Annals of Vascular Surgery
Volume 21, Issue 2 , Pages 143-148, March 2007

Renal Function after Elective Infrarenal Aortic Aneurysm Repair in Patients with Pelvic Kidneys

  • Trung D. Bui

      Affiliations

    • Department of Surgery, University of California Irvine, Orange, CA
    • Surgical Service, VA Long Beach Healthcare System, Long Beach, CA
    • ,
  • Samuel E. Wilson

      Affiliations

    • Department of Surgery, University of California Irvine, Orange, CA
    • Surgical Service, VA Long Beach Healthcare System, Long Beach, CA
    • Corresponding Author InformationCorrespondence to: Samuel E. Wilson, MD, Department of Surgery, 101 The City Drive, Building 53, Route 81, Orange, CA 92868, USA
    • ,
  • Ian L. Gordon

      Affiliations

    • Department of Surgery, University of California Irvine, Orange, CA
    • Surgical Service, VA Long Beach Healthcare System, Long Beach, CA
    • ,
  • Roy M. Fujitani

      Affiliations

    • Department of Surgery, University of California Irvine, Orange, CA
    • Surgical Service, VA Long Beach Healthcare System, Long Beach, CA
    • Department of Surgery, Wilford Hall USAF Medical Center, San Antonio, TX
    • ,
  • John Carson

      Affiliations

    • Department of Surgery, University of California Irvine, Orange, CA
    • Surgical Service, VA Long Beach Healthcare System, Long Beach, CA
    • ,
  • Russell S. Montgomery

      Affiliations

    • Department of Surgery, St. Joseph's Hospital, Orange, CA

Orange and Long Beach, California, and San Antonio, Texas

Article Outline

Pelvic kidneys complicate aortic reconstructions because of increased risk of renal ischemia. Strategies for protection include shunting, cooling, and reliance on collaterals. A review identified two congenital pelvic kidney (not solitary) and five transplanted kidney patients who underwent elective abdominal aortic aneurysm repair. For congenital pelvic kidneys, topical cooling was used in one patient while no preservation was performed for the other patient. Three transplanted kidney patients were shunted, and one had endovascular repair. Postoperative creatinine values were compared to preoperative values. The two congenital pelvic kidney patients had no significant elevation of creatinine postoperatively. The transplanted kidney patient who underwent endovascular repair had no increase in creatinine postoperatively. All transplanted kidney patients who had open repair had significant but transient increase in creatinine postoperatively. Three patients who were shunted intraoperatively had normalization of creatinine. The patient who had persistent elevation of creatinine at discharge was not shunted. Aortorenal shunting or endovascular repair in transplanted pelvic kidney patients maintains renal function. For patients with congenital pelvic kidneys and adequate collaterals, cooling and collateral perfusion is usually sufficient. Though experience is limited, endovascular repair is likely to be superior to open repair in minimizing renal ischemia.

 

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Introduction 

The incidence of congenital pelvic kidney complicating infrarenal aortic reconstruction (aneurysmal or occlusive disease) is rare, with only 12 reported cases;1, 2, 3, 4, 5, 6, 7, 8, 9, 10 A congenital, solitary pelvic kidney has been reported in only two patients.8, 10 On the other hand, the incidence of transplanted pelvic kidney complicating infrarenal aortic reconstruction is increasingly common, with approximately 135 reported cases.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 The vascular surgeon's exposure to this unusual problem will likely increase in the future as the elderly are the fastest growing sector in the dialysis population. Specific protective techniques have been described in the last 25 years to protect the kidney during aortic cross-clamping, including shunting, cooling, and passive use of collaterals.

In this report, we review the clinical course of two patients with a congenital pelvic kidney (not solitary) and five patients with transplanted pelvic kidneys who underwent elective infrarenal aortic aneurysm repair in order to make recommendations for intraoperative management.

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Methods 

This study was a retrospective (1991-2005) chart review of seven patients from the University of California, Irvine Medical Center (n = 1), the Long Beach Veterans Hospital (n = 2), the Wilford Hall USAF Medical Center (n = 3), and St. Joseph's Hospital (n = 1). The literature from 1976-2005 was reviewed.

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Results 

Table I, Table II show the clinical data obtained for patients who had congenital pelvic kidneys (Fig. 1) and for patients who had kidneys transplanted to a pelvic location after elective abdominal aortic aneurysm (AAA) repairs.

Table I. Two patients with congenital pelvic kidneys and normal contralateral kidneys having asymptomatic infrarenal aortic aneurysm repair
Age (years)/sexKidney/locationPathologyOperationCreatinine (mg/dL)aProtection
69/MLeft-sided with a single renal artery from the internal iliac4.4 cm AAA1997, 18 mm tube graft1.2, 1.3, 1.2, NANone
65/MLeft-sided with a single artery from the aortic bifurcation6.3 cm AAA1991, 24 × 12 mm aortobi-iliac bypass with a separate bypass to the pelvic renal artery1.6, 1.8, 1.6, NATopical ice

NA,not available.

aThe creatinine values reported above are given in sequence of value before surgery, peak value after surgery, value at discharge, and value at last follow-up.

Table II. Five patients with transplanted pelvic kidneys having asymptomatic infrarenal aortic aneurysm repairs
Age (years)/sexKidney duration/locationPathologyOperationCreatinine (mg/dL)aProtection
62/M20 years and connected to the left internal iliac artery8 cm AAA and right common iliac artery aneurysm1995, aortobi-iliac bypass2.0, 7.0, 3.3, NADouble-clamp technique of Lacombec
66/M18 years and connected to the right internal iliac artery5 cm AAA1999, aortobi-iliac bypass, Dacron jump graft to the transplant renal artery2.0, 4.1, 1.9, 1.3Temporary aortorenal shuntb
72/M12 years and connected to the right internal iliac arteryAAA with severe bilateral iliac artery occlusive disease1994, 18 × 9 mm aortofemoral bypass, Dacron jump graft to the transplant renal artery1.9, 3.0, NA, 1.5Temporary aortorenal shuntb
64/M10 years and connected to the right external iliac artery6.4 cm AAA and 3 cm left iliac aneurysm1993, 18 × 9 mm aortobi-iliac bypass0.9, 2.5, 1.2, 1.0Temporary aortorenal shuntb
60/MConnected to the left external iliac artery6.5 cm AAA with severe right iliac artery occlusive disease2004, 28 × 16 mm bifurcated AneuRxd endoluminal graft1.2, 1.3, 1.2, 1.2None

NA, not available.

aThe creatinine values are given in the sequence value before surgery, peak value after surgery, value at discharge, and value at last follow-up.

bAll shunts were placed by the same surgeon (R. M. F.) in the same way. The pararenal aorta was exposed, and one or two pursestring sutures were placed anteriorly. The aorta was incised with a #11 blade and the large end of the shunt quickly placed through it. Rommell tourniquets were used to secure the pursestrings. The distal end of the shunt was then placed into the renal artery either through a direct arteriotomy or via the adjacent inflow artery. The shunt was placed and removed without the need for an aortic cross-clamp. The function of the shunt was confirmed with Doppler ultrasound.

cSee Discussion for description of technique.

dAneuRx (Medtronic, Sunnyvale, CA).

Both patients with congenital pelvic kidneys had no significant elevation of their creatinine values. One patient (69-year-old male) had normal creatinine, while the other patient (65-year-old male) had slightly elevated creatinine preoperatively. Cooling measure was performed in one patient (69-year-old male), but no shunting was instituted for either patient.

One patient (60-year-old male) with transplanted kidneys who underwent endvascular AAA stent grafting had no increase in creatinine postoperatively. Three patients (66-year-old male, 72-year-old male, 64-year-old male) with transplanted pelvic kidneys had temporary aortorenal shunt during open AAA repair. All three patients had transient elevation of creatinine values but had normalized at time of discharge or last follow-up. One patient (62-year-old male) was not shunted during open repair and had significant elevation of creatinine postoperatively from 2.0 to 7.0 mg/dL. His creatinine decreased during hospitalization but remained elevated at 3.3 mg/dL at time of discharge.

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Discussion 

Renal function is more susceptible to ischemia in patients undergoing elective AAA repair who have transplanted kidneys than in patients with ectopic pelvic kidneys. Of the 12 reported cases of congenital pelvic kidney complicating aortic reconstruction, 11 underwent open repair1, 2, 3, 4, 5, 6, 7, 8, 9 while only one was stent-grafted,10 with none had creatinine abnormalities at the time of discharge. Seven of these 11 open cases had no shunting or cooling measures done during surgery. Similarly, of our two patients with congenital pelvic kidneys, neither had any creatinine abnormalities after surgery.

Except for patients with congenital solitary pelvic kidney, good results with congenital pelvic kidney should be expected as these patients had a normal kidney above the AAA that was not at risk of ischemic injury. Without the advantage of pre- and postoperative nuclear renal isotope scans to assess excretion and flow, it is difficult to assess the degree of acute tubular necrosis (ATN) in the congenital pelvic kidney in a patient with a normal contralateral kidney. However, Hollis et al.2 reported one patient in whom they found a 6% loss of renal function in the congenital pelvic kidney. Unlike a transplanted pelvic kidney, the congenital pelvic kidney most often has multiple renal arteries (six of seven reported cases), one of which may originate from the diseased distal aorta, mandating an additional third anastomosis prior to reestablishing pelvic kidney flow.1, 2, 3, 4

Of our four patients with a transplanted pelvic kidney who underwent open repair, all developed significant, albeit largely transient, rises in creatinine value. Only one (62-year-old male) of the four transplant patients had an elevation of creatinine at discharge (2.0-3.3 mg/dL). In this patient, the surgeon relied on surface cooling rather than a shunt during surgery. In 47 reported cases of transplanted pelvic kidney with aortic reconstruction,42, 43, 44, 45, 46 the incidence of a 40% or greater rise in postoperative creatinine is 23%. Typically, this initial rise of creatinine levels is followed by a complete or near complete recovery, which is consistent with the natural history of ATN. Seventy percent (7 of 10) of patients developed some degree of postoperative ATN despite the use of shunting or cooling measures. Eighty-one percent (30 of 37) of patients who had no evidence of postoperative ATN were successfully operated on without the use of shunting or cooling measures.42, 43, 44, 45, 46

A preprocedure elevation of creatinine likely puts the patient at a higher risk for clinically apparent ATN postprocedure because of diminished functional renal reserve. In a report by Lacombe,30 of 15 patients with transplanted pelvic kidney complicating aortic reconstruction, a transient >20% elevation of creatinine was seen in two of nine patients with a normal creatinine and in three of six patients with a creatinine of 1.7-3.1 mg/dL. One of our patients (66-year-old male) with 80-90% renal artery stenosis had a lower creatinine after surgical repair. The improvement of ischemic nephropathy measured by the decrease in serum creatinine after renal artery bypass surgery is well described, although unusual.31

Specific shunts described for maintaining flow to the pelvic kidney during aortic cross-clamping include axillofemoral bypass,33, 44 aortoiliac bypass, (either in-line33 or extra-anatomic33, 34), and femoral vein-to-femoral artery bypass using a pump oxygenator.35 The authors of these reports believed their techniques to be neither time-consuming, unnecessary, nor difficult. In three of our patients we placed a Sundt carotid shunt (NeuroCare, Pleasant Prairie, WI) in the pararenal aorta secured by a pursestring suture. The smaller end of the shunt was then placed in the transplanted renal artery. Aortic cross-clamping was not required to place or remove the shunt. Other authors have described a similar technique with an aortic cannula33 or a 7 mm shunt.34 In these cases, the left renal vein can be divided to facilitate aortic exposure without the need to reapproximate it. Schneider and Cronenwett1 placed a Javid carotid shunt (C. R. Bard, Billerica, MA) via a pursestring through the body of the graft after the proximal anastomosis was completed to perfuse the kidney during the distal anastomosis.

Cooling techniques, when done properly, should allow aortic cross-clamp time to extend well beyond an hour. The most commonly described technique is the infusion of 4°C Ringer's lactate under pressure continuously into the kidney. Owens et al.36 reported that infusion of a 4°C solution will lower kidney temperature to 13°C in 5 min. Botta et al.37 infused 4°C Ringer's lactate retrograde through a femoral cannula at a pressure of 80 mm Hg (2.5 L) with good results. Murakami et al.8 recently demonstrated good renal protection with a combination of in situ cold perfusion and topical ice slush in a patient with a congenital solitary pelvic kidney.

Lacombe and others2, 14, 30, 38 recommend avoiding shunts and cooling altogether. They recommend leaving native iliofemoral and lumbar collaterals alone to perfuse the pelvic kidney during aortic cross-clamping. Their technique involves completely dividing the aortic neck proximally between two clamps. Lumbar vessels thus pressurize the contained aneurysm sac by back-perfusion while the proximal aortic anastomosis is being completed. In the Lacombe et al. series, collateral flow generated an average pressure of 35 mm Hg within the aneurysm sac. Once the proximal anastomosis is complete, the sac can be opened and the distal anastomosis performed while the pelvic kidney is perfused by retrograde flow from the ipsilateral internal iliac and femoral arteries. In their published series of 15 patients with aortic reconstructions (eight for occlusive disease and seven for aneurysms), there was no elevation of creatinine greater than 0.1 mg/dL at the time of discharge.30 Some authors have pointed out that having two clamps together makes the proximal anastomosis more difficult.9, 44, 46 This technique has been modified by Hollis et al.2 to use a vascular stapler to avoid the distal clamp. In our one case where this technique was used, the short proximal aortic neck required us to place the distal clamp across the proximal aneurysm sac. This compression of the sac could potentially lead to significant embolization.

Gouny et al.45 reported three patients undergoing aortobi-iliac bypass with no protection. Two of these patients required a third anastomosis of the renal artery to the graft.45 All three patients had a transient rise of creatinine postoperatively which normalized by the time of discharge. A fourth patient in this series had a temporary shunt used but still had the same transient creatinine rise.45 When using a bifurcated graft, performing the distal anastomoses before the proximal anastomosis is another described technique for limiting clamp time.22, 23, 43 By taking the graft limb ipsilateral to the pelvic kidney and anastomosing it distal to the kidney on the external iliac artery, this anastamosis can be done without interrupting the normal aortoiliac flow to the pelvic kidney. Warm kidney ischemic time is then limited to the time it takes to do the proximal aortic anastomosis only.

In suitable aneurysm candidates, the use of an endovascular graft can also be considered for treatment in patients with congenital pelvic kidneys.10 Kaplan et al.10 demonstrated successful exclusion of AAA with normal postoperative creatinine levels in one patient with congenital solitary pelvic kidney. Our result (60-year-old male) and four recent case studies also show successful application of endovascular stent grafting to treat AAA in patients who had transplanted kidneys.39, 40, 41 Endovascular repair obviates the need for renal protection as warm ischemic time is limited to ballooned graft placement. This is also especially attractive for high-risk patients with multiple comorbidities who otherwise may not tolerate open repair. Contrast load and excessive manipulation of the donor artery in renal allograft patients, however, need to be minimized in order to achieve optimal outcomes.

The risk factors currently associated with postoperative ATN include (1) the pelvic kidney constituting all functioning renal mass (e.g., transplant); (2) more than two anastomoses required to revascularize the kidney (e.g., reimplantation or bypass of the pelvic renal artery); (3) an elevated creatinine preoperatively; (4) poor collaterals such as occluded lumbars, inferior mesenteric artery, or internal iliac arteries or a measured aortic sac backpressure of <35 mm Hg; and (5) estimated aortic cross-clamp time of more than 50 min. Though our results and those of previous studies demonstrate normal renal function postoperatively without shunting in congenital pelvic kidney patients, these results are inconclusive due to the presence of abdominal contralateral kidneys and the lack of pre- and postoperative nuclear scans of pelvic kidneys. The recent report by Murakami et al.,8 however, is encouraging and shows that topical cooling and in situ hypothermic perfusion are sufficient to protect renal function in a solitary pelvic kidney with aortic cross-clamping time and renal ischemic time of 58 and 51 min, respectively. We therefore surmise that in congenital pelvic kidney patients with normal intra-abdominal contralateral kidneys and adequate collaterals, cooling measures and a simple expedient operation utilizing, if possible, the proximal aortic double-clamp technique of Lacombe is probably sufficient.

Several useful techniques for protecting the pelvic kidney during reconstruction of the aorta have been described. They can be grouped into shunts, cooling, and passive use of collaterals; and according to published reports, each has yielded good results. With all techniques, ATN is common after surgery and tends to resolve within 2 weeks. Whether an episode of transient ATN shortens transplanted kidney life span is unknown, but we think it is prudent to take reasonable steps to minimize ATN without adding complications to the procedure. Which of the currently available techniques of shunting and cooling are better at preventing ATN than simple clamping is not readily apparent from a review of the literature; however, in our four transplant patients, there appeared to be a benefit to shunting.

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 Presented at the 23rd Annual Meeting of the Southern California Vascular Surgery Society, La Quinta, California, May 13-15, 2005.

PII: S0890-5096(07)00068-4

doi:10.1016/j.avsg.2007.01.004

Annals of Vascular Surgery
Volume 21, Issue 2 , Pages 143-148, March 2007

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