Tadros Rami O, Malik Rajesh K, Ellozy Sharif H, Marin Michael L, Faries Peter L, Vouyouka Ageliki G
Division of Vascular Surgery, The Mount Sinai Medical Center, New York, NY 10029, USA.
Ann Vasc Surg. 2011 Oct;25(7):984.e9-14. doi: 10.1016/j.avsg.2011.05.016. Epub 2011 Aug 10.
Crossed-fused renal ectopia is a rare anomaly that poses a therapeutic challenge in the management of abdominal aortic aneurysms (AAAs). Such challenges include preservation of renal blood flow in the setting of multiple aberrant renal arteries and ureteral anomalies. Several surgical approaches to this dilemma, including the use of traditional surgical techniques, have been described in the literature. We describe a novel approach to the management of a 7-cm inflammatory AAA associated with crossed renal ectopia with fusion.
During routine surveillance computed tomography angiography (CTA) in a 63-year-old man, a rapidly enlarging AAA with new inflammatory changes was detected. The aneurysm had increased in size from 4.8 to 7 cm over a period of 6 months. At the time of presentation, he was found to be hemodynamically stable. Findings from the laboratory tests conducted at the time of admission were normal, with a baseline glomerular filtration rate of 91.2 mL/min and creatinine of 1. The CTA revealed significant thickening of the aortic wall, suggestive of aortic inflammation, the presence of crossed renal ectopia with fusion, and numerous anomalous renal arteries. We identified two right renal arteries arising from the proximal aneurysm sac and three left renal arteries arising from the common iliac arteries. Given the aortic inflammation, an open repair approach was considered high risk compared with an endovascular aneurysm repair (EVAR). However, given the uncharacteristic arterial anatomy, a staged surgical and endovascular management option was selected. We performed an aortic debranching and renal artery revascularization, followed by an EVAR.
We preserved renal function and excluded the aneurysm. The patient was discharged on the postoperative day 6 without periprocedural complications. A CTA was performed at 1- and 6-month follow-up period. This revealed a type 2 endoleak, which was confirmed by MR angiography. However, the aneurysm diameter had decreased in size from 7 to 6.3 cm in 1 month, and from 6.3 to 5.5 cm in 6 months. No further intervention was performed.
Inflammatory AAAs associated with crossed-fused renal ectopia can be successfully managed with aortic debranching and renal artery revascularization followed by an EVAR. This epitomizes the growing role for advanced endovascular therapies in conjunction with open surgical techniques.
交叉融合型肾异位是一种罕见的异常情况，在腹主动脉瘤（AAA）的治疗中带来了挑战。这些挑战包括在存在多条异常肾动脉和输尿管异常的情况下保留肾血流。文献中描述了几种应对这一困境的手术方法，包括使用传统手术技术。我们描述了一种治疗与交叉融合型肾异位相关的7厘米炎性AAA的新方法。
在对一名63岁男性进行常规监测计算机断层扫描血管造影（CTA）时，发现一个快速增大且有新炎性改变的AAA。该动脉瘤在6个月内从4.8厘米增大到了7厘米。就诊时，发现他血流动力学稳定。入院时进行的实验室检查结果正常，基线肾小球滤过率为91.2毫升/分钟，肌酐为1。CTA显示主动脉壁明显增厚，提示主动脉炎症，存在交叉融合型肾异位，以及众多异常肾动脉。我们发现两条右肾动脉起源于近端动脉瘤囊，三条左肾动脉起源于髂总动脉。鉴于主动脉炎症，与血管腔内动脉瘤修复术（EVAR）相比，开放修复方法被认为风险较高。然而，鉴于动脉解剖结构不典型，选择了分期手术和血管腔内治疗方案。我们先进行了主动脉去分支和肾动脉血运重建，然后进行了EVAR。
我们保留了肾功能并排除了动脉瘤。患者术后第6天出院，无围手术期并发症。在术后1个月和6个月进行了CTA检查。结果显示存在2型内漏，磁共振血管造影证实了这一点。然而，动脉瘤直径在1个月内从7厘米减小到了6.3厘米，在6个月内从6.3厘米减小到了5.�厘米。未进行进一步干预。
与交叉融合型肾异位相关的炎性AAA可通过主动脉去分支和肾动脉血运重建，随后进行EVAR成功治疗。这体现了先进的血管腔内治疗与开放手术技术相结合日益增长的作用。
