Repair of complex renal artery aneurysms by laparoscopic nephrectomy with ex vivo repair and autotransplantation

Abstract

Objective: Renal artery aneurysms are being discovered more frequently due to increased use of non-invasive imaging. Complex renal artery aneurysms involving multiple secondary or tertiary branches are not amenable to in vivo or endovascular treatment and often require ex vivo repair with autotransplantation. In order to minimize incisional morbidity and hasten recovery, we developed a technique of laparoscopic nephrectomy combined with backbench ex vivo repair, followed by autotransplantation through a small laparoscopic extraction incision. This study describes our initial experience with this combined technique in patients that were not candidates for endovascular techniques or in vivo arterial reconstruction.

Methods: Seven patients with complex renal artery aneurysms underwent laparoscopic nephrectomy and ex vivo repair with multiple saphenous vein grafts and autotransplantation through the small laparoscopic extraction incision. The aneurysms ranged from 2.5 to 5.0 cm. In all cases, the aneurysm was resected ex vivo, leaving multiple branch arteries that were extended with saphenous vein grafts. Arterial inflow was then re-established with sequential saphenous vein anastomoses to the external iliac artery. Ureteral reconstruction was performed via standard Lich ureteroneocystostomy. Patients were followed postoperatively for two to eight years.

Results: Laparoscopic nephrectomy with ex vivo repair of complex aneurysms was successfully employed in seven patients with renal aneurysms that were not amenable to endovascular or in vivo repair. There were no incisional morbidities and all patients had significant improvements in symptoms post-operatively. Renal function remained unchanged and there were no ureteral complications following surgery. All patients had postoperative ultrasound imaging done at two years which demonstrated patency of the anastomoses. The mean hospital stay was four days (range, two to seven days).

Conclusion: Repair of complex renal artery aneurysms involving distal branch arteries remains a challenge. This new technique combines the advantages of minimally invasive surgery with the effectiveness of ex vivo aneurysm repair.