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Aortoiliac Occlusive Disease in the Presence of a Horseshoe Kidney: A Case Report
Aortoiliac Occlusive Disease in the Presence of a Horseshoe Kidney: A Case Report Adam Gyedu, and Cuneyt Koksoy, Ankara, Turkey
A case of aortoiliac occlusive disease in the presence of a horseshoe kidney anomaly is presented. The importance of careful preoperative planning by way of specialized investigations is stressed and the merits of both the anterior transperitoneal and retroperitoneal approaches to aortoiliac reconstruction in the presence of a horseshoe kidney are outlined.
The presence of horseshoe kidney in conjunction with abdominal aortic disease significantly increases the technical difficulty of aortic reconstruction. Preservation of the renal blood supply and collecting system during the surgical procedure is the goal of operative management. The pertinent issues that remain unresolved include the need for specific preoperative studies, the optimal operative approach, and the safety of isthmus division.1 A horseshoe kidney presents a special challenge during aortic surgery for the following reasons: the horseshoe kidney vascular supply and excretory system must be precisely identified preoperatively, anomalous renal arteries must be preserved, and placement of the vascular graft requires extra care.2-5 We present our experience with a patient who presented with aortoiliac disease and a horseshoe kidney.
CASE REPORT A 67-year-old male presented with bilateral claudication of the lower extremities after walking a distance of about 100 m. His medical history revealed a left femoropopliteal bypass 17 years ago and coronary artery bypass grafting a year before presentation. Preoperative investigations revealed ankle-brachial indices of 0.53 (on the right)
Department of General Surgery, Ankara University Medical Faculty, Ankara, Turkey. _ Correspondence to: Adam Gyedu, Ibni-i Sina Hastanesi, Genel Cerrahi ABD, Samanpazari 06100, Ankara, Turkey, E-mail: drgyedu@ gmail.com Ann Vasc Surg 2008; 22: 290-292 DOI: 10.1016/j.avsg.2007.09.007 Ó Annals of Vascular Surgery Inc. Published online: December 4, 2007
290
and 0.57 (on the left). On the treadmill, his pain-free walking distance (initial claudication distance) and maximum walking distance (absolute claudication distance) were 70 and 114 m, respectively. A bilateral lower extremity angiogram showed advanced atherosclerotic narrowing of the distal abdominal aorta; the right common, internal, and external iliac arteries; and the right femoral artery (Fig. 1). The midportion of the left common iliac artery was completely occluded, and the femoral system was being fed by collaterals from the left internal iliac artery via the left deep femoral artery. Both superficial and deep femoral arteries were patent but with varying degrees of segmental narrowing, reaching as much as 90% in the right superficial femoral artery. With the diagnosis of atherosclerotic aortoiliac occlusive disease, the patient underwent laparotomy through a midline incision. It was during abdominal exploration that the presence of cystic structures in the midline prompted the clinical diagnosis of a horseshoe kidney. Henceforth, the operation was terminated and the abdomen closed. Abdominopelvic computed tomography (CT) later revealed a horseshoe kidney anomaly with both renal pelves being wide and extrarenal and the presence of many renal cysts (Fig. 2). The patient underwent laparotomy again through the same midline incision, and an aortobifemoral bifurcated graft bypass was constructed successfully. Briefly, following the aortic anastomosis, an end-to-side fashion 18 9 mm Dacron graft was passed under the isthmus of the kidney without intervening renal structures. Then, the distal ends of the graft were anastomosed to the common femoral arteries. No renal artery revascularization and isolated perfusion of kidneys with cold solutions were needed. The total aortic clamp time was 20 min. Postoperatively, the patient tolerated the procedure well. He did not develop kidney dysfunction, his preand postoperative creatinine values being 1.6 and 1.8 mg/dL, respectively. Without any complication the patient was discharged on postoperative day 7.
Vol. 22, No. 2, 2008
Fig. 1. Aortoiliac angiogram showing advanced atherosclerotic narrowing of the distal aorta and bilateral iliac systems.
Fig. 2. CT scan showing the horseshoe kidney anomaly.
DISCUSSION Renal development occurs between the fourth and eighth embryonic weeks,6 and a horseshoe kidney is the consequence of anomalous migration and rotation during this period. The horseshoe kidney is localized at the level of the third and fourth lumbar vertebrae. In 95% of cases the kidneys are connected to the lower poles and in 5% to the upper poles.6,7 Most commonly, the renal isthmus has
Case reports 291
a parenchymatous structure and is located in front of the abdominal aorta.6,7 In two-thirds of cases anomalous vascularization of the horseshoe kidney is present.1,4,8 Two classifications of horseshoe kidneys and their anomalous vascularization exist.6,9 According to Papin’s classification, there are three types of horseshoe kidney vascularization based on the number of renal arteries.6 In Papin I, occurring in 20% of cases, there are two normal renal arteries only. In Papin II, there are three to five renal arteries. In Papin III, occurring in 14% of cases, there are more than five renal arteries. Crawford’s classification is based on the origin of renal arteries and has a greater surgical significance than Papin’s.9 In a Crawford I horseshoe kidney, there are two renal arteries of normal origin. In Crawford II, in addition to the two normal arteries there are one to three anomalous renal arteries originating from the infrarenal aorta or iliac arteries. In a Crawford III kidney, all renal arteries have an anomalous origin. Our patient’s horseshoe kidney corresponds to Papin II or Crawford II. Wymenga et al.10 presented their experience with a patient similar to ours; but in their case the diagnosis of a horseshoe kidney was made prior to surgery, and they stressed ultrasonography, intravenous pyelography, and aortography as important for surgical planning. However, as was pointed out by Davidovic et al.11 and in the case of our patient, the diagnosis of a horseshoe kidney is not always made prior to surgery. Ultrasonography can detect a horseshoe kidney by showing an isthmus of renal tissue in front of the aorta.12 However, if the isthmus is narrow, consisting of only a thin band of tissue, or if excessive bowel gas is present, the renal anomaly may be missed.8 CT is considered the best noninvasive method of simultaneous aortic visualization and detection of anomalous kidneys.8,9 Excretory urography was used in earlier series, with a horseshoe kidney detection rate of 75%.5 However, all these techniques are not routinely used in all patients undergoing aortic surgery, especially for occlusive disease. Surgical management of the aorta in patients with horseshoe kidney poses a special challenge. In most cases the aortic graft can be placed posterior to the kidney. During surgery special attention should be given to identification and preservation of renal arteries, and reimplantation into the aortic graft should be performed when necessary. The decision of how to approach the aorta, transperitoneally or retroperitoneally, in a patient with a horseshoe kidney seems to be more of an issue if the patient presents with an aortic aneurysm. As Huber et al.13 point out, an anterior transperitoneal approach makes it easier to define renal arterial and
292 Case reports
venous anatomy, although technical difficulties may be encountered when grafting the aorta. With the retroperitoneal approach, grafting can be done without having to encounter attenuated and sometimes unrecognizable large veins, and the isthmus and drainage systems do not enter the operative field. The disadvantage of this approach, however, is that the arterial anatomy cannot be properly defined in relation to the destination of supply. Here, the necessity to reanastomose accessory renal arteries may not be appreciated within the aneurysm sac, in which case postoperative renal ischemia is likely to occur. In our case, the kidney was approached transperitoneally and the bifurcated graft passed under the isthmus of the kidney, with no accessory renal artery reimplantation required. We had no problems with the arterial blood supply to the kidney, and this was due to the fact that our proximal anastomosis was performed in an end-to-side fashion. We conclude that aortic reconstruction in the presence of a horseshoe kidney requires careful planning and that the operation can be performed transperitoneally. REFERENCES 1. Shortell CK, Welch EL, Ouriel K, Green RM, DeWeese JA. Operative management of coexistent aortic disease and horseshoe kidney. Ann Vasc Surg 1995;9:123-128.
Annals of Vascular Surgery
2. Bergan JJ, Yao JST. Modern management of abdominal aortic aneurysm. Surg Clin North Am 1974;54:175-193. 3. Starr DS, Foster JN, Morris GB. Resection of abdominal aortic aneurysm in the presence of horseshoe kidney. Surgery 1981;89:587-589. 4. Sidell PM, Pairolero PC, Payne WS, Bernatz PE, Spitell JA, Jr. Horseshoe kidney associated with surgery of the abdominal aorta. Mayo Clin Proc 1979;54:97-103. 5. de Vigilio C, Gloviczki P, Cherry KJ, et al. Renal artery anomalies in patients with horseshoe of etopic kidneys: the challenge of aortic reconstruction. Cardiovasc Surg 1995;3:413-420. 6. Papin E, Chirurgie du Rein E. Anomalies du Rein. Paris: G. Dion, 1928. pp 205-220. 7. Arison BJ, Pick JN, Cauldwell EW. The anatomy of common renal anomalies. Ectopis and horseshoe kidneys. J Urol 1942;47:112. 8. O’Hara PJ, Hahaim AG, Hertzer NR, Krazenski LP, Cox GS, Beven EG. Surgical management of aortic aneurysm and coexistent horseshoe kidney: review of a 31-year experience. J Vasc Surg 1993;17:940-947. 9. Banerjee B, Brett I. Ultrasound diagnosis of horseshoe kidney. Br J Radiol 1991;64:898-900. 10. Wymenga LF, van der Tol A, van Dop HR. Horseshoe kidney and aortic surgery. Scand J Urol Nephrol 1995;29: 331-334. 11. Davidovic LB, Kostic DM, Jakovljevic NS, et al. Abdominal aortic surgery and horseshoe kidney. Ann Vasc Surg 2004;18:725-728. 12. Crawford ES, Cosseli JS, Safi HJ, Martin TD, Pool JL. The impact of renal function and extopia on aortic surgery. J Vasc Surg 1988;8:375-383. 13. Huber D, Griffin A, Niesche J, Frawley J, Gray L. Aortic aneurysm surgery in the presence of a horseshoe kidney. Aust N Z J Surg 1990;60:963-966.
A case of aortoiliac occlusive disease in the presence of a horseshoe kidney anomaly is presented. The importance of careful preoperative planning by way of specialized investigations is stressed and the merits of both the anterior transperitoneal and retroperitoneal approaches to aortoiliac reconstruction in the presence of a horseshoe kidney are outlined.
The presence of horseshoe kidney in conjunction with abdominal aortic disease significantly increases the technical difficulty of aortic reconstruction. Preservation of the renal blood supply and collecting system during the surgical procedure is the goal of operative management. The pertinent issues that remain unresolved include the need for specific preoperative studies, the optimal operative approach, and the safety of isthmus division.1 A horseshoe kidney presents a special challenge during aortic surgery for the following reasons: the horseshoe kidney vascular supply and excretory system must be precisely identified preoperatively, anomalous renal arteries must be preserved, and placement of the vascular graft requires extra care.2-5 We present our experience with a patient who presented with aortoiliac disease and a horseshoe kidney.
CASE REPORT A 67-year-old male presented with bilateral claudication of the lower extremities after walking a distance of about 100 m. His medical history revealed a left femoropopliteal bypass 17 years ago and coronary artery bypass grafting a year before presentation. Preoperative investigations revealed ankle-brachial indices of 0.53 (on the right)
Department of General Surgery, Ankara University Medical Faculty, Ankara, Turkey. _ Correspondence to: Adam Gyedu, Ibni-i Sina Hastanesi, Genel Cerrahi ABD, Samanpazari 06100, Ankara, Turkey, E-mail: drgyedu@ gmail.com Ann Vasc Surg 2008; 22: 290-292 DOI: 10.1016/j.avsg.2007.09.007 Ó Annals of Vascular Surgery Inc. Published online: December 4, 2007
290
and 0.57 (on the left). On the treadmill, his pain-free walking distance (initial claudication distance) and maximum walking distance (absolute claudication distance) were 70 and 114 m, respectively. A bilateral lower extremity angiogram showed advanced atherosclerotic narrowing of the distal abdominal aorta; the right common, internal, and external iliac arteries; and the right femoral artery (Fig. 1). The midportion of the left common iliac artery was completely occluded, and the femoral system was being fed by collaterals from the left internal iliac artery via the left deep femoral artery. Both superficial and deep femoral arteries were patent but with varying degrees of segmental narrowing, reaching as much as 90% in the right superficial femoral artery. With the diagnosis of atherosclerotic aortoiliac occlusive disease, the patient underwent laparotomy through a midline incision. It was during abdominal exploration that the presence of cystic structures in the midline prompted the clinical diagnosis of a horseshoe kidney. Henceforth, the operation was terminated and the abdomen closed. Abdominopelvic computed tomography (CT) later revealed a horseshoe kidney anomaly with both renal pelves being wide and extrarenal and the presence of many renal cysts (Fig. 2). The patient underwent laparotomy again through the same midline incision, and an aortobifemoral bifurcated graft bypass was constructed successfully. Briefly, following the aortic anastomosis, an end-to-side fashion 18 9 mm Dacron graft was passed under the isthmus of the kidney without intervening renal structures. Then, the distal ends of the graft were anastomosed to the common femoral arteries. No renal artery revascularization and isolated perfusion of kidneys with cold solutions were needed. The total aortic clamp time was 20 min. Postoperatively, the patient tolerated the procedure well. He did not develop kidney dysfunction, his preand postoperative creatinine values being 1.6 and 1.8 mg/dL, respectively. Without any complication the patient was discharged on postoperative day 7.
Vol. 22, No. 2, 2008
Fig. 1. Aortoiliac angiogram showing advanced atherosclerotic narrowing of the distal aorta and bilateral iliac systems.
Fig. 2. CT scan showing the horseshoe kidney anomaly.
DISCUSSION Renal development occurs between the fourth and eighth embryonic weeks,6 and a horseshoe kidney is the consequence of anomalous migration and rotation during this period. The horseshoe kidney is localized at the level of the third and fourth lumbar vertebrae. In 95% of cases the kidneys are connected to the lower poles and in 5% to the upper poles.6,7 Most commonly, the renal isthmus has
Case reports 291
a parenchymatous structure and is located in front of the abdominal aorta.6,7 In two-thirds of cases anomalous vascularization of the horseshoe kidney is present.1,4,8 Two classifications of horseshoe kidneys and their anomalous vascularization exist.6,9 According to Papin’s classification, there are three types of horseshoe kidney vascularization based on the number of renal arteries.6 In Papin I, occurring in 20% of cases, there are two normal renal arteries only. In Papin II, there are three to five renal arteries. In Papin III, occurring in 14% of cases, there are more than five renal arteries. Crawford’s classification is based on the origin of renal arteries and has a greater surgical significance than Papin’s.9 In a Crawford I horseshoe kidney, there are two renal arteries of normal origin. In Crawford II, in addition to the two normal arteries there are one to three anomalous renal arteries originating from the infrarenal aorta or iliac arteries. In a Crawford III kidney, all renal arteries have an anomalous origin. Our patient’s horseshoe kidney corresponds to Papin II or Crawford II. Wymenga et al.10 presented their experience with a patient similar to ours; but in their case the diagnosis of a horseshoe kidney was made prior to surgery, and they stressed ultrasonography, intravenous pyelography, and aortography as important for surgical planning. However, as was pointed out by Davidovic et al.11 and in the case of our patient, the diagnosis of a horseshoe kidney is not always made prior to surgery. Ultrasonography can detect a horseshoe kidney by showing an isthmus of renal tissue in front of the aorta.12 However, if the isthmus is narrow, consisting of only a thin band of tissue, or if excessive bowel gas is present, the renal anomaly may be missed.8 CT is considered the best noninvasive method of simultaneous aortic visualization and detection of anomalous kidneys.8,9 Excretory urography was used in earlier series, with a horseshoe kidney detection rate of 75%.5 However, all these techniques are not routinely used in all patients undergoing aortic surgery, especially for occlusive disease. Surgical management of the aorta in patients with horseshoe kidney poses a special challenge. In most cases the aortic graft can be placed posterior to the kidney. During surgery special attention should be given to identification and preservation of renal arteries, and reimplantation into the aortic graft should be performed when necessary. The decision of how to approach the aorta, transperitoneally or retroperitoneally, in a patient with a horseshoe kidney seems to be more of an issue if the patient presents with an aortic aneurysm. As Huber et al.13 point out, an anterior transperitoneal approach makes it easier to define renal arterial and
292 Case reports
venous anatomy, although technical difficulties may be encountered when grafting the aorta. With the retroperitoneal approach, grafting can be done without having to encounter attenuated and sometimes unrecognizable large veins, and the isthmus and drainage systems do not enter the operative field. The disadvantage of this approach, however, is that the arterial anatomy cannot be properly defined in relation to the destination of supply. Here, the necessity to reanastomose accessory renal arteries may not be appreciated within the aneurysm sac, in which case postoperative renal ischemia is likely to occur. In our case, the kidney was approached transperitoneally and the bifurcated graft passed under the isthmus of the kidney, with no accessory renal artery reimplantation required. We had no problems with the arterial blood supply to the kidney, and this was due to the fact that our proximal anastomosis was performed in an end-to-side fashion. We conclude that aortic reconstruction in the presence of a horseshoe kidney requires careful planning and that the operation can be performed transperitoneally. REFERENCES 1. Shortell CK, Welch EL, Ouriel K, Green RM, DeWeese JA. Operative management of coexistent aortic disease and horseshoe kidney. Ann Vasc Surg 1995;9:123-128.
Annals of Vascular Surgery
2. Bergan JJ, Yao JST. Modern management of abdominal aortic aneurysm. Surg Clin North Am 1974;54:175-193. 3. Starr DS, Foster JN, Morris GB. Resection of abdominal aortic aneurysm in the presence of horseshoe kidney. Surgery 1981;89:587-589. 4. Sidell PM, Pairolero PC, Payne WS, Bernatz PE, Spitell JA, Jr. Horseshoe kidney associated with surgery of the abdominal aorta. Mayo Clin Proc 1979;54:97-103. 5. de Vigilio C, Gloviczki P, Cherry KJ, et al. Renal artery anomalies in patients with horseshoe of etopic kidneys: the challenge of aortic reconstruction. Cardiovasc Surg 1995;3:413-420. 6. Papin E, Chirurgie du Rein E. Anomalies du Rein. Paris: G. Dion, 1928. pp 205-220. 7. Arison BJ, Pick JN, Cauldwell EW. The anatomy of common renal anomalies. Ectopis and horseshoe kidneys. J Urol 1942;47:112. 8. O’Hara PJ, Hahaim AG, Hertzer NR, Krazenski LP, Cox GS, Beven EG. Surgical management of aortic aneurysm and coexistent horseshoe kidney: review of a 31-year experience. J Vasc Surg 1993;17:940-947. 9. Banerjee B, Brett I. Ultrasound diagnosis of horseshoe kidney. Br J Radiol 1991;64:898-900. 10. Wymenga LF, van der Tol A, van Dop HR. Horseshoe kidney and aortic surgery. Scand J Urol Nephrol 1995;29: 331-334. 11. Davidovic LB, Kostic DM, Jakovljevic NS, et al. Abdominal aortic surgery and horseshoe kidney. Ann Vasc Surg 2004;18:725-728. 12. Crawford ES, Cosseli JS, Safi HJ, Martin TD, Pool JL. The impact of renal function and extopia on aortic surgery. J Vasc Surg 1988;8:375-383. 13. Huber D, Griffin A, Niesche J, Frawley J, Gray L. Aortic aneurysm surgery in the presence of a horseshoe kidney. Aust N Z J Surg 1990;60:963-966.