Prise en charge des artères rénales accessoires au cours du traitement d’anévrisme de l’aorte abdominale chez un patient en insuffisance rénale terminale

25 avril 2020

Auteurs : F. Lareyre, M. Carlier, J. Raffort
Référence : Prog Urol, 2020, 5, 30, 296-297




 



The prevalence of accessory renal arteries has been estimated between 12 to 25% of patients [1]. This anatomic variation can challenge the management of abdominal aortic aneurysm (AAA) repair and its coverage can impact on renal function [1, 2]. Here, we report the case of an 80-year-old man who was admitted for an asymptomatic aortic aneurysm. His past medical history included an end-stage renal failure. CT-scan revealed a maximal aneurysm diameter of 55mm and the aneurysm included multiple accessory renal arteries (Figure 1). The presence of accessory renal arteries within the AAA arose the question whether it should be preserved or not during aneurysm surgical repair. The Society of Vascular Surgery Consensus statement for the treatment of accessory renal artery currently recommends preservation and re-implantation of accessory renal artery of 3mm or greater or those that supply one-third or more of the renal parenchyma [3]. The results of a systematic literature review on the post-operative outcomes after accessory renal artery coverage also revealed that accessory renal arteries less than 3-4mm can be excluded safely during aneurysm repair [1]. In case of accessory renal arteries superior to 3-4mm or supplying one-third or more of the renal parenchyma, the balance between the risk and the benefits of accessory renal artery coverage versus preservation should be evaluated taking into account the patients clinical and anatomic characteristics [1]. After pluridisciplinary concertation and given the context of end-stage renal failure, the decision was taken to create hemodialysis access and to plan an endovascular aneurysm repair (EVAR) with exclusion of the polar renal arteries located within the aneurysm (yellow arrows) and a preservation of renal arteries located above the aneurysm (orange arrows).


Figure 1
Figure 1. 

3D-reconstruction from CT-scan showing AAA with multiple accessory renal arteries




The postoperative period after EVAR was associated with a worsening of the renal function. The creatinine concentration was 335μmol/L the day before the intervention and increased to 399μmol/L the day after and was 704μmol/L at day 14. The estimated glomerular filtration rate calculated according to the CKD-EPI formula was 14mL/min/1.73m2 before the intervention and decreased to 11 and 6mL/min/1.73m2 at day 1 and day 14 postoperatively. The patient then required hemodialysis.


Funding


None.


Disclosure of interest


The authors declare that they have no competing interest.



References



Lareyre F., Panthier F., Jean-Baptiste E., Hassen-Khodja R., Raffort J. Coverage of accessory renal arteries during endovascular aortic aneurysm repair: what are the consequences and the implications for clinical practice? Angiology 2019 ;  70 (1) : 12-19 [cross-ref]
Lareyre F., Mialhe C., Dommerc C., Raffort J. Management of accessory renal artery during abdominal aortic aneurysm repair Angiology 2019 ;  70 (6) : 572-573 [cross-ref]
Chaikof E.L., Brewster D.C., Dalman R.L., Makaroun M.S., Illig K.A., Sicard G.A., et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary J Vasc Surg 2009 ;  50 (4) : 880-896 [cross-ref]






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Elsevier Masson SAS. Tous droits réservés.