Iliac Artery Aneurysm Repair with Preservation of a Single Ectopic Pelvic Kidney

Abstract

An ultrasonographic study in a 60-year-old man incidentally detected an iliac artery aneurysm that gave rise to the renal artery of a single ectopic pelvic kidney. Renal T he surgical treatment of intra-abdominal artery aneurysms is challenging when the renal artery arises from the aneurysm. Preserving the kidney is crucial when repairing the aneurysm. In these cases, renal-preservation solution cannot be used, because it would pass through the renal vein into the general circulation. For this reason, various techniques have been proposed to preserve renal viability. We discuss our surgical correction of an iliac artery aneurysm in a man whose single ectopic pelvic kidney necessitated an alternative treatment. Case ReportIn August 2010, a 60-year-old man with hypertension and type 2 diabetes mellitus underwent abdominal ultrasonography and was incidentally found to have an iliac artery aneurysm. Results of physical examination were unrevealing. Computed tomographic angiograms disclosed a 5 × 7-cm saccular aneurysm in the right common iliac artery; this vessel gave rise to the renal artery of a single ectopic pelvic kidney (Fig. 1). Calibrated angiograms confirmed that the single renal artery originated from the iliac artery aneurysm. No other abnormalities of the cardiovascular system were detected. Because of the high risk of rupture, surgical treatment was recommended.A thermal blanket was used to prevent hypothermia in the patient, whose body temperature remained unchanged throughout the operation. The aneurysm was exposed after dissection of the involved arteries. Cold normal saline solution (8 °C) was infused through the ostium of the renal artery at a rate of 20 cc/min (total volume, 400 cc). Renal-preservation solutions were not infused, because the renal vein was not clamped and such solutions would reach the systemic circulation. Topical cooling of the kidney with normal saline solution was also performed. We performed an aortoiliac bypass with use of a 10-mm Bard ® DeBakey ® Vasculour ® Dacron graft (Bard Peripheral Vascular, Inc.; Tempe, Ariz). The renal artery, which supplied the ectopic pelvic kidney, was implanted onto the graft by means of an end-to-side anastomosis. The duration of renal ischemia was 40 minutes.The patient's postoperative recovery was uneventful, and he was released from the hospital after 13 days. His preoperative serum creatinine level of 1.2 mg/dL had increased 30% to 1.7 mg/dL, but no renal failure was observed. At that time, results of Doppler ultrasonography showed normal renal function, and the results of technetium-99 gammagraphy confirmed patency of the renal vessels. One month after the operation, the patient's serum creatinine level was 1.9 mg/dL; after one year, it was normal at 1.4 mg/dL.

Cold nephroprotection for repair of aortic ectasia and bilateral iliac aneurysms in the presence of pelvic ectopic kidney

“…Initially, in emergency situations needing rapid vascular control, renal clamping should be performed, after forced diuresis with mannitol. This technique is quick and easy; however, it limits the warm ischemia time to 30 min; if this limit is exceeded, the kidney can start to develop acute ischemic tubular necrosis 3 . There are also other strategies, like the use of temporary and permanent shunts and extracorporeal circulation, which have the advantage of preventing ischemia for more time and allowing more relaxed reimplantation of the renal arteries.…”

“…Thus, these patients must be carefully individualized, as the approaches may vary from surgeon to surgeon due to the differential anatomy of the aneurysmal vessels and the vasculature of the solitary pelvic ectopic kidneys 1 . Strategies like using cold saline solution during surgery or mannitol before renal clamping, together with other endovascular and hybrid management techniques, have been proposed as approaches for preserving a solitary pelvic ectopic kidney associated with aortoiliac aneurysmal degeneration 1,3,4 . This is why we present the case of a patient with a solitary pelvic ectopic kidney associated with aneurysmal degeneration of the aortoiliac vessels, who was treated with cold irrigation during the surgical procedure, with no post-operative kidney dysfunction and no short-or medium-term morbidity.…”

Nefroprotección en frío para reparo de ectasia aórtica y aneurismas ilíacos bilaterales ante la presencia de riñón ectópico pélvico

“…Si se decide optar por una corrección abierta, la principal posterior a diuresis forzada con manitol. Esta técnica es rápida y fácil; no obstante, limita el tiempo de isquemia caliente a 30 minutos; si se se supera este límite, el riñón puede empezar a desarrollar necrosis tubular isquémica aguda 3 . También existen otras estrategias, como el uso de shunts temporales y permanentes y el uso de circulación extracorpórea, que tienen la ventaja de prevenir la isquemia por más tiempo y permitir el reimplante de las arterias renales ectópicas con más calma; sin embargo, el tiempo de la intervención quirúrgica es más prolongado, y la técnica es mucho más costosa e impropia para pacientes con alto riesgo quirúrgico 2 .…”

“…Por lo anterior, es esencial individualizar con cuidado a estos pacientes, ya que los enfoques pueden variar entre cirujanos debido a la anatomía diferencial de los vasos aneurismáticos y la vasculatura de los riñones ectópicos pélvicos solitarios 1 . Estrategias como el uso de solución salina fría durante la cirugía o el uso de manitol previo al clampeo renal, en conjunto con otras técnicas de manejo endovasculares e híbridas, se han propuesto como planes de abordaje para la preservación del riñón ectópico pélvico solitario asociado a degeneración aneurismática aortoilíaca 1,3,4 . Es por eso que se presenta el caso de un paciente con un riñón ectópico pélvico solitario asociado a degeneración aneurismática de los vasos aortoilíacos, el cual fue tratado con irrigación en frío durante el procedimiento quirúrgico, sin pérdida de la función renal posoperatoria y sin morbilidad a corto ni mediano plazo.…”