Renal autotransplantation in renovascular hypertension secondary to renal artery aneurysm
Autotrasplante renal en hipertensión renovascular secundaria a aneurisma de arteria renal
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Manuel García-Buitron, César García-Cantón, Pablo Braillard-Poccard, Ana Y. Sánchez-Santana, Ingrid Auyanet-Saavedra, Elvira Bosch-Benítez-Parodi, M. Dolores Checa-Andrés" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Fátima" "apellidos" => "Batista-García" "email" => array:1 [ 0 => "fbatgarc@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Pilar" "apellidos" => "Rossique-Delmas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "J. 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"apellidos" => "Sánchez-Santana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 6 => array:3 [ "nombre" => "Ingrid" "apellidos" => "Auyanet-Saavedra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 7 => array:3 [ "nombre" => "Elvira" "apellidos" => "Bosch-Benítez-Parodi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 8 => array:3 [ "nombre" => "M. Dolores" "apellidos" => "Checa-Andrés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Insular de Gran Canaria, Las Palmas de Gran Canaria, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Urología, Hospital Juan Canalejo, La Coruña, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Autotrasplante renal en hipertensión renovascular secundaria a aneurisma de arteria renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11825_16025_46848_en_11825_f1.jpg" "Alto" => 614 "Ancho" => 649 "Tamanyo" => 79365 ] ] "descripcion" => array:1 [ "en" => "Angiogram" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Content</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor:</span></p><p class="elsevierStylePara">Fibromuscular dysplasia (FMD) is occasionally accompanied by renal artery aneurysms. Percutaneous treatment is the treatment of choice in simple aneurysms and surgical treatment is reserved for complicated aneurysms and other selected cases.<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">We report the case of a 36-year-old male, smoker, known as hypertensive for 20 years, who was monitored in our Hypertension Unit. During the year in which he was monitored, he had hypertensive emergency associated with headaches. Among the additional tests conducted, laboratory and eye fundus tests and renal ultrasound were normal. The echocardiography revealed a mild left ventricular hypertrophy with grade I diastolic dysfunction and the captopril test did not suggest renovascular hypertension (RVHT).</p><p class="elsevierStylePara">Five years later, he was admitted due to an episode of transient ischaemic attack in the context of a hypertensive emergency (210/130mmHg). At that time, the laboratory tests and renal ultrasound were normal and the eye fundus revealed a Keith-Wagener grade I hypertensive retinopathy. Since he was a young male with sustained high blood pressure (HBP) and frequent hypertensive emergencies, we wanted to rule out RVHT. The patient refused all forms of intervention and it was decided to continue ambulatory monitoring; optimal control of blood pressure (BP) was achieved with five drugs (irbesartan 300mg/day, hydrochlorothiazide 12.5mg/day, ramipril 5mg/12h, amlodipine 15mg/day, carvedilol 12.5mg/12h).</p><p class="elsevierStylePara">The following year, he suffered a subarachnoid haemorrhage after rupture of an aneurysm in the right superior cerebellar artery, making a full recovery after embolisation.</p><p class="elsevierStylePara">Subsequently, we observed a significant deterioration in renal function: creatinine (Cr) 3.7mg/dl, creatinine clearance (CrCl) 26.35 ml/min, which partially improved after discontinuation of the angiotensin converting enzyme inhibitor and the angiotensin II receptor antagonist. Given the suspicion of RVHT, a magnetic resonance angiogram was performed on the abdomen, confirming the presence of right renal artery stenosis 11mm from the ostium and an ovoid aneurysm in the final portion of the left renal artery, with a diameter greater than 1.8cm. Subsequently, renal arteriography was performed, in which we observed bilateral renal artery stenosis of probable fibromuscular dysplasia origin (Figure 1). Given these findings, bilateral percutaneous transluminal angioplasty was performed with ad integrum recovery of renal function: Cr 1mg/dl, CrCl 80ml/min and BP controlled with triple antihypertensive therapy (labetalol 300mg/day, amlodipine besylate 10mg/12h, torasemide 5mg/day).</p><p class="elsevierStylePara">Five years later, a follow-up renal ultrasound showed renal asymmetry, not previously observed (left kidney 8.5cm, right kidney 10cm), and therefore a computed tomography angiogram of the renal arteries was requested, confirming left renal artery restenosis, and the presence of an aneurysm on the right kidney of 1.5 x 1.2cm and the known aneurysm on the left side in an hourglass shape whose largest end measured 1 x 1.5 x 2.4cm. Furthermore, the ostium of 4 arterial branches was observed on the left side of the aneurysm. Given these findings, because it is an aneurysm with a complex anatomy, we ruled out the possibility of percutaneous treatment and the patient was taken to the Hospital Juan Canalejo de La Coruña for surgery. During the procedure, left laparoscopic nephrectomy and exeresis of a fragment of internal iliac artery with 4 arterial branches that had previously been selected in a lower limb angiogram were performed. Subsequently, in back table surgery the left renal artery aneurysm was resected in order to anastomose the 4 branches of the iliac artery with the 4 post aneurysm renal branches (Figure 2). Then the left kidney was autotransplanted to the patient's left iliac fossa. After surgery, renal function was normal (Cr 1.2mg/dl, CrCl 97ml/min) and BP was controlled with low-dose triple therapy (carvedilol 6.25mg/day, amlodipine 10mg/day, torasemide 2.5mg/day).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">The arteries most frequently involved in FMD are renal (60%) and internal carotid (30-60%), although other arteries can also be involved, such as cerebral, vertebral, iliac, subclavian and visceral arteries.<span class="elsevierStyleSup">2,3</span> Renal artery aneurysms are diagnosed with a 0.7-1.3% incidence in renal angiograms. They may be asymptomatic, although they are generally associated with HBP (55%), haematuria (30%), flank pain (15%),<span class="elsevierStyleSup">1</span> etc. They can also be associated with renal artery stenosis and kidney failure. Surgical treatment is reserved for complex cases of aneurysms, major aneurysms of 2-2.5cm or when there is a progressive increase in their size. It is also indicated in cases of uncontrolled HBP, failed previous percutaneous treatment and when there are associated complications: renal artery thrombosis, haematuria due to rupture, renal infarction due to dissection or distal embolisation, etc.<span class="elsevierStyleSup">1,4,5</span> Surgery is also indicated in pregnancy, given the high risk of rupture, which could be fatal to both mother and foetus. Autotransplantation after aneurysm resection and ex vivo reconstruction is considered the treatment of choice in complex cases of aneurysms with multiple arterial anastomosis.<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Surgery in this case resulted in a considerable reduction in the number of antihypertensive drugs used, as well as the preservation of renal function and structural integrity.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/11825_16025_46848_en_11825_f1.jpg" class="elsevierStyleCrossRefs"><img src="11825_16025_46848_en_11825_f1.jpg" alt="Angiogram"></img></a></p><p class="elsevierStylePara">Figure 1. Angiogram</p><p class="elsevierStylePara"><a href="grande/11825_16025_46849_en_11825_f2.jpg" class="elsevierStyleCrossRefs"><img src="11825_16025_46849_en_11825_f2.jpg" alt="Back table surgery"></img></a></p><p class="elsevierStylePara">Figure 2. Back table surgery</p>" "pdfFichero" => "P1-E550-S4088-A11825-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11825_16025_46848_en_11825_f1.jpg" "Alto" => 614 "Ancho" => 649 "Tamanyo" => 79365 ] ] "descripcion" => array:1 [ "en" => "Angiogram" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11825_16025_46849_en_11825_f2.jpg" "Alto" => 963 "Ancho" => 1386 "Tamanyo" => 236432 ] ] "descripcion" => array:1 [ "en" => "Back table surgery" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Blanco Díez A, Armas Molina J, Alvarado Rodríguez A, Alcaraz Asensio A, Artiles Hernández J, Chesa Ponce N. 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| 2019 July | 47 | 17 | 64 |
| 2019 June | 42 | 6 | 48 |
| 2019 May | 46 | 14 | 60 |
| 2019 April | 80 | 25 | 105 |
| 2019 March | 43 | 22 | 65 |
| 2019 February | 34 | 17 | 51 |
| 2019 January | 50 | 20 | 70 |
| 2018 December | 75 | 33 | 108 |
| 2018 November | 98 | 14 | 112 |
| 2018 October | 82 | 16 | 98 |
| 2018 September | 76 | 14 | 90 |
| 2018 August | 54 | 20 | 74 |
| 2018 July | 45 | 12 | 57 |
| 2018 June | 64 | 14 | 78 |
| 2018 May | 51 | 12 | 63 |
| 2018 April | 60 | 9 | 69 |
| 2018 March | 64 | 8 | 72 |
| 2018 February | 62 | 6 | 68 |
| 2018 January | 49 | 8 | 57 |
| 2017 December | 64 | 9 | 73 |
| 2017 November | 53 | 10 | 63 |
| 2017 October | 52 | 5 | 57 |
| 2017 September | 48 | 10 | 58 |
| 2017 August | 40 | 11 | 51 |
| 2017 July | 45 | 14 | 59 |
| 2017 June | 35 | 25 | 60 |
| 2017 May | 37 | 6 | 43 |
| 2017 April | 35 | 10 | 45 |
| 2017 March | 29 | 4 | 33 |
| 2017 February | 47 | 6 | 53 |
| 2017 January | 31 | 11 | 42 |
| 2016 December | 44 | 7 | 51 |
| 2016 November | 67 | 9 | 76 |
| 2016 October | 103 | 7 | 110 |
| 2016 September | 154 | 2 | 156 |
| 2016 August | 219 | 11 | 230 |
| 2016 July | 206 | 8 | 214 |
| 2016 June | 146 | 0 | 146 |
| 2016 May | 133 | 0 | 133 |
| 2016 April | 92 | 0 | 92 |
| 2016 March | 76 | 0 | 76 |
| 2016 February | 130 | 0 | 130 |
| 2016 January | 108 | 0 | 108 |
| 2015 December | 119 | 0 | 119 |
| 2015 November | 80 | 0 | 80 |
| 2015 October | 76 | 0 | 76 |
| 2015 September | 79 | 0 | 79 |
| 2015 August | 59 | 0 | 59 |
| 2015 July | 77 | 0 | 77 |
| 2015 June | 43 | 0 | 43 |
| 2015 May | 55 | 0 | 55 |
| 2015 April | 6 | 0 | 6 |
Show all
