Background: Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to propose the most rationale strategy during open repair (OR) of RAAA in the presence of HK.
Methods: We identified and analyzed all patients treated at the clinic due to RAAA and HK. An extensive search was performed on all articles published up to August of 2017 describing open and endovascular repair of RAAA with concomitant horseshoe kidney. The following data were extracted and analyzed: patient number, number of renal arteries, Crawford classification of horseshoe kidney vascularization, type of aortic reconstruction, management with renal arteries, 30-day kidney failure and outcome.
Results: Transperitoneal approach followed by supraceliac aortic cross clamping without the division of the renal isthmus occurred in all our six cases. Four of them required additional procedures with accessory renal arteries after aortic replacement. Three of patients (50%) died during the first 30 postoperative days, while one developed transitory renal insufficiency. The renal isthmus was preserved in 43.90% and divided in 46.34% of cases. Crawford type I of HK vascularization was presented in 21.95% of cases, type II also in 39.02%, while the type III in 19.51% of cases. In 46.33% of cases a procedure with renal arteries was necessary. In 26.82% accessory renal arteries were ligated, while in 19.51% preserved (reattachment or aorto-renal bypass). Thirty-day mortality was 21.95%, while the incidence of postoperative renal failure was also 21.95%. There was not significant correlation between the renal artery ligation and the postoperative renal failure (r=-0.81, P=0.59).
Conclusions: Transperitoneal approach should be preferred during urgent OR of RAAA with concomitant HK. A supraceliac aortic cross clamping and the placement of occlusive Fogarty catheters into both iliac arteries are recommended for proximal and distal bleeding control. Preservation of accessory renal arteries that are larger than 3 mm in diameter or supply more than 30% of renal parenchima is recommended. The division of the renal isthmus should be avoided if vascularized. It seems that renal arteries could be covered in emergency EVAR without any implications on postoperative kidney function, allowing broader aplication of endovascular treatment for thesse patients.