HORSEHOE KIDNEY COMPLICATED BY ABDOMINAL AORTIC ANEURYSM

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.

The retroperitoneal approach to aortoiliac surgery associated with a horseshoe kidney: report of a case

The presence of a horseshoe kidney associated with aortoiliac vascular disease poses technical difficulties in terms of vascular reconstruction. The renal isthmus, position of the renal pelvis and ureters, and variable blood supply to the horseshoe kidney can complicate aortoiliac reconstruction. The left retroperitoneal approach provides excellent exposure of the abdominal aorta in patients with a horseshoe kidney without dividing the renal isthmus and avoids the risk of injury to a ureter in an anomalous position. We herein report the case of a patient with a horseshoe kidney who underwent a successful reconstruction of aortoiliac vascular disease using the left retroperitoneal approach.

Abdominal aortic surgery with concomitant congenital renal fusion

The association between aortic pathology and congenital renal fusion adds little morbidity or mortality to the natural history of either entity. Nevertheless, it complicates the management of aortic pathology, specifically degenerative atherosclerotic disease. The therapeutic goal is to resect the aneurysm or bypass the occlusive segment while preserving renal function. Important principles in the management of these difficult patients include accurate preoperative detection and characterization of the renal abnormality, complete familiarity with the likely anatomic variations associated with this anomaly, adequate exposure of the aortic lesion while preserving renal perfusion, and avoidance of injury to a frequently abnormally located collecting system. In this review we report two cases of abdominal aortic aneurysm associated with congenital renal fusion. The principles of management are thoroughly discussed, and guidelines aimed at facilitating decisions made during the clinical treatment of these difficult patients are suggested.

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

Based on the own experience and on an intesive study of the literature with a total of 52 patients with an aortic aneurysm and a horseshoe kidney the problems of operative treatment are discussed. The conclusion is made, that the treatment of this rare combination has its special difficulties in nearly 2/3 of all cases, but the same results as conventional surgery of aortic aneurysms, when the renal artery abnormalities are respected and treated with adequate vascular surgical skill.

Abdominal aneurysm and horseshoe kidney: a review

Two patients with aortic abdominal aneurysms in association with horseshoe kidney are presented, making a total of 34 cases recorded in the literature. In 29 patients, the aneurysm was resected and five patients were non-resectable. Because of the abnormalities in vascular supply to the abnormal kidney, it is important to diagnose the combination of aneurysm and horseshoe kidney preoperatively. An error in diagnosis should be unusual if an intravenous pyelogram is routinely obtained on all patients. This study may reveal abnormalities which will allow the diagnosis of horseshoe kidney to be made or suspected. If the intravenous pyelogram is abnormal, it should be followed by an aortogram. This may substantiate the diagnosis of aneurysm and horseshoe kidney and provide the necessary detailed information regarding the pattern of blood supply and its relationship to functioning tissue. The amount and disposition of functioning renal parenchyma may be further amplified by renal scan. If this sequence is followed, the unanticipated combination of abdominal aneurysm and horseshoe kidney should be rare.

Horseshoe kidney and abdominal aortic aneurysm

A case of horseshoe kidney and an abdominal aortic aneurysm is presented. The 32 previously described cases are reviewed and the diagnosis and management are discussed. The major factors influencing the operative approach to an aortic aneurysm associated with a horseshoe kidney concern the site of origin of the renal arteries, their number, and the portion of the kidney which each supplies.