Endovascular reconstruction of aortoiliac occlusive disease in a case with claudication and an ectopic pelvic kidney.

INTRODUCTION AND IMPORTANCE: Ectopic kidney is a rare anomaly with an incidence of about 1 in 2500 birth in the population. Concurrency of pelvic kidney and iliac occlusion is rare, and the treatment is challenging because the pelvic kidney is associated with an atypical blood supply. CASE
PRESENTATION: We reported a 68-year-old man with aortoiliac stenosis, right pelvic kidney, and high-risk cardiovascular comorbidities. He presented with the right lower extremity claudication that has been present for four years. Computed tomography angiograms showed total occlusion of right common and external iliac arteries. CLINICAL DISCUSSION: The old method for treating iliac artery stenosis is open surgery, which needs cross-clamping of the aorta. During this procedure, the chance of renal thrombosis and ischemia is high. Thus, the patient underwent an endovascular angioplasty that was done successfully for the patient without any disturbances in kidney function.
CONCLUSION: Traditional treatment of iliac artery stenosis, especially in patients with high-risk cardiovascular comorbidities, may be associated with complications. Endovascular intervention is a safe and effective approach for treating aortoiliac occlusion in patients with ectopic pelvic kidneys. More research and case series are needed to review the results and compare the success rate of this method versus open surgery.

Introduction

An ectopic pelvic kidney is described as an atypically placed kidney in the pelvis caused by abnormal development during embryogenesis [1]. The incidence of the ectopic pelvic kidney is between 1 in 2200 and 1 in 3000 births in the population [2]. Most of the time, pelvic kidneys remain asymptomatic and are discovered incidentally in physical or radiological investigations [3]. However, it may cause significant symptoms like hypertension, urinary tract infections, or renal calculi [4]. Ectopic pelvic kidney coincident with the aortoiliac occlusive disease is rare [5].

A patient with iliac artery occlusion can present with a wide range of clinical symptoms, such as claudication and advanced symptoms of chronic ischemia like ulcers. Severe obstruction in blood flow leads to claudication [6]. In recent years, endovascular treatment has replaced traditional approaches like open surgery due to a lower chance of complication and excellent rates of success and effectiveness [7]. This case report presented an endovascular reconstruction in a patient with ectopic pelvic kidney and aortoiliac occlusion who had high-risk cardiovascular comorbidities. This case report has been reported in line with the SCARE 2020 Criteria [8].

Case presentation

A 68-year-old man with a history of diabetes and hypertension was admitted to the outpatient department of a tertiary educational hospital due to the right lower extremity claudication that has been present for four years. His symptoms have progressed recently and have been compulsively impaired his life quality during the last few months. His blood pressure was 130/80 mmHg. Blood urea and creatinine levels were 30 mg/dl, 1.28 mg/dl, respectively. The right femoral pulse was not detectable on physical examination, but the left femoral pulse was normal. Computed tomography angiography demonstrated an ectopic right pelvic kidney which had normal size, normal parenchyma, and no vascular pedicle, as well as complete right iliac occlusion from its bifurcation site (Fig. 1).

Fig. 1

Reconstruction of computed tomography angiogram demonstrating right pelvic kidney (arrow A) and full occlusion of right common iliac artery (arrow B).

An endovascular approach was planned for the patient due to his high-risk cardiovascular comorbidities. The method was explained to the patient, and he was prepared for the procedure after obtaining informed consent.

Under cardiac monitoring and local anesthesia after prepping and draping, the left femoral artery was cannulated, a 5-French Epsylar (OptiMed, Germany) angiographic sheath was inserted. Hydrophilic guide wire was extended to the aorta. The pigtail catheter was placed over the wire inside the aorta. Primary angiography was performed with a pigtail catheter, which showed total occlusion of the right common iliac artery from the origin (Fig. 2).

Fig. 2

Angiography showed severe right iliac artery occlusion.

Afterward, under sonography guide and local anesthesia, the right femoral artery was cannulated, and a 5-French sheath was inserted. After insertion of the sheath, using a JR catheter and a 300-cm long hydrophilic guide wire (Hi-Torque Command, Abbott, IL) we passed the right iliac artery occlusion and entered the aorta. Control angiography was performed. We made sure that the catheter was inside the aorta. Then we inserted the Supra Core (Abbott, IL) wires on both sides.

Through the wires, we opened the 8 mm * 59 mm balloon-expandable Omnilink Elite (Abbott, IL) stents on both sides using the kissing method. Control angiography showed total occlusion in the right external iliac artery, and then a 7 mm * 120 mm self-expanding EverFlex (Medtronic, MN) stent was inserted in the right external iliac artery (Fig. 3). In the final angiography (Fig. 4), the desired result was obtained. The process was terminated without any complications.

Fig. 3

Insertion of a balloon expandable stent into the right and left iliac artery by kissing stent technique.

Fig. 4

Final angiography shows revascularization of the common iliac artery and right external iliac artery after stent implantation.

Discussion

The ectopic kidney is a rare congenital anomaly that usually is asymptomatic, and the pelvic kidney is often accidently identified on radiographic findings [2]. The unusual shape of the pelvic kidney is often accompanied by vascular abnormalities [9]. In some cases, the pelvic kidney can cause complications such as high blood pressure due to pressure on the pelvic arteries. It can also lead to urinary tract infections due to improper placement. Moreover, it can also lead to kidney stones and colic pain. Sometimes, the pelvic kidney narrows the iliac arteries and impairs blood flow to the lower extremities [4].

In the old method and open surgery for bypass, we need to clamp the aorta. Since the ectopic kidney does not have a specific artery and can receive blood supply from the aorta or iliac artery, clamping the aorta during bypass increases the risk of thrombosis and impaired renal function [10]. Furthermore, during the aortic clamp, the risk of renal ischemia increases due to obstruction of the collateral arteries. Nevertheless, in the endovascular method, only the iliac artery is involved without the need for aortic clamping. So the risk of complication is very low. As mentioned in this case, we were able to perform successful angioplasty without causing any kidney dysfunction.

Traditional treatment of iliac artery stenosis, especially in patients with high-risk cardiovascular comorbidities, may be associated with complications [11]. Hence it is better to use less invasive methods such as angioplasty and endovascular approaches in these patients. Clinical outcomes in the angioplasty approach are admissible, and it has a lower risk of renal insufficiency and complication than open surgery [12]. Endovascular treatment should be considered a first-line approach for all patients with an aortoiliac disease, especially those with high-risk cardiovascular comorbidities, similar to our case [13]. Iliac artery endovascular reconstruction and stenting have been very popular, safe, and practical with acceptable long-term clinical outcomes. Nevertheless, in a recent report of a patient with an anomalous right pelvic kidney, right common iliac artery occlusion, and severe left common iliac artery stenosis for whom aortoiliac endarterectomy was conducted, Rushing et al. described aortoiliac endarterectomy not an outdated surgical technique but a reasonable alternative for revascularization in specific group of patients such as high-grade, focal lesions of the aortoiliac vessels and in the young female with small vessels [14].

In conclusion, endovascular intervention is a safe and effective approach for treating aortoiliac occlusion in patients with ectopic pelvic kidneys. More research and case series are needed to review the results and compare the success rate of this method versus open surgery.

Sources of funding for your research

None.

Ethical approval

The study is exempt from ethical approval in our institution.

Consent

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 on request.

Author contribution

All of the authors contributed in the case study, research, and writing of the manuscript.

Registration of research studies

This is not a First in Man study.

Guarantor

Dr. Javad Salimi Dr. Mahta Mirhashemi Dr. Seyed Amir Miratashi Yazdi.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

None.