Abdominal Aortic Aneurysm with Coexistent Horseshoe Kidney

Horseshoe kidney: Morphologic features, embryologic and genetic etiologies, and surgical implications

The horseshoe kidney (HSK) is the most common congenital abnormality of the upper urinary tract with an incidence of approximately 1 in 500 in the general population. Although individuals with HSK are often asymptomatic, they are at increased risk for neoplasms, infections, ureteropelvic obstruction secondary to lithiasis or vascular compression. Direct injury from trauma is increased in these individuals as is the risk of intraoperative complications secondary to damage involving the typically complex renal or adrenal vascular supply. We briefly review etiological factors including renal and urinary system embryology, genetic mutations, abnormalities related to faulty cell signaling, aberrant cell migration, and other possible causes including environmental exposures and trauma. In addition, we call attention to factors that might influence the success of surgical procedures in patients with HSK. We argue that an understanding of possible etiologies of the HSK and its different subtypes may be useful when planning surgical procedures or considering risk-benefit ratios associated with different surgical options. We briefly present the organization of a HSK in a 100-year-old male demonstrating an unusual vascular supply discovered during a dissection laboratory session in a medical school anatomy course. We describe the structure of the HSK, the position and relationships of the HSK to other structures within the abdomen, and the associated vascular relationships.

Best strategy in managing the association of Horse-shoe-Kidney and Abdominal Aortic Aneurysm: Case report

•

Most common renal anomalies.

•

Rare association of Horse-Shoe-kidney and Abdominal aortic aneurysm.

•

Special challenge in managing this pathology given the close spatial relationship.

•

Frequent renal arterial variation.

•

Surgery or endovascular treatment.

Introduction

Horseshoe Kidney (HSK) is probably the most common of all renal fusion abnormalities. However the association of Abdominal aortic aneurism (AAA) and HSK is rare, and occurred in 0,12% of patient affected by AAA.

Presentation of case

We present a patient with the concomitant presence of AAA and HSK treated by open surgical repair with a transperitoneal approach without section of the isthmus with great outcomes after surgery.

Discussion

The management of AAA associated with HSK presents a special challenge during vascular surgery, given the close spatial relationship and the frequent renal arterial variations that accompanies HSK.

Conclusion

Diagnosis and a well designed surgical strategy are required to avoid surgical post operative complications.

Surgical Repair of Abdominal Aortic Aneurysm in Patients with Simultaneous Urological Disorders: a Single Center Experience

Introduction

Although rare, co-existence of abdominal aortic aneurysms with urological manifestations, suggests a challenging surgical entity in terms of successful aneurysmal repair along with minimally or null urological complications.

Case reports

There are neither available data regarding the incidence of their co-existence nor consensus regarding optimal surgical management. Given the infrequency of their simultaneous presentation, the report of unusual cases as well as proposal for successful surgical management, are always useful and educative.

Conclusion

Precise imaging pre-operatively and meticulous surgical technique intra-operatively are of utmost importance and suggest our vast allies in successful outcomes. Herein, we present our small case series of 3 interesting cases.

Transperitoneal repair of a juxtarenal abdominal aortic aneurysm and co-existent horseshoe kidney with division of the renal isthmus

The co-existence of abdominal aortic aneurysm (AAA) and horseshoe kidney (HSK) is rare. We report a 67-year-old man with an expanding juxtarenal AAA associated with a HSK. The aneurysm had a severely angulated neck and contained a significant amount of mural thrombus. The isthmus of HSK closely lied over the aneurysm, making its exposure extremely difficult. The aneurysm was successfully repaired using transperitoneal approach with division of the renal isthmus and without any need for the renal artery reconstruction. Despite the potential complications, particularly renal insufficiency, associated with division of the renal isthmus and suprarenal cross-clamping of the abdominal aorta, in our case, post-operative period was uneventful and the patient's recovery was satisfactory.

Surgical Treatment of a Voluminous Infrarenal Abdominal Aortic Aneurysm with Horseshoe Kidney: Tips and Tricks

Horseshoe kidney is a common urology anomaly, while its association with infrarenal abdominal aortic aneurysm represents a very rare condition. Surgical approach remains controversial however, we believe that the left retroperitoneal approach should be preferred in order to avoid isthmus resection with any subsequent renal infarction, urinary tract damage and to facilitate renal arteries reimplantation, when required. We present a case of voluminous infrarenal abdominal aortic aneurysm associated with horseshoe kidney, successfully treated through a left retroperitoneal approach on the retro-renal space.

Fused ureters in patient with horseshoe kidney and aortic abdominal aneurysm

Horseshoe kidney (HSK) is a very common developmental abnormality in the kidney. They are associated with abnormalities like multiple renal arteries, abnormal position of the ureter in the renal pelvis and highly placed ureteropelvic junction. These can result in urological complications. However, the ureters run their separate course and empty individually into the urinary bladder. Surprisingly, anatomical anomalies do occur and can lead to unexpected findings on investigation or surgical treatment. Such anomalies can present diagnostic and management challenges to unsuspecting clinicians. This report deals with one of such anomalies that seem not to have been reported before in the literature. This case is a rare finding of fused ureters over the renal isthmus in a patient with HSK who also has aortic abdominal aneurysm (AAA). Simultaneous occurrences of HSK and AAA have been reported severally in the past, and the authors are paying attention on the ureteral anomaly.

Endovascular repair of an abdominal aortic aneurysm in the presence of a hydronephrotic horseshoe kidney

The aim of this paper is to report an unusual case of a patient with an abdominal aortic aneurysm (AAA) and a hydronephrotic horseshoe kidney (HSK) that was repaired by endovascular means. An 81-year-old male patient with a known HSK was found to have hydronephrosis and an AAA. The patient's aneurysm was treated with an endovascular stent graft which required the covering of accessory renal arteries. He had an uneventful recovery with complete resolution of the hydronephrosis evident on a computed tomography scan performed seven months after the surgery. In conclusion, endovascular aneurysm repair is a feasible therapeutic option for an AAA coexisting with an HSK and may be considered as a valid alternative to open repair when concomitant hydronephrosis is present.

Endovascular infrarenal aneurysm repair in patients with horseshoe kidneys: case series and literature review

Horseshoe kidney may cause technical and access problems during open aortic aneurysm repair. The aim of this study is to report two cases from our institution and to review the world's literature on successful endovascular infrarenal aneurysm repair in patients with horseshoe kidneys. A retrospective review of a prospectively entered departmental computerized database was performed for the two patients from our institution. Articles were searched electronically from PubMed and Medline, using the terms ‘horseshoe kidney’ and ‘aneurysm’. Endovascular cases were reviewed from the world's literature. In addition to the two patients from our institution, there were 19 patients with infrarenal aneurysms and horseshoe kidneys in published literature who underwent successful endovascular aneurysm repair. The occlusion of lower-pole or accessory renal arteries does not seem to cause significant endoleak or renal impairment in the long run. In conclusion, our experience and current literature seem to suggest that endovascular repair of infrarenal aortic aneurysms for patients with horseshoe kidneys is safe. Renal impairment will depend on the area of kidney perfused by the accessory renal arteries. The endovascular treatment option is less invasive than open repair, and circumvents the problem of difficult exposure, especially in those patients with significant co-morbidity.

Abdominal aortic surgery and renal anomalies

Introduction. Kidney anomalies present a challenge even for the most experienced vascular surgeon in the reconstruction of the aortoilliac segment. The most significant anomalies described in the surgery of the aortoilliac segment are a horse-shoe and ectopic kidney. Objective. The aim of this retrospective study was to analyze experience on 40 patients with renal anomalies, who underwent surgery of the aortoilliac segment and to determine attitudes on conventional surgical treatment. Methods. In the period from 1992 to 2009, at the Clinic for Vascular Surgery of the Clinical Centre of Belgrade we operated on 40 patients with renal anomalies and aortic disease (aneurysmatic and obstructive). The retrospective analysis involved standard epidemiological data of each patient (gender, age, risk factors for atherosclerosis, type of anomaly, type of aortic disease, presurgical parameter values of renal function), type of surgical approach (laparatomy or retroperitoneal approach), classification of the renal isthmus, reimplantation of renal arteries and perioperative morbidity and mortality. Results. Twenty patients were males In 30 (70%) patients we diagnosed a horse-shoe kidney and in 10 (30%) ectopic kidney. In the cases of ruptured aneurysm of the abdominal aorta the diagnosis was made by ultrasound findings. Pre-surgically, renal anomalies were confirmed in all patients, except in those with a ruptured aneurysm who underwent urgent surgery. In all patients we applied medial laparatomy, except in those with a thoracoabdominal aneurysm type IV, when the retroperitonal approach was necessary. On average the patients were under follow-up for 6.2 years (from 6 months to 17 years). Conclusion. Under our conditions, the so-called double clamp technique with the preservation of the kidney gave best results in the patients with renal anomalies and aortic disease.

Abdominal aortic aneurysm surgery for octogenarians

PURPOSE

To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians.

METHODS

We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006.

RESULTS

Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B.

CONCLUSIONS

We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.