Thirty-nine-year-old woman with a right renal artery aneurysm: Technique for open repair

Renal artery aneurysms (RAA) are rare with an incidence of 0.1% in the general population.1Coleman D.M. Stanely J. Renal Artery Aneurysms.J Vasc Surg. 2015; 62: 779-785Abstract Full Text Full Text PDF PubMed Google Scholar In patients without the ability to become pregnant, these should be repaired at a size ≥ 3.0 cm, due to a mortality risk of about 10% associated with rupture in these populations.2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72: 3S-39SAbstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar In females with the ability to become pregnant, these should be repaired at any size due to high rupture risk associated with the hormonal milieu of pregnancy. 2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72: 3S-39SAbstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar,3Altuwaijri T.A. Renal artery aneurysms in pregnancy-Management of an uncommon but serious vascular lesion.Semin Vasc Surg. 2020; 32: 106-110Crossref PubMed Scopus (3) Google Scholar RAA rupture in pregnant patients has been associated with a high maternal and fetal mortality risk.1Coleman D.M. Stanely J. Renal Artery Aneurysms.J Vasc Surg. 2015; 62: 779-785Abstract Full Text Full Text PDF PubMed Google Scholar,3Altuwaijri T.A. Renal artery aneurysms in pregnancy-Management of an uncommon but serious vascular lesion.Semin Vasc Surg. 2020; 32: 106-110Crossref PubMed Scopus (3) Google Scholar Although endovascular treatment of these aneurysms has become common, direct open surgical repair remains an important approach, particularly for lesions close to the renal hilum that may have multiple segmental branches to best preserve renal perfusion.4Jayet J. Davaine J.M. Tresson P. Verscheure D. Lawton J. Kashi M. et al.Direct Distal Renal Artery Aneurysm Repair.Eur J Vasc Endovasc Surg. 2020; 60: 211-218Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Written informed consent was provided by the patient for publication of this case. This case describes a 39-year-old female who was incidentally diagnosed with a 2.0 cm, right renal artery aneurysm. This was discovered on a computed tomography angiogram (CTA) obtained at the time of a spontaneous coronary artery dissection (SCAD), from which she recovered without any cardiac sequalae. There were no other signs or symptoms suggestive of a connective tissue disorder and she had not undergone genetic testing, though we were suspicious for a diagnosis of fibromuscular dysplasia based on her clinical history. She was pre-menopausal and otherwise healthy without any vascular surgical history and is a mother to five biological children. The patient had no symptoms and renal function was normal. Although the patient did not plan to have more children, given that she has the ability to become pregnant, we planned for operative intervention without further surveillance imaging. The aneurysm was located at the renal hilum with three branches of equal diameter originating from the aneurysm. Given the multiple branches from the aneurysm and proximity to the renal hilum, we proceeded with open repair aiming for aneurysm resection and primary repair. We were, however, prepared to harvest great saphenous vein if it was determined intraoperatively that this would be necessary for a bypass in the case that a primary repair was not feasible. Under general anesthesia, a right subcostal incision was made, the ascending colon and duodenum were retracted through a medial visceral rotation, and the right renal hilum was exposed. The right renal vein was dissected free. Dissection was carried along the right main renal artery towards the hilum where the aneurysm was identified along with three segmental branches. This dissection was tedious due to inflammation in the area, the proximity of the aneurysm to kidney parenchyma, and numerous adherent crossing veins. The main right renal artery and each segmental branch were fully skeletonized and controlled with silastic vessel loops. The patient was then fully heparinized. The main right renal artery was controlled using a Kirchner clamp and each segmental renal artery was controlled with a Sugita clamp. The aneurysm was opened along its length, a portion of the anterior aneurysm wall was resected, and a common wall was maintained between the three branches. Upon opening the aneurysm, it was clear that all three branches were feeding off the aneurysm, with one branch being very posterior. Primary arterial reconstruction was performed using running 5-0 Prolene suture, with all branches incorporated into the suture line for optimal renal perfusion. Appropriate fore and back bleeding were allowed, and the anastomosis was found to be hemostatic. The patient was transferred to the Vascular Surgery floor post-operatively, and was dismissed home on post-operative day 2 with normal renal function. She is maintained on a daily baby aspirin for anti-platelet and repair maintenance. . Final pathology from the aneurysm demonstrated end-stage vascular remodeling, and could not definitely assess for fibromuscular dysplasia, though we are still suspicious for this based on her clinical history. Post-operative three-month follow-up CTA demonstrated patent reconstruction, and she continues to have normal renal function post-operatively. Moving forward, we will obtain an annual CTA of the abdomen and pelvis for surveillance. Renal artery aneurysms are a rare pathology that are often asymptomatic and incidentally discovered. However, timely repair is necessary, particularly in women with the ability to become pregnant, who face significant potential morbidity and mortality with rupture. In cases of complex renal artery aneurysms such as this, open repair with preservation of all segmental branches can optimize renal perfusion.