Abdominal Aortic Aneurysm With Horseshoe Kidney, A Vascular Dilemma
S Christopher Frontario, DO, Nakul Rao, MD, Thomas Bernik, MD.
Englewood Health, Englewood, NJ, USA.
DEMOGRAPHICS: 62-year-old morbidly obese African American male with history of severe obstructive sleep apnea and CVA with aphasia, was referred for evaluation. HISTORY: CT Angiography demonstrated 5.6cm infrarenal AAA with concomitant bilateral iliac artery aneurysms and central horseshoe kidney with aberrant vasculature (Figure 1: A-C). Given the complexity of the vascular pathology, the patient’s body habitus, the location of the solitary kidney in relation to the aneurysm, additional diagnostic imaging was performed for optimal pre-operative planning. Split renal function testing resulted in near even distribution of renal function. Diagnostic aortogram with selective renal angiography was performed via radial access. This demonstrated 20% right and left renal artery peripheral perfusion (Figure 1: D, E respectfully) and a dominant short anterior renal artery trunk supplying the central 50% of renal parenchyma (Figure 1: F). PLAN: Multiple operative strategies were explored along with all potential and associated pitfalls. These included open repair via transabdominal and retroperitoneal approach. A hybrid option was constructed with open retrograde visceral bypass followed by endograft placement. Endovascular possibilities included a fenestrated endograft, anterior renal trunk snorkel, iliac extension with flared limbs, coiling the hypogastric with extension into external iliac, and use of iliac branch endoprosthesis. Ultimately, an endovascular option was implemented with anterior renal artery snorkel through brachial cutdown, bifurcated aortic graft, iliac extension limbs, bilateral flared iliac limbs, and aortic extension cuff (Figure 1: G, H). Angiography confirmed what appeared to be a delayed type II endoleak versus gutter leak which fully resolved a week after discharge. DISCUSSION: Abdominal Aortic aneurysms in the setting of horseshoe kidney are a rare and complex aortic pathology. The need for methodical planning ensuring aneurysm exclusion, while preserving renal function, and minimizing morbidity and mortality is essential. In the elective setting, open, hybrid, and endovascular repairs are all feasible options, each with inherent advantages and disadvantages. Due to the patient’s severe comorbidities and morbid obesity, we chose what seemed like the most reasonable endovascular repair with central renal snorkel despite the patient’s you age. 
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