Journal of Vascular Surgery
Volume 34, Issue 1 , Pages 169-171, July 2001

Saccular renal artery aneurysm treated with an autologous vein-covered stent☆☆☆

Sendai, Japan

From the Second Department of Surgerya and the Department of Radiology,b Tohoku University School of Medicine

Received 28 September 2000; accepted 10 January 2001.

Article Outline

Abstract 

A 32-year-old woman underwent an autologous saphenous vein-covered stent deployment for the treatment of a saccular aneurysm on the distal renal artery. Complete exclusion of the aneurysm was immediately obtained. One year after the treatment, remarkable shrinkage of the aneurysm was demonstrated by means of computed tomography, and wide patency of the renal artery and the stent was shown by means of angiography. (J Vasc Surg 2001;34:169-71.)

 

Several surgical procedures have been described for the repair of renal artery aneurysms. These include tangential aneurysmectomy and primary aneurysmorraphy, saphenous vein angioplasty, bypass grafting, and ex vivo reconstruction with reimplantation or autotransplantation.1, 2 Furthermore, interventional embolization therapy has also been reported to be successful.3 We report on the treatment of renal artery aneurysm with the percutaneous transfemoral insertion of an autologous vein-covered stent.

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Case report 

A 32-year-old woman complaining of backache and fever visited her local hospital. After the administration of antibiotics for several days, these symptoms disappeared. Twelve days later, she was admitted to another hospital for abdominal pain. A saccular aneurysm on the right renal artery and an aneurysm of the ileal branch of the superior mesenteric artery, 32 mm in diameter, were revealed by means of computed tomography (CT) and angiography. Partial resection of the ileum, including the aneurysm of the ileal branch, was performed at the hospital. The pathologic feature of the aneurysm of the ileal branch was unclear, but medial degeneration was observed. No evidence of mycotic etiology was found. After recovery, the patient was transferred to our hospital for treatment of the renal artery aneurysm.

Her blood pressure was 110/72 mm Hg on admission and remained normotensive before operation. She had no abdominal bruit. She did not have any particular familial or past history. Her renal function was normal, and her serum renin level was 3.64 ng/dL per hour, which was slightly higher than the cutoff level (0.5-2.0 ng/dL per hour) for healthy adults. She had no signs of inflammation, such as elevations of the number of white blood cells and serum C reactive protein level.

A contrast-filled mass 35 mm in diameter with no calcification was shown by means of an abdominal CT scan (Fig 1, A ).

The mass was located in the hilum of the right kidney, posterior to the renal artery. A saccular aneurysm with a narrow neck originating from the distal renal artery was revealed by means of digital subtraction angiography (Fig 1, B ). No other aneurysm was found in the arteries of the brain, neck, chest, abdomen, or lower extremities by means of CT scan, angiography, or magnetic resonance imaging.

After we obtained informed consent from the patient, vein-covered stent deployment was performed. With the patient under general anesthesia, the greater saphenous vein, 5 mm in diameter and without the valve, was harvested from her left thigh and trimmed to 13 mm in length (Fig 2, A ).

A 14-mm-long Palmaz-Schatz stent (model PS-1435; Johnson and Johnson Medical Co, Tokyo, Japan) was covered with the vein graft and sutured diametrically to the graft with 8-0 polypropylene sutures on each end. This covered stent was then mounted on a 4 × 20-mm balloon catheter (model 10-326; Symmetry; Fig 2, B ). A 10F arterial sheath was inserted in the right femoral artery, and 3000 IU of heparin was administered intravenously. The balloon catheter with the covered stent was then introduced into the right renal artery over a guidewire (0.018 in/180 cm; Cook, Bloomington, Ind). After inflation of the balloon and expansion of the covered stent at the aneurysmal neck, closure of the leak and exclusion of the aneurysm were shown by means of arteriography (Fig 3, A ).
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  • Fig. 3. 

    A, Arteriography after operation showing complete exclusion of aneurysm. B, Computed tomography scan 1 year after operation revealing remarkable shrinkage of aneurysm (arrow ).

No dissection or stenosis of the renal artery was depicted.

The patient had an uneventful recovery and was discharged from our hospital on the 18th postoperative day. On discharge, her blood pressure remained at the preoperative value. Warfarin was given for 2 weeks after the procedure, followed by cilostazol (200 mg/d).

One year after the operation, no stenosis in the right renal artery and no leakage into the aneurysm were demonstrated by means of angiography. Remarkable shrinkage of the aneurysm, which was hardly detectable, was revealed by means of CT scanning (Fig 3, B ).

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Discussion 

The use of a covered stent has recently been reported in the endovascular management of vascular injury4, 5, 6 and peripheral aneurysm.7, 8, 9, 10 To our knowledge, only Bui et al10 have described the use of a covered stent (expanded polytetrafluoroethylene covered) for treatment of renal artery aneurysm, with our case being the first in which an autologous vein-covered stent was used for this disease.

In our case, the saccular aneurysm was located in the hilum of the kidney originating from the distal renal artery, and the pathologic features of the aneurysm were unclear. If we had chosen open surgery, we may have had to perform arterial reconstruction with ex vivo surgery instead of a simple aneurysmectomy and patchplasty, depending on the morphologic and pathologic features of the aneurysmal neck and the renal artery. Therefore, we chose to use stent-graft deployment to avoid surgical trauma and to reduce the renal ischemic time.

Autologous vein4, 6, 9 and prosthetic grafts5, 7, 8, 10 have been used to cover stents. However, long-term patency results are not available. We expected autologous vein-covered stent to possess long-term patency, possibly because of rapid endothelialization and reduction of intimal hyperplasia. For the same reason, some reports recommend the use of autologous veins to cover stents.4, 6, 9 Although an expanded polytetrafluoroethylene graft is a commercially available covering prosthesis and therefore requires no surgery to obtain,10 we preferred to use an autologous vein to produce a covered stent for the reasons aforementioned.

Autologous veins for covering stents are available from various sites. The antecubital vein,4 profunda femoris vein,6 and saphenous vein9 have all been used as coverings for endoluminal stents. A suitable vein must be chosen based on diameter, thickness, and strength, and surgery to obtain the vein should not be too invasive. In our case, the saphenous vein was selected to cover the stent because it has sufficient strength and is a superior size match for the renal artery.

Most renal artery aneurysms, especially saccular aneurysms, are located on the branch of the renal artery. In some of these cases, in which the aneurysmal necks are near the branching point, this interventional approach would be difficult to perform. However, in cases in which the location of the neck would be on the vessel without a branch nearby, this procedure may be one of the therapeutic alternatives.

In summary, a saccular aneurysm in the renal artery was successfully treated by using saphenous vein-covered stent deployment, with a remarkable reduction in size 1 year after surgery. We think that an autologous vein provides better patency than prosthetic materials for stent covering, although the long-term patency of autologous vein-covered stent is unknown and further observation is necessary.

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References 

  1. Busuttil RW, Gelabert HA. Visceral artery aneurysms. In: 4th ed.  Haimovici H editors. Haimovici's vascular surgery, principles and techniques. Boston: Blackwell Science; 1996;p. 848–851
  2. Stanley JC, Messina LM, Zelenock GB. Splanchnic and renal artery aneurysms. In: 4th ed.  Moore WS editors. Vascular surgery, a comprehensive review. Philadelphia: WB Saunders; 1993;p. 442–447
  3. Routh WD, Keller FS, Gross GM. Transcatheter thrombosis of a leaking saccular aneurysm of the main renal artery with preservation of renal blood flow. AJR Am J Roentgenol. 1990;154:1097–1099
  4. Colon PJ, Ramee SR, Mulingtapang R, Pridjian A, Bhatia D, Collins TJ. Percutaneous bailout therapy of a perforated vein graft using a stent-autologous vein patch. Catheter Cardiovasc Diagn. 1996;38:175–178
  5. Marin ML, Veith FJ, Panetta TF, Cynamon J, Barone H, Schhnholz C, et al.  Percutaneous transfemoral insertion of a stented graft to repair a traumatic femoral arteriovenous fistula. J Vasc Surg. 1993;18:299–302
  6. Kerns DB, Darcy MD, Baumann DS, Allen BT. Autologous vein-covered stent for the endovascular management of an iliac artery-ureteral fistula: case report and review of the literature. J Vasc Surg. 1996;24:680–686
  7. Marin ML, Veith FJ, Panetta TF, Cynamon J, Bakal CW, Suggs WD, et al.  Transfemoral endoluminal stented graft repair of a popliteal artery aneurysm. J Vasc Surg. 1994;19:754–757
  8. May J, White G, Waugh R, Yu W, Harris J. Transluminal placement of a prosthetic graft-stent device for treatment of subclavian artery aneurysm. J Vasc Surg. 1993;18:1056–1059
  9. Nieuwenhove YV, Van den Brande P, Van Tussenbroek F, Debing E, Von Kemp K. Iatrogenic carotid artery pseudoaneurysm treated by an autologous vein covered stent. Eur J Vasc Endovasc Surg. 1998;16:262–265
  10. Bui BT, Oliva VL, Leclerc G, Courteau M, Harel C, Plante R, et al.  Renal artery aneurysm: treatment with percutaneous placement of a stent-graft. Radiology. 1995;195:181–182

☆ Competition of interest: nil.

☆☆ Reprint requests: Hiroto Rikimaru, MD, Second Department of Surgery, Tohoku University School of Medicine, 1-1 Seiryou-Cho, Aoba-Ku, Sendai, 980-8574, Japan.

PII: S0741-5214(01)90586-5

doi:10.1067/mva.2001.115798

Journal of Vascular Surgery
Volume 34, Issue 1 , Pages 169-171, July 2001

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