery multiple aneurysms arising from single site associated with stenoses. Angioplasty, although standard of care in such lesions, was not feasible and open surgical revascularisation using exclusion of aneurismal segment and renal revascularisation using reversed great saphenous vein graft interposition provided excellent results. Conclusion: The First case of Renal artery Fibromuscular dysplasia presenting as ‘Bunch of Grapes’ sign is reported. Detailed evaluation of renovascular hypertension and its successful surgical correction using vein graft exclusion bypass is described.

Treating coil migration in combination therapy involving stenting and coiling for a wide-necked renal aneurysm

A man with a wide-necked renal artery aneurysm underwent combination therapy involving stenting and coiling to embolize it. However, a large section of one of the coils had migrated outside the stent implanted across the orifice of the aneurysm. After repositioning the migrated coil inside the stent, the implantation of another stent together with sandwiching of the coil between two stents repaired the prolapsed coil. This report describes precautions that should be taken during combination therapy involving stenting and coiling to embolize a wide-necked aneurysm.

V859 ROBOTIC RENAL ARTERIAL ANEURYSM REPAIR IN SOLITARY KIDNEY

You have accessJournal of UrologyReconstruction, Transitional Cell Carcinoma & Adrenal1 Apr 2011V859 ROBOTIC RENAL ARTERIAL ANEURYSM REPAIR IN SOLITARY KIDNEY Casey Ng, Andre Abreu, Andre Berger, Mukul Patil, Osamu Ukimura, Mihir Desai, Monish Aron, and Inderbir Gill Casey NgCasey Ng Los Angeles, CA More articles by this author , Andre AbreuAndre Abreu Los Angeles, CA More articles by this author , Andre BergerAndre Berger Los Angeles, CA More articles by this author , Mukul PatilMukul Patil Los Angeles, CA More articles by this author , Osamu UkimuraOsamu Ukimura Los Angeles, CA More articles by this author , Mihir DesaiMihir Desai Los Angeles, CA More articles by this author , Monish AronMonish Aron Los Angeles, CA More articles by this author , and Inderbir GillInderbir Gill Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.681AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal artery aneurysm is a rare disease with prevalence from 0.09% to 0.3% in the general population. It may be associated to hypertension, local symptoms and catastrophic rupture in certain situations. Repair of complex renal aneurysm have included saphenous vein bypass and extracorporeal bench aneurysmectomy with reconstruction and autotransplantation. We are presenting a case of robotic renal artery aneurysm repair in solitary kidney. METHODS A 50 years old female with history of a kidney stone, solitary right kidney and 20 years history of 2-drug hypertension, presents with a 3-month history of flank pain. Computer tomography of the abdomen revealed a partially calcified 2.4cm saccular aneurysm with fibromuscular dysplasia of the proximal renal artery that has less than 50% stenosis. She has a past history of left nephrectomy due to kidney stone disease. RESULTS Using the Da-Vinci robotic platform, the aneurysm sac was excised and the renal artery was reconstructed. Total operative time was 3.5 hours with a warm ischemia time of 32 minutes. Estimated blood loss was 200cc. Patient tolerated the procedure well without any intraoperative complications. She was discharged home on POD 6 with a serum creatinine of 1.0. CONCLUSIONS This is the first report of a robotic renal arterial aneurysm repair in a solitary kidney. The use of the robotic platform allows for minimal warm ischemia time and avoids the need for a transplant team. Robotic renal arterial aneurysm repair is a feasible and safe procedure for patients with complex renal artery aneurysm. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e345 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Casey Ng Los Angeles, CA More articles by this author Andre Abreu Los Angeles, CA More articles by this author Andre Berger Los Angeles, CA More articles by this author Mukul Patil Los Angeles, CA More articles by this author Osamu Ukimura Los Angeles, CA More articles by this author Mihir Desai Los Angeles, CA More articles by this author Monish Aron Los Angeles, CA More articles by this author Inderbir Gill Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Role of the MDCT urography in diagnosis of renovascular diseases

PurposeThe current study aimed to evaluate the efficiency of the MDCT urography in the diagnosis of renovascular diseases. Material and methodsTen consecutive patients were recruited from the Urology out patients’ clinics of Assuit University. Their ages ranged from 22 to 60years. Prior to Multidetector Computed Tomography (MDCT) examination, relevant clinical data and renal function tests were obtained in every patient. ResultIn the current study MDCT easily diagnosed during the arterial phase, six patients with renal aneurysms, two patients with nutcracker syndrome, one patient with arteriovenous malformation (AVM) and one patient of renal artery stenosis. ConclusionMDCT plays an important role in the evaluation and management of both primary renovascular disease and the secondary manifestations of each disease. MDCT angiography with multiplanar reconstruction and three-dimensional display is valuable in studying patients with renovascular lesions involving the proximal renal vessels.

Stent-Assisted Coil Embolization of a Traumatic Wide-Necked Renal Segmental Artery Pseudoaneurysm

We present the case of an Afghan woman with a renal segmental artery false aneurysm of the right kidney due to a shell splinter injury. Stent-assisted coil embolization of the aneurysm is described in detail.

Anatomic Study of Juxta Renal Aneurysms: Impact on Fenestrated Stent-Grafts

Fenestrated stent-grafts allow for treatment of patients with juxtarenal aneurysms (JRA) when they present with contraindications for conventional treatment. The fenestrated module is a custom-made module, specially designed to fit a specific patient, using computed tomographic scan measurements, which entails manufacturing delay and high cost. The aim of our study was to evaluate the possibility to reproduce the interrenal aorta anatomy to design a standard fenestrated module that would fit the maximum number of patients with JRA. On a three-dimensional working station, we analyzed 289 preoperative computed tomographic scan results of patients with JRA and who were treated with fenestrated stent-grafts comprising two fenestrations for the renal arteries and a scallop for the superior mesenteric artery (SMA). On curvilinear reconstructions, we successively measured the interrenal aorta diameter, its orientation, as well as the height of each renal ostium, taking the ostium center of the SMA as a reference mark. Later, a statistical analysis of these measures distribution was performed so as to design a fenestrated module that would fit the maximum number of patients. The center of the left renal artery presented with a median orientation of 82.5° (range, 37.5-150) and a median distance of 9 mm (range, 0-30), in relation to the SMA ostium. The ostium center of the right renal artery presented with a median orientation of 285° (range, 240-337.5) and a median distance of 8 mm (range, 3-30), in relation to the SMA ostium. By positioning the current renal fenestrations (6-mm wide), on the basis of the calculated median positions, in our series, only 20% of the patients could be treated with a standard fenestrated module. Should the diameter of these fenestrations be increased by 10 mm, it would then be possible to treat 50% of our patients. The anatomy of the interrenal aorta and its branches is quite reproducible to design standard fenestrated stent-grafts that could treat half of the patients with JRA.

Renal aneurysms and pseudoaneurysms

Pseudoaneurysms and aneurysms are abnormal dilatations of the vessel lumen. Pseudoaneurysm is a perfused hematoma contained by the adventitia and perivascular tissues that is in communication with the lumen of an adjacent artery or vein. Aneurysm is a dilatation of the vessel lumen involving all three layers of the blood vessel wall. Renal artery aneurysms (RAA) are uncommon but the widespread use of cross-sectional imaging and incidental detection of RAA may result in an increasing number of cases diagnosed. Renal artery pseudoaneurysms are suspected in bleeding patients after penetrating renal trauma. Imaging plays a major role in the detection of renal pseudoaneurysms and aneurysms and diagnoses aneurysm rupture and active bleeding. Computed tomography (CT), magnetic resonance imaging, and digital subtraction angiography can characterize lesion size, shape, and location and identify other aneurysms and pseudoaneurysms, helping to narrow the differential diagnosis and to understand the vascular anatomy for guiding proper treatment. Endovascular treatments have contributed considerably in the management of renal pseudoaneurysms and aneurysms. The use of coil embolization or covered stent placement prevents the mortality and mobility of surgery. The article describes imaging features and the endovascular therapies to treat these vascular processes and their possible complications.

Primary aortic infections and infected aneurysms.

Primary infections of the aorta and infected aortic aneurysms are rare and are life threatening. Most of them are due to bacterial infection occurring in an atheromatous plaque or a pre existing aneurysm during bacteremia. Rarely spread from a contiguous septic process may be the cause. The reported hospital mortality ranges from 16-44%. Gram positive bacteria are still the most common causative organisms. More recently, Gram negative bacilli are seen increasingly responsible. The mortality rate is higher for the Gram negative infection since they most often cause supra renal aneurysms and are more prone for rupture. Best results are achieved by appropriate antibiotics and aggressive surgical treatment. Excision of the infected aneurysm sac as well as surrounding tissue and in situ reconstruction of aorta is the preferred treatment. Pedicled omental cover also helps to reduce infection. Long term antibiotic is needed to prevent reinfection. Mortality is high for those who undergo emergency operation, with advanced age and for nonsalmonella infection.

Multivisceral fibromuscular dysplasia: an unusual case of renal and superior mesenteric involvement.

Fibromuscular dysplasia (FMD), a disease process which leads to arterial stenosis and aneurysm formation, has been reported to occur in almost every arterial bed in the body. However, multivisceral FMD is rare, and we report a 43-year-old woman with hypertension who had incidental finding of FMD of both renal arteries and the superior mesenteric artery (SMA). The left renal aneurysms and right renal stenosis were successfully treated by aneurysm resection and aortorenal bypass and percutaneous transluminal angioplasty, respectively. The asymptomatic FMD of the SMA was treated conservatively. The indications for intervention in patients with asymptomatic FMD have not been clarified till date, and we therefore advise a close surveillance program.