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A double shunt technique for the prevention of ischaemia of a congenital, solitary, pelvic kidney during abdominal aortic aneurysm repair: a case report
© Makris et al; licensee BioMed Central Ltd. 2011
Received: 21 October 2009
Accepted: 6 March 2011
Published: 6 March 2011
Congenital solitary pelvic kidney is a rare condition, and its association with an abdominal aortic aneurysm is even more unusual. To the best of our knowledge, only two such cases have been reported in the literature to date.
We report the case of a 59-year-old Caucasian man with a congenital solitary pelvic kidney, who was found to have an abdominal aortic aneurysm 83 mm in diameter. Abdominal computed tomography angiography clearly identified two renal arteries, one originating from the aortic bifurcation. and the other from the proximal portion of the right common iliac artery. At surgery, renal ischaemia was prevented by introduction of an axillofemoral shunt (consisting of two femoral cannulas and a vent tube of extracorporeal circulation) from the right axillary to the right femoral artery, and a second Argyle shunt from the right common iliac artery to the origin of the left renal artery. A 20 mm Dacron tube graft was then implanted. Our patient's postoperative renal function was normal.
The renal preservation double shunt technique used in this case seems to be effective during abdominal aortic aneurysm repair.
Congenital solitary pelvic kidney (CSPK) has been reported to be present in 1 in 22,000 post-mortem examinations . The combination of this rare renal anomaly with an abdominal aortic aneurysm (AAA) poses a therapeutic challenge because, by definition, suprarenal aortic clamping is always mandatory in these cases. Therefore, patients with these concomitant disorders are at high risk of developing renal ischaemia during conventional open repair of their aneurysm. We describe and comment on our experience of managing a case with this dual pathology.
A 59-year-old Caucasian man was referred to our vascular department with a pulsatile abdominal mass around the umbilicus. He had a known history of a solitary pelvic kidney. This congenital anomaly had been diagnosed during evaluation of recurrent urinary tract infections 10 years previously.
The combination of a CSPK with an AAA is exceedingly rare. Several maneuvers have been proposed to maintain blood flow to solitary, ectopic or transplanted pelvic kidneys during aortic cross-clamping. Axillofemoral [2, 3] or temporary abdominal in-line (Gott) [2, 4] shunts are considered an excellent solution, but their placement can be difficult and time-consuming. The double proximal clamping technique, as described by Lacombe  and modified by Hollis , represents an effective alternative, as groin incisions are avoided. However, it requires adequate patent lumbar circulation, and manipulation of the aneurysmal sac could potentially lead to distal embolization.
To the best of our knowledge, this is only the third publication in the literature describing the management of CSPK with AAA. Kaplan et al. first presented a patient with a single renal artery arising from the right common iliac artery . The AAA was successfully repaired endoluminally with a tube stent graft, and no further attempt of preservation of renal blood flow was made. However, tube endografts are nowadays considered obsolete and have been abandoned since the early 1990 s. However, fixation of a second-generation stent graft usually necessitates the sacrifice of aberrant or accessory renal arteries originating from the aneurysmal sac or most commonly, from the iliac vessels, and therefore, minimal invasive endovascular repair cannot be used in patients with CPSK. In our case, it was obvious that the placement of the limb of a bifurcated graft or the contralateral occluder of an aortic-unifemoral device would result in disastrous renal infarction and subsequent functional impairment.
Murakami et al also reported a 77-year-old patient with an AAA associated with a CSPK, which was supplied by two aberrant renal arteries , one originating from the aortic wall just above the aortic bifurcation, and the other from the left common iliac artery. The aneurysm was repaired by interposition of a tube graft. Renal preservation during aortic cross-clamping was achieved by a combination of in situ cold perfusion and topical ice slush. Their patient's creatinine values did not show any significant elevation at the time of discharge. Although cooling techniques and in situ hypothermic perfusion should prevent renal ischaemia for more than an hour , we felt that shunting offered the best protection for our patient.
In conclusion, the presence of CSPK in conjunction with AAA significantly complicates aortic reconstructive surgery, and demands careful planning. The optimal operative management and the appropriate method of preservation of renal blood supply must be selected individually, based on anatomic considerations and the surgeon's opinion. A variety of protective techniques, including shunting, cooling and passive use of collaterals have been used to prevent intra-operative renal ischaemia. The double shunt technique described above can be safely accomplished with favorable results.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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