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Ruptured abdominal aortic aneurysm with horseshoe kidney
CASE R E P O R T S
Ruptured abdominal aortic aneurysm with horseshoe kidney M a r c i a A. G u t o w i c z , M . D . , and S t a n t o n N . SmuUens, M . D . , Philadelphia, Pa. A case of ruptured abdominal aortic aneurysm associated with horseshoe kidney is presented. Two aspects o f the operation are discussed: the vascular supply to the kidney and isthmus and the division of the isthmus. I t is important in handling these cases either on an emergency basis or electively to be aware of the various vascular anomalies. (J VAsc SURG 1984; 1:689-91.)
T h e association o f abdominal aortic aneurysm with horseshoe kidney is a well-known entity, with 50 cases reported to date. O n l y six cases o f ruptured abdominal aortic aneurysm with c o n c o m i t a n t horseshoe kidney have been reported in the w o r l d literature, with two deaths o c c u r r i n g a m o n g the six. '-5 T h e following is a case presentation o f a successful repair o f a r u p t u r e d abdominal aortic aneurysm in association with a horseshoe kidney. CASE R E P O R T A 60-year-old white man was first seen on February 13, 1980, with an asymptomatic abdominal aortic aneurysm. The patient had a significant past medical history of gram-negative meningitis with resultant hydrocephalus treated with a ventriculoperitoneal shunt. He was also known to have chronic obstructive pulmonary disease with a maximal breathing volume of 35% of predicted normal and a Po~ of 55 on room air. Aortography was performed at that time, and a horseshoe kidney with an abdominal aortic aneurysm measuring 5.5 cm was seen. There were multiple accessory renal arteries visualized arising above the aneurysm (Fig. 1). The patient was deemed a high surgical risk for elective aneurysm repair and was advised to be followed periodically by ukrasound examination. This was carried out by his attending physician and no change was noted. He was next seen after an emergency admission on the evening of December 2, 1981, when he presented with hypotension, a thready pulse, and a large painful abdominal mass. In the emergency department he was given intravenous fluids and an ultrasound examination was performed, which showed the aneurysm to now measure 8 to 10 cm. He was immediately taken to the operating room where, at the time of exploration, a large left retroperitoFrom the Thomas Jefferson University Hospital. Reprint requests: Marcia A. Gutowicz, M.D., Wilmington Veterans Administration Hospital, 1601 Kirkwood Highway, Elsmere, DE 19805.
neal hematoma was seen (Fig. 2). Control o f the aorta was initially obtained below the diaphragm, and the hematoma about the neck o f the aneurysm was entered. Control of the aorta below the renal vessels was then obtained and the clamps removed to this level. The large hematoma around the horseshoe kidney made identification difficult, but two small vessels to the isthmus were seen. Because of massive bleeding from the lumbar arteries at the level of the aortic bifurcation, division o f the isthmus was necessary. The isthmus was oversewn with multiple sutures of interrupted "0" chromic catgut. The aortic aneurysm was replaced with a 22 mm woven Dacron tube prosthesis and the anastomosis was made with 3-0 polypropylene (Fig. 3). After completion o f the aneurysm repair and reperitonealization of the tissues overlying the aorta, a gastrostomy tube was inserted. Estimated blood loss was 2000 ml. Postoperatively, difficulties were encountered in weaning the patient from the respirator and intubation was continued for 6 days. He did well after this and was discharged on December 17, 1981. The patient was readmitted on January 14, 1982, with nausea, vomiting, and dehydration. A urinary tract infection due to Escherichia coli was documented and successfully treated with tobramycin. An intravenous pyelogram showed the divided horseshoe kidney to be functioning normally but with some dilatation of the right ureter (Fig. 4). His blood urea nitrogen during this hospitalization was 20 m g / d l and creatinine level was 1.4 mg/dl. He was discharged on January 23, 1982, and has continued to do well until the present time. DISCUSSION The reported incidence o f horseshoe kidney is 1 in 400, with predominance in the male population. 6 T h e horseshoe kidney occurs because o f midline fusion between the fourth and eighth week o f fetal life, preventing migration and rotation o f kidneys. Sixty percent o f the patients are s y m p t o m a t i c during the 689
Journal of VASCULAR SURGERY
690 Gutowicz and Smullens
Fig. 3. Operative repair with woven Dacron graft.
Fig. 1. Two arteries to each half of kidney (arrows) arise above aneurysm. Isthmic arteries not visualized.
HEMATOMA
Fig. 2. Operative findings. patient's lifetime, with complications including infection, stone formation, and hydronephrosis. Associated with horseshoe kidney is a wide array of vascular anomalies that present a challenge to the vascular surgeon. In dealing with the problem of combined horseshoe kidney and abdominal aortic aneurysm,
one encounters two main areas of importance from a technical point of view. One relates to the 80% occurrence of vascular anomalies and the second to the handling of the kidney isthmus, v Various types of vascular anomalies have been reported, with from 1 to 10 aberrant vessels being identified. However, there are patterns that are usually present that will aid the surgeon in identifying the specific problem at hand. The more common arterial distributions include, first, a single vessel to each half of the kidney; second, a single vessel to each half o f the kidney and one to the isthmus; third, two vessels to each half of the kidney and two to the isthmus; fourth, multiple renal vessels to all portions of the anomalous kidney. s Anomalous vessels may originate from any portion of the aorta, the aneurysm, the iliac arteries, or the inferior mesenteric artery. These types of abnormalities can be conveniently grouped into three categories. Group I, occurring 20% o f the time, would be those with no vascular abnormalities. Group II comprises those with minor renovascular abnormalities such as the isthmic artery arising from the aortic bifurcation. Group III represents major renovascular abnormalities. This may be the type of case in which up to 10 renal arteries arising from the aneurysm may occur. Also associated with the horseshoe kidney may be anomalous urinary collecting systems and anomalous venous drainage with abnormally thin-walled veins. Parenchymal considerations regarding the kidney itself are also important in terms of operative techniques. Ninety percent of the fusions occur at the lower pole of the kidney. The isthmus in this case is usually at the L-4 to L-5 level. The isthmus
Volume 1 Number 5 September 1984
Ruptured abdominal aortic aneurysm 691
contention, however, that the isthmus need not be divided electively but only if necessary to gain adequate exposure. CONCLUSION A seventh case of ruptured abdominal aortic aneurysm associated with a horseshoe kidney has been presented. It is important in managing these cases either electively or in an emergency situation to be aware of the vascular abnormalities. When present, small vessels to the isthmus may be divided. If larger anomalous blood vessels involving major blood supply to the kidney are present, reimplantation to the aortic prosthesis would be the procedure of choice. In general, the renal isthmus may be divided safely if necessary, but in a high percentage of cases the resection or bypass can be carried out without the necessity o f doing this. Special thanks to Emily A. Milano, B.Sc., R.Ph., in preparation of this article.
Fig. 4. Postoperative intravenous pyelogram. itself may be a fibrous band without blood supply or it may be the size of a normal functioning kidney. The renal pelves and the ureters lie anteriorly because of the failure of rotation of the kidneys. These lie close to the midline and may be easily damaged during the dissection. The isthmus itself has been divided in approximately 34% of the cases that have been reported. This has been done without apparent incident. The presence of the horseshoe kidney in itself is not an indication to divide the isthmus, since it is frequently possible to mobilize the kidney and place the graft posterior to the isthmus. Theoretically, division of the isthmus could result in a urine leak, which would have a devastating effect on the synthetic graft if it became contaminated. It is our
REFERENCES 1. Mannick JA, Brooks JW, Bosher LH. Ruptured aneurysms of the abdominal aorta: A reappraisal. N Engl J Med 1964; 271:915-9. 2. Cayten GC, Davis AV, Berkowitz HD, et al. Ruptured abdominal aortic aneurysms in the presence of horseshoe kidneys. Surg 1972; 135:945-9. 3. Vereeckan L, Derom F, DeRoose J. A case of ruptured aneurysm associated with horseshoe kidney. Acta Chit Belg 1973; 72:46-51. 4. VanDeldren PW, Brands LC. Ruptured aneurysrn of the abdominal aorta in the presence of a horseshoe kidney. Acta Chir Neerl 1975; 27:271-6. 5. Connelly TL, McKinnon W, Smith RB, Perdue G. Abdominal aortic surgery and horseshoe kidney. Arch Surg 1980; 115:1456-62. 6. Campbell MF. Urology. Philadelphia: WB Saunders Co, 1970; 1448. 7. Eisendrath DN, Phifer FM, Culver HB. Horseshoe kidney. Ann Surg 1935; 82:735-43. 8. Cohn LN, Stoney RJ, Wylie EJ. Abdominal aortic aneurysm and horseshoe kidney. Ann Surg 1969; 170:870-6.
Ruptured abdominal aortic aneurysm with horseshoe kidney M a r c i a A. G u t o w i c z , M . D . , and S t a n t o n N . SmuUens, M . D . , Philadelphia, Pa. A case of ruptured abdominal aortic aneurysm associated with horseshoe kidney is presented. Two aspects o f the operation are discussed: the vascular supply to the kidney and isthmus and the division of the isthmus. I t is important in handling these cases either on an emergency basis or electively to be aware of the various vascular anomalies. (J VAsc SURG 1984; 1:689-91.)
T h e association o f abdominal aortic aneurysm with horseshoe kidney is a well-known entity, with 50 cases reported to date. O n l y six cases o f ruptured abdominal aortic aneurysm with c o n c o m i t a n t horseshoe kidney have been reported in the w o r l d literature, with two deaths o c c u r r i n g a m o n g the six. '-5 T h e following is a case presentation o f a successful repair o f a r u p t u r e d abdominal aortic aneurysm in association with a horseshoe kidney. CASE R E P O R T A 60-year-old white man was first seen on February 13, 1980, with an asymptomatic abdominal aortic aneurysm. The patient had a significant past medical history of gram-negative meningitis with resultant hydrocephalus treated with a ventriculoperitoneal shunt. He was also known to have chronic obstructive pulmonary disease with a maximal breathing volume of 35% of predicted normal and a Po~ of 55 on room air. Aortography was performed at that time, and a horseshoe kidney with an abdominal aortic aneurysm measuring 5.5 cm was seen. There were multiple accessory renal arteries visualized arising above the aneurysm (Fig. 1). The patient was deemed a high surgical risk for elective aneurysm repair and was advised to be followed periodically by ukrasound examination. This was carried out by his attending physician and no change was noted. He was next seen after an emergency admission on the evening of December 2, 1981, when he presented with hypotension, a thready pulse, and a large painful abdominal mass. In the emergency department he was given intravenous fluids and an ultrasound examination was performed, which showed the aneurysm to now measure 8 to 10 cm. He was immediately taken to the operating room where, at the time of exploration, a large left retroperitoFrom the Thomas Jefferson University Hospital. Reprint requests: Marcia A. Gutowicz, M.D., Wilmington Veterans Administration Hospital, 1601 Kirkwood Highway, Elsmere, DE 19805.
neal hematoma was seen (Fig. 2). Control o f the aorta was initially obtained below the diaphragm, and the hematoma about the neck o f the aneurysm was entered. Control of the aorta below the renal vessels was then obtained and the clamps removed to this level. The large hematoma around the horseshoe kidney made identification difficult, but two small vessels to the isthmus were seen. Because of massive bleeding from the lumbar arteries at the level of the aortic bifurcation, division o f the isthmus was necessary. The isthmus was oversewn with multiple sutures of interrupted "0" chromic catgut. The aortic aneurysm was replaced with a 22 mm woven Dacron tube prosthesis and the anastomosis was made with 3-0 polypropylene (Fig. 3). After completion o f the aneurysm repair and reperitonealization of the tissues overlying the aorta, a gastrostomy tube was inserted. Estimated blood loss was 2000 ml. Postoperatively, difficulties were encountered in weaning the patient from the respirator and intubation was continued for 6 days. He did well after this and was discharged on December 17, 1981. The patient was readmitted on January 14, 1982, with nausea, vomiting, and dehydration. A urinary tract infection due to Escherichia coli was documented and successfully treated with tobramycin. An intravenous pyelogram showed the divided horseshoe kidney to be functioning normally but with some dilatation of the right ureter (Fig. 4). His blood urea nitrogen during this hospitalization was 20 m g / d l and creatinine level was 1.4 mg/dl. He was discharged on January 23, 1982, and has continued to do well until the present time. DISCUSSION The reported incidence o f horseshoe kidney is 1 in 400, with predominance in the male population. 6 T h e horseshoe kidney occurs because o f midline fusion between the fourth and eighth week o f fetal life, preventing migration and rotation o f kidneys. Sixty percent o f the patients are s y m p t o m a t i c during the 689
Journal of VASCULAR SURGERY
690 Gutowicz and Smullens
Fig. 3. Operative repair with woven Dacron graft.
Fig. 1. Two arteries to each half of kidney (arrows) arise above aneurysm. Isthmic arteries not visualized.
HEMATOMA
Fig. 2. Operative findings. patient's lifetime, with complications including infection, stone formation, and hydronephrosis. Associated with horseshoe kidney is a wide array of vascular anomalies that present a challenge to the vascular surgeon. In dealing with the problem of combined horseshoe kidney and abdominal aortic aneurysm,
one encounters two main areas of importance from a technical point of view. One relates to the 80% occurrence of vascular anomalies and the second to the handling of the kidney isthmus, v Various types of vascular anomalies have been reported, with from 1 to 10 aberrant vessels being identified. However, there are patterns that are usually present that will aid the surgeon in identifying the specific problem at hand. The more common arterial distributions include, first, a single vessel to each half of the kidney; second, a single vessel to each half o f the kidney and one to the isthmus; third, two vessels to each half of the kidney and two to the isthmus; fourth, multiple renal vessels to all portions of the anomalous kidney. s Anomalous vessels may originate from any portion of the aorta, the aneurysm, the iliac arteries, or the inferior mesenteric artery. These types of abnormalities can be conveniently grouped into three categories. Group I, occurring 20% o f the time, would be those with no vascular abnormalities. Group II comprises those with minor renovascular abnormalities such as the isthmic artery arising from the aortic bifurcation. Group III represents major renovascular abnormalities. This may be the type of case in which up to 10 renal arteries arising from the aneurysm may occur. Also associated with the horseshoe kidney may be anomalous urinary collecting systems and anomalous venous drainage with abnormally thin-walled veins. Parenchymal considerations regarding the kidney itself are also important in terms of operative techniques. Ninety percent of the fusions occur at the lower pole of the kidney. The isthmus in this case is usually at the L-4 to L-5 level. The isthmus
Volume 1 Number 5 September 1984
Ruptured abdominal aortic aneurysm 691
contention, however, that the isthmus need not be divided electively but only if necessary to gain adequate exposure. CONCLUSION A seventh case of ruptured abdominal aortic aneurysm associated with a horseshoe kidney has been presented. It is important in managing these cases either electively or in an emergency situation to be aware of the vascular abnormalities. When present, small vessels to the isthmus may be divided. If larger anomalous blood vessels involving major blood supply to the kidney are present, reimplantation to the aortic prosthesis would be the procedure of choice. In general, the renal isthmus may be divided safely if necessary, but in a high percentage of cases the resection or bypass can be carried out without the necessity o f doing this. Special thanks to Emily A. Milano, B.Sc., R.Ph., in preparation of this article.
Fig. 4. Postoperative intravenous pyelogram. itself may be a fibrous band without blood supply or it may be the size of a normal functioning kidney. The renal pelves and the ureters lie anteriorly because of the failure of rotation of the kidneys. These lie close to the midline and may be easily damaged during the dissection. The isthmus itself has been divided in approximately 34% of the cases that have been reported. This has been done without apparent incident. The presence of the horseshoe kidney in itself is not an indication to divide the isthmus, since it is frequently possible to mobilize the kidney and place the graft posterior to the isthmus. Theoretically, division of the isthmus could result in a urine leak, which would have a devastating effect on the synthetic graft if it became contaminated. It is our
REFERENCES 1. Mannick JA, Brooks JW, Bosher LH. Ruptured aneurysms of the abdominal aorta: A reappraisal. N Engl J Med 1964; 271:915-9. 2. Cayten GC, Davis AV, Berkowitz HD, et al. Ruptured abdominal aortic aneurysms in the presence of horseshoe kidneys. Surg 1972; 135:945-9. 3. Vereeckan L, Derom F, DeRoose J. A case of ruptured aneurysm associated with horseshoe kidney. Acta Chit Belg 1973; 72:46-51. 4. VanDeldren PW, Brands LC. Ruptured aneurysrn of the abdominal aorta in the presence of a horseshoe kidney. Acta Chir Neerl 1975; 27:271-6. 5. Connelly TL, McKinnon W, Smith RB, Perdue G. Abdominal aortic surgery and horseshoe kidney. Arch Surg 1980; 115:1456-62. 6. Campbell MF. Urology. Philadelphia: WB Saunders Co, 1970; 1448. 7. Eisendrath DN, Phifer FM, Culver HB. Horseshoe kidney. Ann Surg 1935; 82:735-43. 8. Cohn LN, Stoney RJ, Wylie EJ. Abdominal aortic aneurysm and horseshoe kidney. Ann Surg 1969; 170:870-6.