Segmental replacement to treat abdominal aortic aneurysm with bilateral accessory renal artery.

Enhanced abdominal computed tomography angiography of a 72-year-old man confirmed a large gourd-shaped abdominal aortic aneurysm (AAA) with a top and bottom diameter of 35 and 55 mm, respectively. The bilateral accessory renal arteries (ARAs), inferior mesenteric artery, and lumbar arteries arose from a constricted segment between the two parts of the aneurysm (A/Cover). The diameter of both the right and left ARAs was 4.5 mm. We planned open surgery for the AAA by reconstructing the ARAs through the transperitoneal approach to preserve renal function. Because the segment of the abdominal aorta from which the ARAs, inferior mesenteric artery, and lumbar arteries had arisen was not dilated, we preserved the aortic segment in a tube shape (B). That is, the top and bottom of the AAA were replaced with an I-shaped artificial graft and a bifurcated graft, respectively. All arterial anastomoses proceeded under simple clamping. Postoperative computed tomography angiography showed that all branches were patent (C). The patient was discharged on postoperative day 14 without complications.

The patient approved publication of his clinical case.

Discussion

The reported prevalence of bilateral ARAs is 5% to 10%.1, 2 To the best of our knowledge, there have been no reports of open surgical treatment for AAA with bilateral ARAs. There are some reports that ARA occlusion during endovascular abdominal aneurysm repair is not associated with deterioration of renal function.3, 4 On the other hand, ARA occlusion causes renal infarction and some degree of ischemic damage to the kidney parenchyma. For that reason, the ARA should be preserved if at all possible. Hosaka et al had the same opinion and reported an ARA preservation technique during endovascular therapy.

We considered several surgical approaches, for example, island technique or the individual reconstruction of arteries. However, because these branch arteries were close to the short segment of the abdominal aorta in our patient, we reconstructed them by preserving the aorta in a tube shape. We considered this to be the simplest strategy, and the outcome was successful. Although the preserved segment of the aorta was not dilated, future aneurysmal changes remain a concern. Therefore, this patient will be carefully followed up.