NDT Advance Access originally published online on October 25, 2005
Nephrology Dialysis Transplantation 2006 21(1):221-222; doi:10.1093/ndt/gfi218
© The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Case Report
Acute renal failure following endovascular repair of an infrarenal abdominal aortic aneurysm
Natalia Ridao-Cano1,
Antolina Rodriguez1,
Jaime Torrente1,
Juan Gallego2 and
Alberto Barrientos1
Departments of 1 Nephrology and 2 Interventional Radiology, Hospital Clinico Universitario San Carlos, Madrid, Spain
Correspondence and offprint requests to: Dr Natalia Ridao-Cano, Servicio de Nefrologia, Primera planta Norte, Hospital Clinico Universitario San Carlos, C/Prof. Martín Lagos s/n, 28040, Madrid, Spain. Email: nataliaridaocano{at}yahoo.es
Keywords: renal artery occlusion; vascular endograft
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Introduction
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Endovascular repair of an abdominal aortic aneurysm (AAA) is
today a widely accepted alternative to conventional open surgical
treatment, especially in patients with a high risk of complications
[
1]. We describe a case of acute renal failure following the
implantation of an endograft in a patient with infrarenal AAA
and only one functioning kidney.
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Case
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The patient was a 73-year-old man diagnosed with an infrarenal
AAA very close to the right renal artery and an atrophied left
kidney. We implanted a bifurcated Talent endograft (World Medical/Medtronic/AVE,
Santa Rosa, CA). The procedure was uneventful but, a few hours
later, the patient underwent anuric acute renal failure requiring
haemodialysis. The patient was subjected to further arteriography
16 days after endovascular repair (
Figure 1), in which the right
renal artery was seen to be completely occluded by the the stent
and a faint intrarenal vascular tree fed by the right suprarenal
artery. Open surgery was performed 22 days later, in which an
internal saphenous vein bypass from the common hepatic artery
to the right renal artery was undertaken. The biopsy showed
acute tubular necrosis. Afterwards, renal function improved.
Magnetic resonance angiography follow-ups showed the good condition
of the aortic endograft and patency of the hepatorenal bypass
(
Figure 2). A year later, the patient showed a plasma creatinine
of 1.9 mg/dl.
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Fig. 1. This arteriograph demonstrates a complete occlusion of the right renal artery by the displaced graft, but the intrarenal vasculature remained preserved by collateral irrigation depending on the suprarenal artery (thin arrows).
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Fig. 2. Magnetic resonance angiography follow-up that shows the correct functioning of the endograft and hepatorenal bypass.
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Discussion
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Several renal complications related to the endovascular repair
procedure have been described [
2]. In our patient, the renal
artery of his only kidney was occluded as the result of a migrating
endograft. We initially ruled out this possibility because the
renal artery appeared to be patent in the arteriography conducted
just after the procedure. Graft migration was therefore not
immediate. The two possible diagnoses were first, nephropathy
due to radiocontrast and, secondly, renal atheroembolism. However,
the prolonged period of anuria prompted our decision to undertake
arteriography again.
The most interesting feature of this case was the observation of how a kidney with acute ischaemia of the renal artery can be kept viable for 22 days when its only blood supply is the collateral circulation. The kidney's collateral circulation is very rich due to branches arising from the capsular, suprarenal, lumbar and uretheral circulation, and some 20–30% of subjects have accessory renal arteries [3]. This collateral circulation usually develops over time in chronic ischaemic processes such as arteriosclerosis, although it is less likely to occur in acute processes. Moreover, it is important to take into account the possibility of several complications after endovascular procedures in patients with renal disease [2,4,5].
Conflict of interest statement. None declared.
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References
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- Buth J, Van Marrewijk CJ, Harris PL, Hop WCJ, Riambau V, Laheij RJF, on behalf of the EUROSTAR collaborators. Outcome of endovascular abdominal aortic aneurysm repair in patients with conditions considered unfit for an open procedure: a report on the EUROSTAR experience. J Vasc Surg 2002; 35: 211–221[CrossRef][Web of Science][Medline]
- Surowiec SM, Davies MG, Fegley AJ et al. Relationship of proximal fixation to postoperative renal dysfunction in patients with normal serum creatinine concentration. J Vasc Surg 2004; 39: 804–810[CrossRef][Web of Science][Medline]
- Libertino JA, Zinman L, Breslin DJ, Swinton NW, Lagg M. Revascularization of ischemic nonfunctioning kidneys with restoration of renal function. J Am Med Assoc 1980; 244: 1340–1344[Abstract/Free Full Text]
- Lau LL, Hakaim AG, Oldenburg WA et al. Effect of suprarenal versus infrarenal aortic endograft fixation on renal function and renal artery patency: a comparative study with intermediate follow-up. J Vasc Surg 2003; 37: 1162–1168[CrossRef][Web of Science][Medline]
- Cayne NS, Rhee SJ, Veith FJ et al. Does transrenal fixation of aortic endografts impair renal function? J Vasc Surg 2003; 38: 639–644[CrossRef][Web of Science][Medline]
Received for publication: 28. 2.05
Accepted in revised form: 20. 9.05
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