[Aortic aneurysm and horseshoe kidney--case report and collective review (author's transl)]

Case report: Aortobiiliac bypass with autotransplantation of the horseshoe kidney and renal vascular reconstruction

INTRODUCTION AND IMPORTANCE

This case report describes the rare encounter of a large infrarenal abdominal aortic aneurysm (AAA) and a horseshoe kidney (HEN), which was managed through comprehensive preoperative planning and effective multidisciplinary collaboration, with the patient being fully informed and consenting to the publication of data and images.

CASE PRESENTATION

The patient was referred to the Department of Vascular Surgery with increasing abdominal pain. Computed tomography angiography showed that the aneurysm was significantly advanced. For surgical correction of the aortic aneurysm, the horseshoe kidney was autotransplanted intraoperatively to ensure renal vascular reconstruction for further renal perfusion after treatment of the aneurysm.

DISCUSSION

Abdominal aortic aneurysm carries a significant risk of rupture, with more than half of ruptures being fatal before reaching the hospital. When the AAA occurs concomitantly with a HEN, detailed imaging is critical for planning the procedure, as the unusual arterial supply to the HEN complicates the procedure and requires careful strategies to protect renal function while treating the aneurysm.

CONCLUSION

The treatment of complex cases with severe disease manifestations and difficult anatomy requires careful planning to ensure effective treatment and optimise patient survival and quality of life.

Management of aortic aneurysm in the presence of a horseshoe kidney

BACKGROUND

The coexistence of an aortic aneurysm and a horseshoe kidney poses a technical challenge to the vascular surgeon at the time of aneurysm repair. The aim of this review is to develop a guideline for the treatment of patients with this dual pathology.

METHOD

A literature review combined with local experience provided a total of 176 cases. These were divided into two groups: asymptomatic aneurysms (134) and ruptured aneurysms (42), both in combination with a horseshoe kidney.

RESULTS

Six types of operative approach were described: transperitoneal approach with or without separation of the renal isthmus, retroperitoneal approach, placement of a stent-graft, aneurysmal wrap and exploration without exclusion of the aneurysm. Diagnosis of the horseshoe kidney was made before operation in 81 per cent of patients in the asymptomatic group, and in 55 per cent (23 of 42) in the ruptured group. Computed tomography proved to be the most reliable diagnostic procedure. Occlusion of renal arteries originating from the aneurysm was reported in 51 per cent in the asymptomatic group, and in 74 per cent (23 of 31) in the ruptured group.

CONCLUSION

The preferred surgical options for asymptomatic patients with an aortic aneurysm and a horseshoe kidney are the placement of a stent-graft or a retroperitoneal approach; both avoid many of the technical difficulties related to the presence of the horseshoe kidney. The approach of choice for a ruptured aneurysm is transperitoneal. Separation of the renal isthmus should be avoided.

[Aortic aneurysm and anomalies of the kidney (author's transl)]

Because of the embryological position of the kidney in the small pelvis anomalies of the kidney are mostly localized in the area of the distal aorta. Therefore they can make the resection of an aortic aneurysm more difficult. While anomalies of the renal veins and the urinary tract hardly impair the resection of an aortic aneurysm, an abnormal arterial vascularization of the kidney can be an essential problem during operation. According to criteria concerning localization the arterial anomalies are divided into 4 types. For every type techniques of resection and reconstruction guaranteeing the viability of the abnormal arteries and the kidney are demonstrated.