Renal autotransplantation to treat renal artery aneurysm: case report

CONTEXT: Renal artery aneurysm (RAA) is uncommon and usually asymptomatic, but complications like rupture or thromboembolism of the aneurysm can occur, with consequent renal infarction. Most of the clinical findings are found incidentally through imaging examinations, in investigating other diseases. Renal autotransplantation (RAT) is an alternative treatment for complex RAA, with satisfactory results described in the literature.CASE REPORT: The patient was a 48-year-old man with a history of systemic arterial hypertension, thrombocytopenia and advanced hepatosplenic schistosomiasis. He complained of right lumbar pain, which was investigated through imaging examinations (computed tomography and angiotomography). These revealed right RAA of 2.5 cm in diameter. Evaluation by the vascular surgery team found that this was untreatable using endovascular methods. The treatment performed was open right nephrectomy with kidney preservation in solution, followed by aneurysmectomy, suturing of the injured artery and kidney reimplantation in the right iliac fossa with anastomosis of the iliac vessels and ureter. The durations of the surgery and kidney ischemia were 385 and 140 minutes, respectively. The patient was discharged on the 20th postoperative day, with creatinine concentration of 1.4 mg/dL, urea 41 mg/dL, urine volume 1400 mL/24 h and ascites treated with diuretics.CONCLUSION: RAT is indicated basically in three situations: extracorporeal reconstruction of complex aneurysms of the renal pedicle, extensive ureteral injury, and conservative kidney cancer surgery in patients with a single kidney. This study presents a case of a patient with advanced liver disease and RAA that was untreatable using endovascular methods and was successfully treated using RAT.

背景：肾动脉瘤（Renal Artery Aneurysm, RAA）较为少见，通常无明显临床症状，但可能出现动脉瘤破裂或血栓栓塞等并发症，进而引发肾梗死。多数患者的临床表现在排查其他疾病时，经影像学检查偶然发现。肾自体移植（Renal Autotransplantation, RAT）是复杂性肾动脉瘤的可选治疗方案，相关文献报道其疗效令人满意。
病例报告：患者为48岁男性，有系统性动脉高血压、血小板减少症及晚期肝脾型血吸虫病病史。患者因右侧腰痛就诊，遂行影像学检查（计算机断层扫描（computed tomography）与血管造影CT（angiotomography）），结果提示直径2.5cm的右侧肾动脉瘤。血管外科团队评估后认为，该病例无法通过血管内介入方法治疗。最终实施的治疗方案为：开放式右肾切除并离体保存肾脏，随后行动脉瘤切除术、受损动脉缝合术，再将肾脏重新植入右侧髂窝，并行髂血管与输尿管吻合术。手术总时长及肾脏缺血时长分别为385分钟与140分钟。患者于术后第20日出院，出院时肌酐浓度为1.4mg/dL，尿素为41mg/dL，24小时尿量1400mL，腹水经利尿剂治疗得到控制。
结论：肾自体移植的适应证主要包括三类：肾蒂复杂性动脉瘤的体外重建、广泛输尿管损伤，以及孤立肾患者的肾癌保守手术。本研究报道了1例合并晚期肝病、无法通过血管内介入方法治疗的肾动脉瘤患者，经肾自体移植治疗后获得成功。