A Novel Surgical Approach to Symptomatic Left Renal Vein Aneurysm
Anthony Rios, M.D., Pouria Parsa, John Eidt, Gregory Pearl, M.D..
Baylor University Medical Center, Dallas, TX, USA.
Objectives: Visceral venous aneurysms are extremely uncommon and renal vein aneurysms are among the rarest in this subset. Renal venous aneurysms are frequently asymptomatic, but patients may present with flank pain or hematuria. Treatment ranges from watchful waiting to surgical repair. We describe a patient with renal vein aneurysm presenting with recurrent pulmonary embolism with no other identifiable source and propose a novel surgical option for its repair by transposing the inferior mesenteric vein to the left renal vein thereby draining the left kidney to the portal system. Methods: We describe a 23 year old female with history of submassive pulmonary embolus presenting with recurrent pulmonary emboli. Duplex ultrasonography and computed tomography revealed a 9 x 2.4cm bi-lobed aneurysm originating from the left renal vein. Venography revealed no arteriovenous fistula. The patient underwent elective resection. The surgery was completed through an upper midline incision with exposure of the inferior vena cava and the left renal vein and tributaries (Figure 1). The inferior mesenteric vein was mobilized to its confluence with the splenic vein. The left renal vein was entered and incision was carried down the aneurysm extending toward the ovarian vein. Thrombus was noted within. The left renal vein was transected at the inferior vena cava, the ovarian vein was ligated distally and the aneurysm was removed. The inferior mesenteric vein was transposed to the remaining distal portion of the left renal vein using a 6-0 Prolene suture (Figure 2). Results: The patient recovered well and the left renal vein remained patent on follow up imaging. Conclusions: Renal vein aneurysms are exceedingly rare, as is the presentation of submassive pulmonary embolism resulting from such. In the setting of recurrent pulmonary embolism when lower extremity deep venous thrombosis is not present, visceral venous aneurysms should be considered. In addition, we introduce a novel solution to draining the left kidney utilizing an inferior mesenteric vein transposition. This bypass has remained patent and the patient has remained symptom-free.
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