Repair Of Renal Artery Aneurysms Research Articles

Case Report: Treatment of Renal Artery Aneurysms by Ex Vivo Renal Artery Aneurysm Repair and Transplantation

BackgroundRenal 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. Patients and MethodsThree patients with incidentally identified renal artery aneurysms have been referred to our renal transplantation program in the last 3 years. All three had aneurysms located at renal artery branches making endovascular repair challenging and thus underwent hand-assisted laparoscopic nephrectomy with ex vivo aneurysmectomy, with heterotopic autotransplantation in two cases and allotransplantation in the third case. ResultsAll three cases resulted in successful renal artery aneurysm repair and reimplantation and good renal function of the implanted kidney. ConclusionsLaparoscopic nephrectomy with ex vivo aneurysm repair and reimplantation can be a successful approach to surgical management, especially in cases where the aneurysm involves multiple artery branches and endovascular repair is challenging. Given the excellent results with this surgical approach, living and deceased donor kidneys with aneurysms should be strongly encouraged if deemed reparable.

Outcomes of Endovascular Treatment and Open Repair for Renal Artery Aneurysms: A Single-Center Retrospective Comparative Analysis

PurposeTo compare outcomes of endovascular repair and open repair in treatment of renal artery aneurysms (RAAs). Materials and MethodsRetrospective analysis included 93 RAAs in 86 patients (56 women; mean age ± SD, 48.8 y ± 12.4) treated from January 2002 to December 2015. Endovascular group comprised 52 RAAs in 45 patients, and operative group comprised 41 RAAs in 41 patients; mean follow-up duration was 49.9 months. Operative variables and perioperative and follow-up outcomes were compared between the 2 groups. ResultsEndovascular group had shorter operative time (85.2 min vs 270.4 min; P < .001), less estimated blood loss (38.8 mL vs 416.7 mL; P < .001), shorter intensive care unit (ICU) stay (0 d vs 1.2 d; P < .001), and shorter hospitalization time (7.0 d vs 12.63 d; P = .013) compared with operative group. In-hospital mortality was 0% in both groups. Overall complication rates did not differ between endovascular (22.2%) and operative (19.5%) groups (P = .758). During follow-up, no deaths occurred in either group. Follow-up morbidity was 13.5% for endovascular group and 4.9% for operative group (P = .106). There were no significant differences between groups in average percentage change of estimated glomerular filtration rate (−2.3% ± 12.2 vs −0.8% ± 12.4; P = .538), systolic blood pressure (1.7% ± 10 vs −1.6% ± 8.3; P = .207), and diastolic blood pressure (−0.2% ± 9.7 vs −1.2% ± 10.4; P = .741). ConclusionsEndovascular repair and open repair of RAA had similar favorable perioperative and midterm outcomes, but endovascular repair had shorter operative time, ICU stay, hospitalization time, and less estimated blood loss.

Contrast-enhanced ultrasound to evaluate organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms.

To evaluate the organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms (VAAs) by contrast-enhanced ultrasound (CEUS) and colour-coded duplex sonography (CCDS). Between April 1995 to January 2016, 168 patients (78 males, 90 females; median age: 62 years) were diagnosed with VAAs at our hospital site. 60/168 patients (36%) fulfilled treatment criteria and had either open (29/60, 48%) or endovascular (31/60, 52%) aneurysm repair. Patients' characteristics and presentations were consecutively reviewed. Technical success and organ microvascularization were determined by CCDS/CEUS and correlated to computed tomography angiography (CTA) or magnetic resonance imaging (MRI). 18/60 patients (30%) presented with acute bleeding. 16/18 emergency patients (89%) were treated by endovascular means. After emergency treatment, two patients showed segmental liver malperfusion by CEUS and CTA. One small bowel resection had to be performed.42/60 patients (70%) were electively treated. 27/42 patients (64%) had open and 15/42 (36%) endovascular aneurysm repair. There were no liver or bowel infarctions after elective treatment of hepatic or mesenteric artery aneurysms (n = 13) in CCDS/CEUS and in CTA. Treatment of patients with splenic or renal artery aneurysms led to partial or complete organ loss in 42% (8/19) after operative and in 50% (5/10) after endovascular treatment (p < 0.05). The endovascular approach is the preferred therapeutic option in emergency to control bleeding. In contrast to hepatic or mesenteric procedures, patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully because of a high rate of partial or complete organ loss demonstrated by CEUS - either after open or endovascular aneurysm repair.

Surgical repair of a complex renal artery aneurysm through bench surgery and autotransplantation

Abstract A 58-year-old woman with underlying medically controlled hypertension presented after an episode of sudden-onset chest pain. Chest computed tomography imaging revealed a left renal artery aneurysm (RAA) measuring 1.6 cm in diameter with mural thrombi in the distal left renal artery at bifurcation level. An interval enlargement of approximately 0.4 cm in diameter was noted within a 6-month period; however, endovascular intervention was not feasible because of the complex RAA pattern. She was hospitalized and received a hand-assisted laparoscopic nephrectomy, ex vivo repair of the RAA, and autotransplantation into the left iliac fossa. The procedure was successful, and the postoperative course went smoothly. The kidney graft was evaluated using a magnetic resonance angiography 1-year postoperatively, which showed no signs of surgical complications or RAA recurrence.

Unusual Origin of Right Renal Artery: A Report of Two Cases.

The knowledge of variations in origin of renal arteries at different levels of vertebra is important before the kidney transplantation, as it has technical limitation in selecting the appropriate kidney (left or right) for laparoscopic procurement. Generally both renal arteries originate from abdominal aorta at right angle below the origin of Superior Mesenteric Artery (SMA) between L1 and L2 vertebral intervertebral disc space [1]. We encountered with the unusual high origin of right renal artery before the origin of celiac artery at level of 11th and 12th thoracic vertebrae in 2 cases. During routine pre operative assessment of live renal donor, Computed Tomographic Angiography (CTA) was performed in radio diagnosis department of our Institute. We observed an anatomic variation of origin of right renal artery before the origin of celiac artery in two cases within past 8 months. Both the donors were female. Case 1: Donor was 26-year-old. Computed Tomographic Angiography (CTA) showed single right renal artery originated from aorta at level of the 11th thoracic vertebrae. CTA also showed that there were two left renal arteries, both originated from aorta between 1st and 2nd lumbar vertebrae and two right renal veins [Table/Fig-1]. [Table/Fig-1]: Volume-rendered (VRT) coronal image of computed tomographic angiography of abdominal aorta shows high origin of right renal artery at level of 11th thoracic vertebrae. Case 2: In our second case, donor was 56-year-old. CTA showed single right renal artery originates from aorta at level of IV disc space between 11th and 12th thoracic vertebrae. It also showed that single left renal artery originated from aorta at level of 1st lumbar vertebrae [Table/Fig-2]. [Table/Fig-2]: Thick Maximum Intensity Projection (MIP) coronal image of computed tomographic angiography of abdominal aorta shows high origin of right renal artery above the origin of celiac trunk and below the level of diaphragm. Rest of the abdominal organs were unremarkable in CTA of abdomen. Both the kidneys were in their usual normal position, relation and appearance in both the cases. In our both cases, right renal artery originated from aorta above the level of celiac axis and below the level of diaphragm. There were no accessory renal arteries on right side. In our first case due to high origin of right renal artery donor nephrectomy was performed on left side despite of dual renal arteries. In our second case donor is in waiting list for nephrectomy, but surgeons are planning to take left kidney due to this rare variation. Anatomic variation of the origin of renal arteries has been broadly divided into two groups by Garti et al., (a) multiple renal arteries originating from the aorta or branches thereof; (b) ectopic origin of a single main renal artery [2,3]. Knowledge regarding embryology of renal vasculature and its structural development is necessary to understand different type of anomalies which may occur [4]. The abnormal location of renal arteries is due to various position of kidney during development. Normally kidneys developed in the pelvic cavity. At that time they receive blood from the neighbouring vessels. After taking its normal position in abdomen their blood supply also changes sequentially [5]. So variations in origin of renal arteries are explained by the development of mesonephric arteries. These arteries form a vascular net known as rete arteriosum urogenitale which supplies the both kidneys, supra renal glands and gonads on either side between the cervical sixth and lumbar third vertebrae. Gradually these arteries degenerate leaving only one mesonephric artery, and it became major arterial supply to the kidneys. So it could be possible that origin of renal artery above the celiac axis [1,6,7]. There are a large number of variants in origin of renal artery noted in literature [1,2,6–8]. But very few papers concern this variation, a renal artery arising from aorta at level of 11th and 12th thoracic vertebrae above celiac trunk. Knowledge of anomalous origin of renal arteries serves as the road map before surgery. If surgeons have knowledge about this, they can minimize the trauma to the vessels during various surgical procedure like donor nephrectomy, repair of renal artery aneurysm and endourological procedures. There are many theories regarding the origin of renal artery and knowledge regarding its origin has major implications in the field of transplant surgery and interventional radiology. In future there will be more similar reports will be reported as more use of non invasive imaging.

Case report – Surgical repair of complex renal artery aneurysm by bench surgery and autotransplantation

Case report – Surgical repair of complex renal artery aneurysm by bench surgery and autotransplantation

Surgical Repair of Renal Artery Aneurysms

The pathogenesis of renal artery aneurysms (RAAs) is degenerative, which eventually leads to weakening of the vessel wall and, in extreme cases, rupture. RAAs are a rare occurrence. Patients generally are asymptomatic, with a small number presenting with uncontrollable hypertension or hematuria. Most RAAs are discovered incidentally on imaging and do not pose an immediate health threat. However, the risk of rupture is an indication for prophylactic repair in certain patients. Interest in interventional radiologic procedures in the management of RAAs has recently increased; however, open repair should still be considered in select instances. In this case series, we present three patients for whom an open approach was indicated and performed.

Management and outcomes of isolated renal artery aneurysms in the endovascular era

Isolated renal artery aneurysms are rare, and controversy remains about indications for surgical repair. Little is known about the impact of endovascular therapy on selection of patients and outcomes of renal artery aneurysms. We identified all patients undergoing open or endovascular repair of isolated renal artery aneurysms in the Nationwide Inpatient Sample from 1988 to 2011 for epidemiologic analysis. Elective cases were selected from the period 2000 to 2011 to create comparable cohorts for outcome comparison. We identified all patients with a primary diagnosis of renal artery aneurysms undergoing open surgery (reconstruction or nephrectomy) or endovascular repair (coil or stent). Patients with concomitant aortic aneurysms or dissections were excluded. We evaluated patient characteristics, management, and in-hospital outcomes for open and endovascular repair, and we examined changes in management and outcomes over time. We identified 6234 renal artery aneurysm repairs between 1988 and 2011. Total repairs increased after the introduction of endovascular repair (8.4 in 1988 to 13.8 in 2011 per 10 million U.S. population; P = .03). Endovascular repair increased from 0 in 1988 to 6.4 in 2011 per 10 million U.S. population (P < .0001). However, there was no concomitant decrease in open surgery (5.5 in 1988 to 7.4 in 2011 per 10 million U.S. population; P = .28). From 2000 to 2011, there were 1627 open and 1082 endovascular elective repairs. Patients undergoing endovascular repair were more likely to have a history of coronary artery disease (18% vs 11%; P < .001), prior myocardial infarction (5.2% vs 1.8%; P < .001), and renal failure (7.7% vs 3.3%; P < .001). In-hospital mortality was 1.8% for endovascular repair, 0.9% for open reconstruction (P = .037), and 5.4% for nephrectomy (P < .001 compared with all revascularization). Complication rates were 12.4% for open repair vs 10.5% for endovascular repair (P = .134), including more cardiac (2.2% vs 0.6%; P = .001) and peripheral vascular complications (0.6% vs 0.0%; P = .014) with open repair. Open repair had a longer length of stay (6.0 vs 4.6 days; P < .001). After adjustment for other predictors of mortality, including age (odds ratio [OR], 1.05 per decade; 95% confidence interval [CI], 1.0-1.1; P = .001), heart failure (OR, 7.0; 95% CI, 3.1-16.0; P < .001), and dysrhythmia (OR, 5.9; 95% CI, 2.0-16.8; P = .005), endovascular repair was still not protective (OR, 1.6; 95% CI, 0.8-3.2; P = .145). More renal artery aneurysms are being treated with the advent of endovascular techniques, without a reduction in operative mortality or a reduction in open surgery. Indications for repair of renal artery aneurysms should be re-evaluated.

Ex vivo repair of renal artery aneurysms

Renal artery aneurysms (RAAs) are rare but remain challenging lesions when treatment is required. Endovascular techniques may be useful in selected, more proximal lesions with amenable morphology, but open surgical repair is often required for more distal, anatomically complex hilar RAAs that often have several branches and unfavorable anatomy. This study reviewed a single-center experience with ex vivo repair of 14 of these more complex, distal RAAs. The records of 14 consecutive patients having ex vivo RAA repair between 1997 and 2013 were retrospectively reviewed. Demographic data, operative details, and blood pressure and renal function status were recorded. Graft patency was observed with renal duplex sonography. Fourteen hilar RAAs were repaired in 10 women and 4 men with a mean age of 54 years. Hypertension was present in 12 (86%). Preoperative renal dysfunction was present in two (14%). Aneurysm size averaged 2.9 cm. Six RAAs (43%) were symptomatic with flank or abdominal pain. Ex vivo repair was performed in all cases with use of saphenous vein for renal-renal bypass. No patient had pelvic autotransplantation or concomitant aortic reconstruction. Ex vivo RAA repair was technically successful in 12 cases; two patients required nephrectomy. Two patients with pre-existing renal insufficiency had improvement postoperatively, but hypertension was clinically unchanged in all patients. No patient required postoperative dialysis. Duplex sonography documented continued graft patency in the 12 technically successful cases during a mean follow-up of 19 months. Open ex vivo surgical repair with renal-renal bypass is a successful and durable treatment for complex distal RAAs that require repair. These procedures had low morbidity and mortality and an acceptable rate of renal function preservation. Blood pressure control in these patients did not change significantly after RAA repair.

PC86. Contemporary Management and Outcomes of Renal Artery Aneurysm Repair

PC86. Contemporary Management and Outcomes of Renal Artery Aneurysm Repair

MP15-20 ROBOTIC UROLOGICAL SURGERY FOR BENIGN INDICATIONS: THE USC EXPERIENCE

MP15-20 ROBOTIC UROLOGICAL SURGERY FOR BENIGN INDICATIONS: THE USC EXPERIENCE

Successful Excision of a Suspected Mycotic Transplant Renal Artery Patch Aneurysm With Renal Allograft Autotransplantation

Successful Excision of a Suspected Mycotic Transplant Renal Artery Patch Aneurysm With Renal Allograft Autotransplantation

Current treatment of renal artery aneurysms may be too aggressive

Most studies recommend repair of renal artery aneurysms (RAAs) >2 cm in diameter in asymptomatic patients, but other studies have suggested that their natural history may be more benign. We hypothesized that rupture and death in patients with asymptomatic RAAs is low and that current recommendations for RAA treatment at 2 cm may be too aggressive. Retrospective review of all RAAs treated at a tertiary care medical center from 2002 to 2012. Fifty-nine RAA were identified in 40 patients (mean age at diagnosis, 56 years; male:female ratio, 17:23); 31 were saccular, 8 were fusiform, and 5 were bilobed. Twenty-nine patients were asymptomatic; the remainder of patients presented with hematuria (n = 4), abdominal pain (n = 3), difficult-to-control hypertension (n = 3), or flank pain (n = 2). Aneurysm location included the main renal artery bifurcation (n = 35), main trunk (n = 7), primary branch (n = 6), pole artery (n = 6), and secondary branch (n = 1). Operative management of RAAs included vein patch (n = 6), prosthetic patch (n = 4), primary repair (n = 3), plication (n = 1), patch and implantation (n = 1), and ex vivo repair (n = 1). Eight asymptomatic RAAs were treated surgically (mean RAA diameter = 2.4 ± 0.1 cm, range, 2-3 cm), with the remaining 33 asymptomatic RAAs being managed conservatively (mean RAA diameter = 1.4 ± 0.1 cm, range, 0.6-2.6 cm). Mean hospital length of stay was 4 days, with no late postoperative complications and 0% mortality. Non-operated patients were followed for a mean of 36 ± 9 months, with no late acute complications and 0% mortality. Mean RAA growth rate of patients with multiple imaging studies was 0.60 ± 0.16 mm/y. The rate of aneurysm rupture and death in our untreated RAA patients is zero, the growth rate is 0.60 ± 0.16 mm/y, and there were no adverse outcomes in asymptomatic RAAs >2 cm that were observed. We may currently be too aggressive in treating asymptomatic RAAs.

Vascular fluorescence imaging control for complex renal artery aneurysm repair using laparoscopic nephrectomy and autotransplantation.

Intraoperative fluorescent imaging using indocyanine green enables vascular surgeons to confirm the location and states of the reconstructed vessels during surgery. Complex renal artery aneurysm repair involving second order branch vessels has been performed with different techniques. We present a case of ex vivo repair and autotransplantation combining the advantages of minimally invasive surgery and indocyanine green enhanced fluorescence imaging to facilitate vascular anatomy recognition and visualization of organ reperfusion.

Endovascular vs Open Repair of Renal Artery Aneurysms: Outcomes of Repair and Long-Term Renal Function

Endovascular repair of a renal artery aneurysm (RAA) can be as safe and effective as open repair in selected patients with appropriate anatomy.

Ex Vivo Repair of Renal Artery Aneurysms

Ex Vivo Repair of Renal Artery Aneurysms

Contralateral renal disease in patients undergoing renal artery aneurysm repair: the fate of the "other" kidney and implications for clinical management

Contralateral renal disease in patients undergoing renal artery aneurysm repair: the fate of the "other" kidney and implications for clinical management

Endovascular vs Open Repair of Renal Artery Aneurysms: Outcomes of Repair and Long-Term Renal Function

Endovascular treatment (ER) of renal artery aneurysms (RAA) has been widely used recently due to its assumed lower morbidity and mortality compared with open surgery (OS). The purpose of this study was to investigate the outcomes of OS and ER, and compare long-term renal function. Data from 2000 to 2012 were retrospectively collected to identify patients who were treated for RAA in a single institution. Morbidity, mortality, freedom from reinterventions, and renal function were compared between OS and ER for RAA. Forty-four RAA repairs were identified in 40 patients (28 women, mean age ± SD 54 ± 13 years). Twenty RAA were repaired with OS (45%) and 24 RAA (55%) with ER. Mean aneurysm sizes were 2.5 ± 1.5 cm (OS) and 2.2 ± 2.2 cm (ER; p = 0.66). Endovascular repair included coil embolization with or without stent placement in 19 patients (79%) and stent grafts in 4 (17%). Open surgery included excision or aneurysmorrhaphy of the aneurysm in 11 kidneys (55%), graft interposition or bypass in 4 (20%), and 4 nephrectomies (20%). There was 1 technical failure in each group. Comorbidities were similar between the 2 groups (American Society of Anesthesiologists III-IV: OS, 40%; ER, 58%; p = 0.44). Endovascular repair and OR had equivalent perioperative morbidity (any complication OS, 15%, ER, 17%, p = 1.0) and no mortality (OS, 0%, ER, 0%). Endovascular repair was associated with shorter hospitalization (OS, 6.3 ± 2.5; ER, 2 ± 3.4 days, p < 0.001). Mean follow-ups were 21 ± 32 months (OS) and 27 ± 36 months (ER). A 30% reduction in glomerular filtration rate occurred in 12.5% of OS patients and 9.1% of ER patients (p = 1.00). Freedom from reintervention at 12 and 24 months were OS, 82%/82% and ER, 82%/74%, respectively (log-rank-test = 0.23). Endovascular repair of RAA is as safe and effective as open repair in selected patients with appropriate anatomy. There was no difference in decline in renal function between OS and ER.

Robot‐assisted laparoscopic renal artery aneurysm repair with selective arterial clamping

Renal artery aneurysms represent a rare clinical entity, and most are managed with endovascular techniques when treatment is indicated. Laparoscopic and robot-assisted repair of renal artery aneurysms has been described; however, few reports exist in the literature. We describe our experience with the surgical management of a 1.6-cm right-sided renal artery aneurysms in a 35-year-old man who presented with flank pain. Using the DaVinci Si surgical platform (Intuitive, Sunnyvale, CA, USA), the aneurysm was resected and the renal artery was reconstructed. Segmental branches of the renal artery were dissected and selectively clamped during resection, allowing for regional rather than global renal ischemia. Operative time was 240 min, with an estimated blood loss of 200 cc. Warm ischemia time was only regional, for a duration of 44 min. Follow-up functional analysis showed preserved renal function in the right kidney. We describe our technique and show the technical feasibility of robot-assisted renal artery aneurysm repair. Furthermore, use of the DaVinci Si system facilitates segmental artery dissection, and allows for selective clamping during reconstruction. This avoids global renal ischemia and optimizes functional preservation.

Clinical Outcomes After Repair of Renal Artery Aneurysms

Clinical Outcomes After Repair of Renal Artery Aneurysms