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We described new landmarks and recommendations to avoid this complication during tibial tuberosity transfer.

WHAT THIS PAPER ADDSIn the era of endovascular techniques, open surgery for distal renal artery aneurysms remains a valuable option when performed in experienced reference centres. This study describes in detail the operative technique used for repair of 24 renal artery aneurysms with direct reconstruction, over a period of three years. Follow up, including patency rate, assessment of arterial pressure as well as renal function monitoring based on serum creatinine levels, is reported.Objective: Treatment of renal artery aneurysms (RAA) remains controversial. Endovascular treatment has increased for main trunk and for very distal aneurysms, whereas for lesions located at the bifurcation surgical treatment seems to be a valid option. The goal of this study was to describe the technique of direct reconstruction of RAA and to report on outcomes. Methods: This study comprised single centre prospective collection of data with retrospective analysis (January 2015 to August 2018) of patients operated on for distal RAA using direct reconstruction. Results: A total of 24 RAA in 21 patients (seven men and 14 women, mean age 59 AE 13 years) was included. History of hypertension was found in 15 patients and renal insufficiency was present in one. Mean preoperative systolic and diastolic blood pressures were 134 AE 21 mmHg and 74 AE 10 mmHg, and mean preoperative rates of creatinine and glomerular filtration rate were 67 AE 13 mmol/L and 93 AE 49 mL/min/ 1.73 m 2 , respectively. Indications for repair were a diameter >20 mm in seven cases (mean diameter ¼ 25 AE 2 mm) or rapid growth in one case, symptomatic aneurysm in 12 cases (hypertension, haematuria, pain), and a concomitant lesion in four cases (splenic aneurysm, abdominal aortic aneurysm, occlusive visceral artery lesions). All lesions were distal, main artery bifurcation in 22 cases and hilar in two cases. The main aetiology was fibromuscular dysplasia (16 cases) followed by atherosclerosis (seven cases) and one case of Ehlers Danlos Syndrome. In situ reconstruction was possible for 22 RAA, while two cases required kidney autotransplantation. The mean renal ischaemia time was 18 AE 5 min. At two years, the patency rate was 100%, and mean systolic blood pressure decreased (134 mmHge122 mmHg, p ¼ .047). Renal function was stable from 93 AE 49 pre-operatively to 95 AE 35 mL/min/1.73 m 2 in the post-operative course (p ¼ .56). Conclusion: Direct reconstruction appears to be efficient for most RAA. This technique is complementary to ex vivo autotransplantation and endovascular treatment.

This hybrid technique, consisting of AAA endovascular exclusion combined with open IIA revascularization, is safe and effective for preservation of pelvic vascularization. It is associated with long-term patency and low morbidity rates. We have been using this technique since before the advent of branched dedicated devices, allowing preservation of the IIA with good results. This technique should continue to be proposed, especially in patients not eligible for endovascular iliac branch repair because of anatomic contraindications, to avoid pelvic ischemia if the IIA has to be sacrificed.