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Objective: Repair of abdominal aortic aneurysms in the presence of horseshoe kidney (HSK-AAA) can be technically challenging due to the variable renal arterial blood supply and proportional perfusion of accessory renal arteries. Partial cardiopulmonary bypass can be used in open repair to maintain renal perfusion during revascularization. Endovascular repair may require selective coiling of large (>3mm) accessory renal arteries to prevent type II endoleaks. We herein present a contemporary case series of 4 patients with AAA-HSK: 3 undergoing EVAR and 1 undergoing open repair.
Methods: Patient 1 had a HSK-AAA supplied by 2 renal arteries originating from the aortic bifurcation. After infusion of 22,000 units of heparin, a partial right femoral artery-to-vein cardiopulmonary bypass for retrograde perfusion of hypothermic blood was utilized for open repair with a 20 mm Dacron tube graft. Endovascular repair included pre-operative coil embolization of a 3 mm accessory renal artery feeding the lower poles and renal isthmus, the AAA was treated with a bifurcated prosthesis (W.L. Gore & Associates, Flagstaff, AZ) Patient 2. Patient 3 and 4 had accessory renal arteries both less than 3 mm which were covered with a unibody bifurcated prosthesis with an aortic cuff (AFX, Endologix Inc., Irvine CA).
Results: All 4 patients tolerated the procedures well. There were no endoleaks on completion imaging. There were no post-operative complications. Serial post-operative imaging with CTA confirmed successful repair without endoleak or aneurysm expansion. Two-year longitudinal follow-up demonstrated no change in renal function for patients treated with EVAR. Utilization of the partial cardiopulmonary circuit resulted in no change in renal function.
Conclusions: This contemporary series re-affirms that HSK-AAA can be safely treated by EVAR or operative repair. A partial cardiopulmonary bypass circuit can maintain renal perfusion during operative repair. Logistical concerns include higher heparin doses and potential bleeding. Endovascular repair of HSK-AAA may require coverage of non-dominant arteries < 3 mm and coil embolization of larger accessory renal arteries to mitigate type II endoleaks. Precise pre-operative knowledge of the anomalous renal perfusion is requisite for successful planning and treatment of HSK-AAA.

AAA-HSK Repair: Operative with Partial Cardiopulmonary Bypass and EVAR

Age/Gender	Creatinine (preop/postop)	Aneurysm Size	Arterial Supply of HSK	Accessory Renal Arteries	Perioperative Adjuncts	Type of Repair
72M	0.8/1.0	5.8cm infrarenal AAA	2 left and 3 right main renal arteries	Two small accessory right and left renal arteries	None	Endovascular; unibody bifurcated Endologix stent graft
75M	1.5/1.5	6.4cm infrarenal AAA	1 right and 1 left main renal artery	Three >3mm, 1 right and 2 left accessory renal arteries	Coil embolization of three accessory renal arteries	Endovascular; unibody bifurcated prosthesis (Gore Excluder)
62M	1.0/1.1	5.8cm infrarenal AAA	1 right and 1 left main renal artery	Two small accessory right and left renal arteries	None	Endovascular; unibody bifurcated Endologix stent graft with suprarenal extension
64M	1.0/1.0	5.4cm infrarenal AAA	Right and left renal arteries originating from aortic bifurcation	None	Intraoperative partial cardiopulmonary bypass with ostial hypothermic infusion of cold blood	20mm dacron tube graft; Atrium Hemashield Gold