Abdominal aortic surgery in the presence of a horseshoe kidney

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.

Surgical treatment of abdominal aortic aneurysm in association with horseshoe kidney. Three case reports and a review of technique

Horseshoe kidney is a rare congenital anomaly that can create various technical problems during surgery for repair of abdominal aortic aneurysm. The diagnosis of this anomaly should be confirmed preoperatively in order to plan surgical strategy. Nowadays, in more than 90% of all cases, ultrasonography, contrast computerized tomography, urography, and angiography are the best instrumental methods of detecting this anomaly in association with abdominal aortic aneurysm. The transperitoneal approach assures the best exposure of the kidney, the ureters, the aneurysm, and both iliac vessels, but the renal isthmus can pose a problem in reimplanting aberrant renal arteries. When it is known preoperatively that renal revascularization should be performed, the left extraperitoneal approach is a better choice. In any event, the coexistence of horseshoe kidney and abdominal aortic aneurysm does not preclude the treatment of the latter. In elective surgery of abdominal aortic aneurysm, the morbidity and mortality rates in the presence of horseshoe kidney are much the same as those in the presence of normal kidneys. The best results in this kind of surgery are obtained by adapting one's surgical technique to each anatomical variant that is encountered.