Resection and patch aortoplasty for right renal artery aneurysm through a midline laparotomy

BACKGROUND: Renal artery aneurysm (RAA) is a rare but potentially life-threatening vascular pathology. Surgical management depends on the aneurysm’s location and morphology. In cases with extensive aortic calcification or anatomical complexity, standard clamping techniques may be infeasible, requiring alternative hemostatic strategies. We present a unique case of RAA in a patient with Takayasu’s arteritis and diffuse aortic calcification, in whom intra-aortic balloon occlusion and patch aortoplasty were used as a salvage technique during surgical repair. CASE PRESENTATION: An 80-year-old woman with a history of Takayasu’s arteritis was referred for surgical treatment of an enlarging right RAA (55 × 74 mm), incidentally detected on imaging during hospitalization for pneumonia. Preoperative computed tomography (CT) demonstrated diffuse calcification of the entire aorta and an aneurysm located at the origin of the right renal artery. The distal segment of the right renal artery was occluded, and the right kidney could not be identified. Due to anticipated bleeding risk and poor clamping accessibility, cardiopulmonary bypass was established via the right femoral vessels. Multiple intra-aortic balloon occlusion catheters were inserted, though several ruptured intraoperatively. Hemostasis was ultimately achieved by inflating a balloon inserted directly through the operative field and performing a patch closure of the dilated right renal artery ostium. The patient required massive transfusion and temporary renal replacement therapy postoperatively. She was discharged to rehabilitation on postoperative day 49. Postoperative CT confirmed patch integrity, but a localized aortic dissection at the balloon site was observed. CONCLUSIONS: This case illustrated the technical challenges of surgical approaches for RAA in patients with severe aortic calcification due to Takayasu’s arteritis. Intra-aortic balloon occlusion is a useful alternative to conventional clamping but carries a risk of rupture, particularly in calcified aorta. Patch aortoplasty may be considered for elderly patients where graft replacement is not feasible. Preoperative imaging is essential to plan individualized strategies for bleeding control and vascular access in high-risk patients.