Renal artery aneurysm in a transplanted kidney: ex vivo graft repair and reimplantation

Abstracts

Aneurisma verdadeiro de artéria renal em rim transplantado é ocorrência rara. As possibilidades de tratamento dependem do tamanho, da localização do aneurisma e da clínica apresentada pelo paciente. Descreve-se um caso de aneurisma gigante de artéria renal em rim transplantado que recebeu tratamento ex vivo e reimplante na fossa ilíaca direita. Detalhes do procedimento cirúrgico são descritos.

Aneurisma da artéria renal; autotransplante renal; complicações em rim transplantado

CASE REPORT

^I

^IIUrology Service, Department of Surgery, SCMPG, Ponta Grossa, PR, Brazil

^IIIResident, Vascular Surgery Service, Department of Surgery, SCMPG, Ponta Grossa, PR, Brazil

Correspondence

ABSTRACT

True aneurysm of a renal artery in a transplanted kidney is a rare occurrence. Treatment options depend on size and location of the aneurysm and the patient’s clinical condition. We report a case of a giant aneurysm of the renal artery in a transplanted kidney that was treated ex vivo and reimplanted in the right iliac fossa. Details of the surgical procedure are described.

Keywords: Renal artery aneurysm, renal autotransplant, complications in a transplanted kidney.

Introduction

Kidney transplants currently represent a well-established therapy and are the treatment of choice for irreversible chronic kidney failure throughout the world. The greater survival rate of these patients has resulted in an increased likelihood of vascular complications due to atherosclerosis.¹ Treatment of such complications requires surgical strategies that ensure the renal graft is protected.² Surgery can be performed conventionally,in situ, using an endovascular technique,³ or, when anatomical conditions do not allow such an approach, by nephrectomy followed by hypothermic perfusion, correction of the vascular pathology and reimplantation of the kidney in the iliac fossa.^4-7

Case report

A 51-year-old male patient received a renal transplant form a living donor 60 months ago. The surgery was performed uneventfully, and the patient remained asymptomatic up to 2 months ago, when, during a control, he started showing gradual increase in serum creatinine, reaching 2.7 mg/dL. He was then submitted to clinical investigation. Ultrasound showed aneurysmal dilatation of the transplanted renal artery, extending from the hilum to the external iliac artery anastomosis and with a mural thrombus. Contrast-enhanced computed tomography (Figure 1) confirmed the findings and aneurysm size, measuring 3.9 x 4.0 x 6.5 cm.

Surgery

O implante renal foi retirado da fossa ilíaca direita e recebeu tratamento ex vivo, sendo perfundido pela veia renal com solução de Euro-Collins. During bench surgery the aneurysm was found to have caused erosion of the parenchyma and was removed. The great saphenous vein was used to prepare a spiral vein graft with a diameter similar to that of the renal vein (Figure 2).

The kidney was reimplanted in the right iliac fossa so that the spiral vein graft was positioned between the stump of the renal vein and the common iliac vein. A segment of the great saphenous vein was used to make the bridge between the stump of the renal artery and the common iliac artery. An end-to-side anastomosis was performed between the urinary tract and the native ureter (Figure 3).

During the postoperative period, the patient’s renal function improved and creatinine fell to 1.4mg/dL. He was discharged from hospital without any complications.

Discussion

Complications arising from renal artery aneurysms are associated with a threat to life from rupture, particularly in pregnant patients,⁸ and loss of the graft in cases of kidney transplant.⁹ Surgical treatment is recommended for aneurysms greater than 2 cm in diameter or that lead to some type of symptomatology as a result of their presence.¹⁰ In 1967 Ota et al. carried out the first ex vivo repair of a renal artery for renovascular hypertension.¹¹ In 1971 Grein et al. used the same technique to correct a renal artery aneurysm.¹² Richardson et al. described a case of a ruptured renal artery aneurysm in a pregnant patient with a transplanted kidney in 1990.¹³ Resection of an aneurysm in a transplanted kidney with local repair was described by Dunkow et al. in 1994¹⁴ and Guleria et al. in 1998.¹⁵ More recently, use of endovascular techniques has proven to be particularly effective in cases with favorable anatomical conditions.^3.16 The need to resect a long segment of the artery affected by the aneurysm and to sacrifice part of the renal vein involved in this case - both needed for the nephrectomy - required insertion of a venous segment in the renal artery stump and making of a spiral graft for the vein. Such condition forced an ex vivo repair and reimplantation of the kidney graft a second time.

Kidney reimplantation with extracorporeal vascular reconstruction is a complex technique recommended in cases where the arterial aneurysm cannot be corrected using either endovascular techniques or in situ treatment. It represents a valid alternative in specific cases.

References

• 1. Lachachi F, Ostyn E, Sekkal S, et al. Successful surgical management of a ruptured abdominal aortic aneurysm in a renal transplant patient. A case report. J Cardiovasc Surg (Torino). 1998;39:765-7.
• 2. Ierardi RP, Coll DP, Kumar A, Solomon BR, Kerstein MD, Matsumoto T. Abdominal aortic aneurysectomy after kidney transplantation: case report and review of the literature. Am Surg.1996;62:961-6.
• 3. Cardozo MA, Lichtenfels E, Erlin Jr N, Raupp E, Tarasconi DP. Endovascular treatment of renal artery aneurysm using microcoil embolization and renal blood flow preservation: case report. J Vasc Bras. 2007;6:167-70.
• 4. Zhang J, Feng R, Feng X, et al. [Aneurysm repair in vitro and renal revascularization and renal autogenous transplantation for complex renal artery aneurysm in solitary kidney]. Zhonghua Wai Ke Za Zhi. 2007;45:1253-6.
• 5. Galmés I, Burgos FJ, Rodriguez-Luna JM, et al. ["Ex-situ" reconstructive surgery of the renal arteries]. Actas Urol Esp. 1996;20:30-6.
• 6. López-Fando Lavalle L, Burgos Revilla J, Sáenz Medina J, et al. [Renal autotransplantation: a valid option in the resolution of complex cases]. Arch Esp Urol. 2007;60:255-65.
• 7. Unno N, Yamamoto N, InuzuKa K, et al. Laparoscopic nephrectomy, ex vivo repair, and autotransplantation for a renal artery aneurysm: Report of a case. Surg Today. 2007;37:169-72.
• 8. Dayton B, Helgerson RB, Sollinger HW, Acher CW. Ruptured renal artery aneurysm in pregnant uninephric patient: successful ex vivo repair and autotransplantation. Surgery. 1990;107:708-11.
• 9. Cánovas Ivorra J, Guardiola Mas A, Nicolas Torralba JA, et al. [Dissecting aneurysm of the renal artery in patient with transplantation. Report of case. Review of the literature]. Arch Esp Urol. 2003;56:1059-62.
• 10. El Tayar AR, Labruzzo C, Haritopoulos K, Hakin NS. Renal artery aneurysm: ex vivo repair and autotranplantation: case report and review of the literature. Int Surg. 2003;88:61-3.
• 11. Ota K, Mori S, Awane Y, Ueno A. Ex situ repair of renal artery for renovascular hypertension. Arch Surg. 1967;94:370-3.
• 12. Glein LE, Glaes G, Gustafsson A, Storm B. Total bloodlesseness for extracorporeal organ repair. Rev Surg. 1971;28:305-16.
• 13. Richardson AJ, Liddington M, Jaskowski A, Murie JA, Gillmer M, Morris PJ. Pregnancy in a renal transplant recipient complicated by rupture of a transplant renal artery aneurysm. Br J Surg. 1990;77:228-9.
• 14. Dunkow PD, Abraham JS, Johnson RW. True aneurysm of the transplanted renal artery in a kidney transplant recipient. Nephrol Dial Transplant 1994;9:1495-7.
• 15. Guleria S, Ahmad N, Pollard SG, Newstead CG, Lodge PA. Transplant renal artery aneurysm following venous patch repair of a traction injury to the renal artery. Nephrol Dial Transplant 1998;13:1577-8
• 16. Henke PK, Cardneau JD, Welling TH 3rd, et al. Renal artery aneurysms. A 35-year clinical experience with 252 aneurysms in 168 patients. Ann Surg. 2001;234:454-62.

Renal artery aneurysm in a transplanted kidney: ex vivo graft repair and reimplantation

Cesar Roberto Busato^I; Carlos Alberto de Lima Utrabo^I; Wilson Freire de Sousa^II; Ricardo Zanetti Gomes^I; Joel Kengi Hosoume^I; Eliziane Hoeldtke^I; Rafael Inácio Brandão^III; Dieyson Martins de Melo Costa^III

Publication Dates

• Publication in this collection
  26 May 2009
• Date of issue
  Mar 2009

History

• Accepted
  16 Dec 2008
• Received
  29 July 2008