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Objectives
Despite improvements in endovascular technology, abdominal
aortic aneurysms (AAA) associated with horseshoe kidneys continue to present challenging anatomy. This report describes a case of an elderly man with a peri-renal horseshoe kidney whose AAA was successfully treated and renal function preserved.
Methods
An 83 year old man with severe emphysema and hypertension presented with a symptomatic 7.1 centimeter AAA and acute renal insufficiency. A CT additionally demonstrated a 6.4 centimeter right iliac artery aneurysm, a 2.6 centimeter left common femoral artery (CFA) aneurysm and a horseshoe kidney whose right renal artery originated from the aneurysm.
Given the severity of his pulmonary disease, risk of embolization to his renal arteries, and difficulty cross-clamping the aorta with the horseshoe kidney, the decision was to perform an EVAR with preservation of his right renal artery.
The left CFA aneurysm was excised and replaced with a dacron graft, and an Endurant (Medtronic, Minneapolis, MN) main body deployed. An occlusion plug was used to convert the endograft into an aortouniiliac system. The right renal artery was then serially stented with two iCAST (Atrium Medical Corp., Hudson, NH) stents, a Viabahn (Gore Medical, Flagstaff, AZ) stent, and two Endurant limb extensions into the distal left common iliac artery. A femoral-femoral bypass was then performed to provide left leg perfusion.
Results
Completion angiography demonstrated straight-line flow from the aorta to the right iliac limb, across the femoral-femoral bypass with perfusion of the right renal artery via retrograde filling of the left common iliac artery. Follow-up CT at 2 weeks demonstrated filling of the right renal artery and entirety of the horseshoe kidney. His creatinine remained 0.9 post-operatively.
Conclusions
Patients presenting with both AAA and horseshoe kidneys are rare. This patient presented with the challenging anatomy of not only a horseshoe kidney, but with a peri-renal AAA. Options included either reimplantation or ligation of the right renal artery, but would have necessitated an open surgery or worsened renal failure in this patient. The complex aneurysm repair chosen demonstrates an alternative method, allowing for preservation of the perfusion and function of his horseshoe kidney.