Case Report
Different Surgical Approach to Sacculer Renal Artery Aneurysm: Case Report
Haydar Yasa1* and Füruzan Aktuğ2
1Department of Cardiovascular Surgery, Batı Anadolu Central Hospital, Turkey
2Department of Anestesiology, Batı Anadolu Central Hospital Anestesiology and Reanimation Clinic, Turkey
*Corresponding author: Haydar Yasa, Department of Cardiovascular Surgery, Batı Anadolu Central Hospital Bayraklı-İzmir, Turkey
Published: 12 Jun, 2017
Cite this article as: Yasa H, Aktuğ F. Different Surgical
Approach to Sacculer Renal Artery
Aneurysm: Case Report. Clin Surg.
2017; 2: 1503.
Abstract
Renal artery aneurysms are rare and are often detected incidentally in examinations for different
purposes. Fifty-six -year-old female patient , intraarterial digital substracting saccular in 25 mm
× 20 mm originating from the renal artery angiography revealed the presence of an aneurysm.
Midline aneurysm was excised by laparotomy. Saphena 2 cm × 2 cm patch and 6.0 prolene form
over and over was implanted with sewing technique. Cross - clamp time was 13 minutes. Successful
surgical correction is possible with almost complete intervention. The repair technique was safe
with patchplasty. We believe that a successful alternative surgical option of saphneouse ptachplasty
technigue.
Keywords: Artery; Aneurysm; Surgery; Saphena; Patchplasty
Figure 1
Figure 2
Introduction
Renal artery aneurysms are rare balloons that appear incidentally in the arterial wall, which are rarely seen in studies to make it complicated. Prevalence is reported between 0 and 1% l for different studies [1]. Renal artery is defined as an aneurysm when the diameter of the renal artery segment is greater than 50% of its normal diameter. Renal artery aneurysm may occur with symptoms related to hypertension, pain, hematuria and parenchymal renal infarction. Although the prognosis of patients with asymptomatic disease is better, the risk of rupture and fistula increases with increasing diameter. In this study, we aimed to discuss treatment approaches by reviewing successful surgical repair of renal artery aneurysm and renal artery aneurysm in a 56-year-old woman who was diagnosed with hypertension.
Case Presentation
A 56-year-old female patient was referred to our center for surgical treatment after detection of
hypertension etiology and a 25 mm × 20 mm anastomosis originating from the right renal artery
was detected in the abdominal ultrasonography and renal angiography. There was no feature in
the story. Laboratory examinations included full blood count, biochemistry, and urinalysis.
Abdominopelvic ultrasonography revealed a 23 mm × 17 mm × 14 mm hypoechoic lesion in the
right renal hilus posterior to the renal vein. In examining color renal doppler; Right kidney long axis
was 96 mm, left kidney 96 mm, parenchymal thicknesses were calculated as 13 mm on the right and
14 mm on the left.
Both renal parenchyma echoes were naturally detected. Anechoic cystic structure with peripheral
calcification of approximately 23 mm × 17 mm was observed in the right renal sinus at the middle
kidney. Doppler is in review; It was observed that there was current in the cognitive structure. The
findings were thought to be compatible with segmental renal artery aneurysm. Flows from both
renal arteries had Early Systolic Peak (ESP). The index of renal intrarenal arterial Resis- Tivity (RI)
was 0.58 on the right and 0.61 on the left. The main renal artery velocities were within normal limits
at the exit site ofthe aorta. Intraarterial Digital Substracting Angiography (DSA) revealed a 25 mm ×
20 mm size aneurysm originating from the renal artery (Figure 1). Surgical treatment decision was
made because of the symptomatic nature of the patient and the size of the lesion.
Median laparotomy was performed under general anesthesia, and transperitoneal approach
was reached in the right renal hilus and surgical dissection was performed. The right aneurysmatic
segment originating from the right renal artery was uncovered and suspended proximal and distal
(Figure 2). A 2 cm long safen ven graft was prepared at the same time in the right lower extremity.
Separated from the middle, the patch was made. Vascular clamps
were placed 3 minutes after intravenous administration of 5000 iu
conventional heparin. The kidney was topically cooled with ice water.
The aneurysm was excised. Safen 2 cm × 2 cm patch graft 6.0 was
implanted with over-and-over stitch technique (Figure 3). Clamp was
removed after air removal. The cross-clamp time was calculated as 13
minutes. After the bleeding control, one abdominal drain was placed
and closed according to the anatomy of the folds and the operation
was terminated. One day, intensive care follow-up was performed
and discharged on postoperative day 5. Follow-up and treatment are
continuing smoothly at the third month of follow-up.
Discussion
Renal artery aneurysms constitute 22% of visceral aneurysms [2].
The prevalence in the general population is reported to be 0,1%-1%
[1]. Anatomically classified as saccular, fusiform, dissec- taneous
and mixed, 70%, 22.5% and 12% of cases with subacute, fusiform
and dissecting aneurysms generally, the age of detection is 46±18
years, men and women are equally affected and the aneurysm is most
commonly located in the main renal artery.
Men and women are equally affected and the aneurysm is most
commonly located in the main renal artery. It most commonly occurs
due to fibromuscular dysplasia and atherosclerosis [3]".
There are no pathognomonic symptoms and signs associated with
renal artery aneurysm. The most common finding in symptomatic
patients is hypertension (30%), flank pain (11%) and headache due to
hypertension (11%) as well as asymptomatic patients [2].
It is suggested that hypertension is due to renal ischemia
(microinfarcts originating from distal embolization, folding or
compression of the renal artery) [4]". Abdominal murmur may be
helpful in diagnosis and may be detected in about 10% of patients." 5.
Hematuria may be microscopic or macroscopic. In fact, the murmur
was not detected in this case, which was obese, and hematuria was
not detected.
Etheiology is responsible for atreosclerosis, fibrodysplastic
diseases. Secondary renal artery aneurysm; [3,4]". In our present case,
the present findings (female patient, lack of significant hypertension,
renal (renal), hypertension, hypertension, hypertension, diabetic
retinopathy, Arterial appearance, location of the aneurysm) was not
considered fibrodysplasia, but atherosclerosis was considered as the
underlying etiology.
The definitive diagnosis is to show the lesion by angiography.
Peripheral dissection, thrombosis, renal infarction, hemorrhage, and
rupture are potential complications of renal artery aneurysms [5]".
We believe that hypertensive cases should be investigated by doppler
ultrasonography for renal artery disease.
Presence of hypertension, diameter greater than 2 cm, increase in
pregnancy and progressive diameter increase rupture risk 2. There is
no consensus on the indications for surgery in publications related to
aneurysm size. Researchers who reported that operations should be
performed on lesions larger than 1-1.5 cm or 2.5 cm. However, the
risk of rupture in aneurysms smaller than 1 cm in diameter is low and
operation is not recommended [2,5]".
In addition, there are opinions that asymptomatic cases can
be seen conservatively regardless of the aneurysm size1. Surgical
indications for symptomatic and/or diameter of the aneurysm
as >2 cm, renal infarct and/or uncontrolled hypertension, or
accompanying pregnancy and growth aneurysms should be treated
as surgical indications 3,6. Surgical treatment indications are the
most controversial diameter of the aneurysm. Some studies report
rupture of aneurysms of diameter less than 2 cm, but other studies
have indicated that surgical treatment is not required for aneurysms
of this diameter [2] other major surgical indications for aneurysm
rupture and surrounding tissue erosion are [1,4,5]".
Resection and primary repair for repair, end-to-end anastomosis,
ven graft, arterial aortic reimplantation, synthetic graft and splenorenal
anastomosis are surgical methods. In this study, aneurysm resection
and patchplasty with vena safena magna were performed. We believe
that it is possible to complete the shorter cross-clamping process
with Safen patchplasty repair technique. It also has the advantages
of autogenous grafts, lower thrombogenic activity, less bleeding
problems and more economic benefits. We believe that closure of the
primaries in the cases may be helpful in avoiding the risk of stenosis
of the renal artery, the increase in blood flow velocity and the risk of
progressive renal parenchyma damage and hypertension.
We also believe that topical hypothermia can reduce renalparenchyma damage and provide good protection against possible
prolonged cross-clamp times.
Although surgical repair is usually preferred, percutaneous
interventional methods have been reported to be successful [5-7].
In cases of high risk for operation, percutaneous treatment options
include balloon coiling or onyx embolization, stent coiling with
stents, Embolization and alcohol injection into the aneurysm [3,5,6]".
In our case, an aneurysm was located distal to the renal artery and
branching zone, so endovascular intervention was not appropriate
and surgical treatment was preferred. Collateral branches should not
be obliterated in endovascular procedures.
Figure 3
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