Asian Cardiovasc Thorac Ann 2002;10:176-177
© 2002 Asia Publishing EXchange Pte Ltd
Giant Aneurysm of Renal Artery: Surgical Management
Lokeswara Rao Sajja, MCh,
Sitaram Reddy Benjaram, FRCS,
Sarbeswar Sahariah, MS1,
Vijay Kumar Devaraj, MCh
Department of Cardiothoracic and Vascular Surgery
1 Renal Transplant Unit Apollo Hospitals Hyderabad, Andhra Pradesh, India
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Sitaram Reddy Benjaram, FRCS Tel: 91 40 360 7777 Fax: 91 40 360 8050 Department of Cardiothoracic and Vascular Surgery, Apollo Hospitals, Jubilee Hills, Hyderabad, Andhra Pradesh 500033, India.
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ABSTRACT
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Giant aneurysm of the renal artery is rare even though renal artery aneurysms are diagnosed more often since the introduction of abdominal ultrasonography and selective renal arteriography. A 52-year-old man with an aneurysm of the left renal artery measuring 16 x 13 x 10 cm presented with features of an expanding aneurysm. He underwent resection of the aneurysm and a left nephrectomy.
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INTRODUCTION
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Renal artery aneurysms are diagnosed more often with the advent of ultrasonography and selective renal angiography for evaluation of hypertension. The majority of these lesions (83%) are detected incidentally in the evaluation of peripheral atherosclerotic arterial disease.1 Most are small in size and amenable to excision and repair. A few necessitate nephrectomy because the large size of the aneurysm results in compression and destruction of renal parenchyma.
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CASE REPORT
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A 52-year-old man presented with abdominal pain of 10 days' duration, which was localized to the left loin. There was no history of a burning sensation during micturi-tion, hematuria, or pyuria. He was a known hypertensive for 4 years and has been on irregular antihypertensive medication. His heart rate was 76 beats•min-1, blood pressure was 140/90 mm Hg, and all peripheral pulses were well felt. Examination of the cardiovascular system was unremarkable. On abdominal examination, a tender mass of 10 x 10 cm was detected in the left loin. The left renal angle was dull on percussion and no bruit was detected. The bowel sounds were well heard. Ultra-sonography of the abdomen showed a large aneurysm of the left renal artery, containing a clot. Computed to-mography demonstrated a secular aneurysm arising from the left renal artery, which measured approximately 10 x 9.6 x 10 cm, and compressed and displaced the ipsilateral kidney laterally. The abdominal aorta was normal in size and there was no other associated intra-abdominal abnormality (Figure 1
). Biochemical studies revealed a blood urea of 310 mg•L-1 and serum creatinine of 18 mg•L-1.
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Figure 1. Computed axial tomographic scan of the abdomen showing an aneurysm of the left renal artery and compressed left kidney. AA = abdominal aorta, LK = left kidney, RAA = renal artery aneurysm.
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An emergency operation was performed through a thoracoabdominal approach. The aneurysm was observed arising from the left renal artery, and measuring 16 x 13 x 10 cm. It involved almost the whole of the renal artery but there was a short segment where the artery could be clamped proximal to the aneurysm. The abdominal aorta was looped proximal and distal to the renal artery for clamping the aorta if necessary. The left kidney was found to be compressed and displaced laterally to form a crescent shape over the top of the aneurysm. A kidney-preserving repair was considered technically difficult, hence excision of the aneurysm was performed along with a left nephrectomy. The patient withstood the procedure well and was discharged from hospital on the 9th postoperative day.
The resected specimen was a circumscribed oval mass measuring 16 x 13 x 10 cm, with the compressed left kidney at the periphery of the mass. A cut section revealed thick walls with a cystic area filled with a blood clot, and grayish white myxoid areas. Microscopic examination of the arterial wall showed patchy infiltrates of neutrophils and a few lymphocytes and plasma cells, with a thrombus attached to the wall and in the lumen. In one focus, cholesterol clefts were seen. These features were consistent with a renal artery aneurysm probably of atherosclerotic origin. The kidney was unremarkable. The specimen was not sent for bacteriological culture as the clinical features were not suggestive of mycotic aneurysm.
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DISCUSSION
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Renal artery aneurysm is an unusual lesion in the general population, with a reported incidence of 0.3% to 1.3% in patients undergoing arteriography.2 The majority of renal artery aneurysms are small and asymptomatic and require no treatment. Aneurysms of the renal arteries in pregnant women are often large and prone to rupture with an associated high mortality for the mother and child.3 In nonpregnant patients, a giant aneurysm of a renal artery is rare, and the largest reported so far was 5.8 cm in diameter.4 Renal artery aneurysms in the general population are different from those in pregnant women, and are associated with hypertension and other vascular diseases in 80% of patients.5 The hypertension may be of renovascular origin due to renal artery stenosis associated with the aneurysm, or it may be idiopathic and possibly an etiological factor in aneurysm formation.2 The risk of rupture of such aneurysms is exceedingly low and repair is not recommended routinely for the prevention of rupture in asymptomatic lesions measuring less than 2 cm in diameter. Any larger or symptomatic aneurysm needs some type of intervention.
The common indications for surgical repair are expanding aneurysm, intractable hypertension, hematuria, and renal infarction. Although resection and repair of the aneurysm with preservation of the kidney is the preferred method of treatment, some cases require nephrectomy when excision and repair are impossible.1,6 Complex renal artery aneurysms involving the main branches of the renal artery can be managed by repair under extracorporeal circulation using continuous cold perfusion, or by substitution of the pathological segment with the patient's internal iliac artery, or autotransplantation to the iliac fossa.7 Other modalities of treatment include embolization of the aneurysm with preservation of renal blood flow, as reported by Tateno and colleagues.8 When surgical treatment has been performed as an elective procedure, the results have been excellent from a kidney-sparing standpoint. However, in patients with an expanding aneurysm and loin pain as the presenting feature, as in this patient, it is not always possible to carry out a kidney-sparing procedure, and one may have to resort to excision of the aneurysm along with a nephrectomy, more so if the kidney has been compressed to a great extent.5
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REFERENCES
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ABSTRACT
INTRODUCTION
