Management of Aortoiliac Aneurysms with Atypical Renal Artery Anatomy

Renal artery anomalies occur at a rate of 1-2% and present a challenge to vascular surgeons performing aortic surgery. We describe adjuncts used to manage such anatomic variants.

A single surgeon registry of all abdominal aortic aneurysms repaired in an academic center was retrospectively reviewed. Patients with prior renal transplants, congenital pelvic kidneys, or horseshoe kidneys were included. Open repair was reserved for patients with no endovascular or hybrid repair options.

Over an 8-year period, 18 patients were identified (renal transplant n = 9, horseshoe kidney n = 3, congenital pelvic kidney n = 6). All transplant patients were treated with endovascular repair. Four required cross-femoral bypasses, 1 for retrograde allograft perfusion after aorto-uni-iliac (AUI) procedure to the contralateral external iliac artery and 3 for contralateral limb perfusion after endograft extension into iliac artery ipsilateral to allograft. Three transplant patients required carotid access due to severe iliofemoral occlusive disease or allograft origin off the internal iliac artery. Two horseshoe kidney patients underwent open repair with direct reimplantation of accessory renal arteries, whereas 1 underwent endovascular repair with exclusion of an isthmus branch. Of the congenital single/pelvic kidney cohort, 2 underwent open repair with renal reimplantation, 2 underwent endovascular aneurysm repair, 1 was treated with AUI and cross-femoral bypass, and one was treated with a staged iliorenal bypass and subsequent fenestrated endovascular repair. Intravascular ultrasound was used to minimize contrast use in patients with chronic renal insufficiency (Cr > 1.5 mg/dL, n = 6). Over a mean follow-up of 31 months (range, 1-110), there were no aortic deaths or reintervention, no decline in renal function (measured by serum creatinine and glomerular filtration rate), and 100% patency of the preserved renal arteries.

Atypical renal anatomy should not preclude repair of aortic aneurysms. Repair of such aneurysms is safe and achieves good long-term outcomes with the use of the described techniques.