Successful Kidney Transplantation Using Elderly Living Donor with Extremely Large Renal Cyst and Double Arteries.

The authors describe a kidney transplant procedure using a living donor with a large cyst and double arteries. Due to the lack of regular transplant activity from a deceased donors, we decided to use the, so called, expanded criteria living donors, which means older age (more than 65 years), hypertension, some structural anomalies of the kidneys (cysts, multiple renal arteries), ABO incompatible kidney transplant, etc. The surgical procedure was the unroofing of a large cyst and wadding with perirenal fat. The 10 years survival rate is quite successful and we can recommend it.

Robot-assisted Partial Nephrectomy With Selective Artery Clamping for Renal Cell Carcinoma in Horseshoe Kidney.

BACKGROUND: Robot-assisted partial nephrectomy (RAPN) has become the standard treatment for small renal tumors, including highly complex cases. However, applying RAPN to renal tumors in the horseshoe kidney (HSK) is clinically challenging due to malformations and complex blood supply. Herein, we present two cases of RAPN in patients with HSK treated using selective artery clamping methods. CASE REPORTS: A 61-year-old male with a 15 mm renal tumor located on the upper pole of the right HSK was referred to our Department. The patient underwent RAPN via the transperitoneal approach, following a three-dimensional computed tomography (3D-CT) assessment. Additionally, before surgery, we confirmed which renal arteries would be clamped in surgery by examining the kidney regions supplied by each renal artery. The second patient referred to our Department, a 45-year-old male, had a 46 mm renal tumor located on the isthmus of the HSK. His tumor received blood supply from two renal arteries, with the bilateral collecting systems converging and forming a ureter on 3D-CT. The patient underwent RAPN through an intraperitoneal approach in the semi-lateral position, with port placement lower than in standard RAPN. Pathological examinations revealed clear-cell renal cell carcinoma with negative surgical margins in both cases. Both patients had no recurrences or metastases at 53 and 13 months post-surgery, respectively. CONCLUSION: We present cases successfully treated with RAPN with selective artery clamping methods for HSK using 3D-CT without encountering complications, even in isthmus tumors.

Transarterial Embolization of Renal Arteriovenous Malformations: Treatment Outcomes According to Angiographic Classification.

PURPOSE: To assess the different adjunctive catheter techniques required to achieve complete occlusion of renal arteriovenous malformations (rAVMs) of different angioarchitectural types. MATERIALS AND METHODS: Overall, data on 18 patients with rAVM (Type 1, n = 7; Type 2, n = 2; Type 3, n = 9; mean age, 53.8 years) who underwent 25 procedures between 2011 and 2022 were reviewed. The clinical presentations, endovascular techniques, arteriovenous malformation (AVM) occlusion rate, adverse events (including the incidence of renal infarction), and clinical symptoms and outcomes (including recurrence/increase of AVM) were analyzed according to the Cho-Do angioarchitectural classification. Posttreatment renal infarction was classified as no infarction, small infarction (<12.5%), medium infarction (12.5%-25%), and large infarction (>25%) using contrast-enhanced computed tomography or magnetic resonance imaging. RESULTS: Hematuria and heart failure were presenting symptoms in 10 and 2 patients, respectively. The embolic materials used were as follows: Type 1 rAVM, coils alone or with n-butyl-2-cyanoacrylate (nBCA); Type 2 rAVM, nBCA alone or with coils; and Type 3 rAVMs, nBCA alone. Fourteen patients underwent adjunctive catheter techniques, including flow control with a balloon catheter and multiple microcatheter placement, alone or in combination. Immediate postprocedural angiography revealed complete occlusion in 15 patients (83%) and marked regression of rAVM in 3 (17%). Small asymptomatic renal infarctions were observed in 6 patients with Type 3 rAVMs without any decrease in renal function. No major adverse events were observed. All symptomatic patients experienced symptom resolution. Recurrence/increase of rAVM was not observed during the mean 32-month follow-up period (range, 2-120 months). CONCLUSIONS: Transarterial embolization using adjunctive catheter techniques according to angioarchitectural types can be an effective treatment for rAVMs.

Anterograde Aortic Bypass Technique for Renal Preservation in Aneurysmal Repair With Horseshoe Kidney: A Novel Approach With Reduced Renal Ischemic Time.

The purpose of this article is to highlight an innovative technique in the surgical management of aortic aneurysms in the presence of a horseshoe kidney. The technique involves an anterograde aortic bypass from the distal thoracic aorta to the major renal artery with the primary advantage to a significant reduction in renal ischemia time.

Anomalous origin of the left suprarenal, inferior phrenic arteries and left ovarian artery in a human cadaver.

This report addresses three variants identified within a female cadaver. Specifically, these were an anomalous origin of the right suprarenal artery, an abnormal bilateral ovarian vein branch, and a arterial tortuosity of the left ovarian artery. Indeed, the cadaver evinced abnormal origins in the case of the middle suprarenal artery (MSA), right inferior phrenic artery (IPA), and the renal capsule artery (emanating from the right renal artery). The MSA and IPA shared a common trunk with the inferior suprarenal artery. It was additionally observed that the right ovarian vein anastomoses the branches from the right kidney posterior inferior along with those to the renal fat capsule. Abnormal origin was evident in the case of the left ovarian artery, and arterial tortuosity was apparent in the lower region of the vessels. This report addresses both the clinical import of these variations and their likely causes. In the subdiaphragmatic region, surgical success and prognosis may be impacted by such anomalies; accordingly surgeons must be aware of anatomical variants of the ovarian and suprarenal arteries.

Venous supply of horseshoe kidneys and normal kidneys: an angio-multislice computed tomography-based study.

BACKGROUND: Horseshoe kidney (HSK) is a common developmental anomaly which can be associated with many atypical anatomical variants of blood supply. The aim of this study was to identify the anatomical variants of renal veins supplying HSK, with particular emphasis on their relationship with the arterial system. MATERIALS AND METHODS: The analysis included 94 patients with HSK and 248 persons with normal kidneys (NK). Based on computed tomography-angiography, the number of renal arteries and veins was determined, along with the levels the arteries branched off the aorta and the veins communicated to their parental vessels. RESULTS: Four hundred and twenty-three renal arteries (4.5 per person) and 364 renal veins (3.78 per persons) were found in HSK group (p = 0.004), as compared with 598 arteries (2.41 per person) and 567 veins (2.29 per person) in the NK group (p = 0.025). Mean number of renal veins in women with HSK was higher than in men (4.11 vs. 3.72 per patient, p = 0.03). In the HSK group, the number of renal arteries correlated significantly with the number of renal veins only among men (ks = 0.35, p = 0.009). In patients with NK, significant correlations between the number of renal arteries and renal veins were found both in the whole group and among men and women. CONCLUSIONS: Horseshoe kidneys are drained by a higher number of renal veins than NK, especially in women; this also refers to accessory renal veins. The number of renal veins for HSK is less dependent on the number of corresponding arteries than these for NK.

A unique case of extrarenal calyces and associated vascular variations in an adult female cadaver.

The following urogenital and vascular anomalies were observed in the left kidney of an 81-year-old female cadaver during routine dissection: three extrarenal calyces; an accessory renal artery originating directly from the abdominal aorta; and a circumaortic renal vein. The typical renal anatomical structures were identified, from anterior to posterior, as the renal vein, renal artery, and ureter appearing near the hilum of the left kidney. After closer examination, three extrarenal calyces were observed exiting from the hilum of the left kidney to form the pelvis, then narrowed and became the ureter which descended 21.5 cm to empty into the bladder. The accessory renal artery originated from the lateral aspect of the abdominal aorta 7.3 cm below the aortic origin of the left renal artery. A corresponding accessary renal vein, identified as a circumaortic vein, left the hilum 4.5 cm below the left renal vein and travelled posterior to the abdominal aorta to drain into the inferior vena cava. Extrarenal calyces are rare among urogenital tract variations. They can be associated with embryological abnormalities such as renal ectopia, horseshoe kidney or malrotation as well as clinical manifestations such as pelviureteric junction obstruction and hydronephrosis. Compression of the accessory renal artery can cause decreased blood flow to the inferior pole of the left kidney, thereby causing fibrosis, atrophy, or renal failure. The retro-aortic path of the circumaortic renal vein has been associated with posterior nutcracker phenomenon, haematuria, left renal vein thrombus formation, and renal vein hypertension. This unique combination of a collecting system anomaly and extrarenal vessel variations could have significant implications in abdominal surgery.

Triple V-plasty: Novel Renovascular Reconstruction Technique in Live-Donor Transplantation.

INTRODUCTION: Donor renovascular anomalies, including multiplicity, length and caliber of blood vessels, could hinder renal transplantation, especially from live-donors. However, meticulous back-bench vascular reconstruction ascertaining orientation and patency of individual vessels can be effective in utilization of renal grafts with multiple renal arteries, helping to expand the pool of live-donors. SURGICAL TECHNIQUE: Sequential v-plasty of individual donor renal arteries using fine, non-absorbable, monofilament (7-0 or 8-0 Prolene) suture in an uninterrupted fashion enables creation of a single, wide ostium for anastomosis with the target, inflow recipient (usually external or common iliac) artery. Additionally, entwined donor hilar renovasculature may necessitate incisional separation and re-anastomosis of a bifid vein for proper renovascular orientation following graft implantation in the recipient. CONCLUSION: Application of never-before described ex vivo renovascular reconstruction led to live-donor renal transplantation between two pairs of donor-recipient through the National Kidney Registry with successful long-term outcomes.

Refractory hypertension secondary to renal artery stenosis with a honeycomb-like structure.

BACKGROUND: A honeycomb-like structure (HLS) is a rare abnormality characterized by a braid-like appearance. Angiograph and intravascular examination, including coherence tomography and intravascular ultrasound (IVUS), can further confirm the multiple intraluminal channels or honeycomb structure, which can also be described as looking like 'swiss cheese', a 'spider web' or a 'lotus root'. Previous studies have mostly reported this abnormality in coronary arteries, with a few cases in renal arteries. More information about the characteristics and development of HLS is needed. CASE PRESENTATION: A 69-year-old Han man with resistant hypertension received abdominal enhanced computerised tomography and was revealed to have left renal artery stenosis with the possibility of left renal infarction. Renal artery angiography confirmed a 95% stenosis located in the proximal segment of the left renal artery, and the middle segment was blurred with multi-channel-like blood flow. Further IVUS was performed and identified multiple channels surrounded by fibrous tissue. It was a rare case of HLS in the renal artery secondary to the thrombus, with organisation and recanalisation. Balloon dilatation and stent implantation at the proximal segment of the left renal artery were performed successfully. Blood pressure was well controlled after the procedure. CONCLUSIONS: The IVUS findings are helpful for forming interventional therapeutic strategies for HLS lesions in the renal artery.

Renal Artery Reconstruction for Refractory Hypertension Caused by Congenital Renal Artery Deficiency.

Renovascular hypertension is a common cause of secondary hypertension. According to the epidemiological survey, the prevalence of renovascular hypertension accounts for 1-5% of the population with hypertension. Most of the cases are associated with atherosclerosis and Fibromuscular Dysplasia (FMD). Owing to the lack of standard treatment, they will eventually develop into chronic kidney disease, which significantly affects the patient's quality of life. Hypertension is considered a prerequisite for renal artery surgery; renal function research is used to guide the treatment of unilateral lesions because endovascular intervention can only slightly improve hypertension and renal function. We advocate open surgery for patients with congenital dysplasia of renal vascular hypertension, in which the most common surgical operations are aortorenal artery bypass, renal artery endarterectomy, and renal artery replantation. This paper reports a rare case of renovascular hypertension. The patient was a 13-year-old female, and the operation was risky and complicated. He was diagnosed with a congenital absence of the right renal artery. The right renal function was recovered, and the blood pressure was well controlled after the Aorta-Right Renal Artery Bypass.

Renal denervation in a patient with a highly tortuous renal artery using a guide extension catheter: a case report.

BACKGROUND: Catheter-based renal denervation (RDN) has been introduced to treat resistant hypertension. Although the technology of RDN has been largely improved, denervation of tortuous renal arteries remains challenging. CASE PRESENTATION: This is a case report of a 49-year-old man with drug resistant hypertension. The patient was selected for RDN after ruling out possible causes of secondary hypertension. Computed tomography angiography showed a highly tortuous left renal artery. An Iberis multielectrode ablation catheter failed to reach the target vessel with a regular guiding catheter. A 5-French extension catheter was introduced into the proximal segment of the main left renal artery to provide extra support force, which enabled successful ablation of the highly tortuous left renal artery. His ambulatory blood pressure was significantly decreased at 1 month follow-up. CONCLUSIONS: It is feasible and effective to use a guide extension catheter for denervation of highly tortuous renal arteries. The present study provides a useful method to ablate tortuous and angled renal arteries and branches.

An Uncommon Variant of Nutcracker Syndrome Secondary to Left Renal Vein Compression Between the Right Renal Artery and The Proper Hepatic Artery.

Nutcracker syndrome refers to the compression of the left renal vein between the abdominal aorta and the superior mesenteric artery. The subsequent venous congestion of the left kidney, when symptomatic, could be associated with left flank pain, hematuria, varicocele, dyspareunia, dysmenorrhea, and proteinuria. Here we describe a 42-year-old female patient with simultaneous Dunbar syndrome and a rare variant of nutcracker syndrome in which the left renal vein (LRV) compression is secondary to the unusual path of the vein between the right renal artery and the proper hepatic artery. For both the nutcracker syndrome and the Dunbar syndrome, open approach by median mini-laparotomic access for transposition of LRV, and resection of the diaphragmatic pillars and arcuate ligament was attempted. During the intervention, due to anatomical issues, the LRV transposition was converted to endovascular stenting of the LRV, moreover the implanted stent was transfixed with an external non-absorbable suture to avoid migration. At the 12 months follow-up the patient was asymptomatic, and the duplex scan confirmed the patency of the celiac trunk without re-stenosis and a correct position of the LRV stent with no proximal or distal migration.

Clinical effect of accessory renal artery coverage after endovascular repair of aneurysms in abdominal and thoracoabdominal aorta.

BACKGROUND: The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms. METHODS: An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality. RESULTS: Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I2 = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I2 = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I2 = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I2 = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I2 = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I2 = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I2 = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I2 = 0%). CONCLUSIONS: ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.

Crossing vessels with suspension versus transposition in laparoscopic pyeloplasty of patients with ureteropelvic junction obstruction: a retrospective study.

PURPOSE: To compare the effects of two different methods of laparoscopic pyeloplasty for the treatment of crossing vessels. METHODS: From January 2016 to August 2019, 33 patients with ureteropelvic junction obstruction (UPJO) underwent laparoscopic pyeloplasty at our center, including 21 men and 12 women, ranging from 14 to 66 years of age. There were 20 and 13 cases on the left and right sides, respectively. Patients underwent laparoscopic pyeloplasty (Anderson-Hynes operation). During the operation, either a Hem-o-lok clip suspension or transposition was used to treat the crossing vessels. The double-J stent was removed 8 weeks after the operation. The clinical data of patients were collected and follow-ups were regularly performed after the operation. RESULTS: All the crossing vessels were successfully preserved, and none of them were severed during the operation. The average operation time was 210.6 ± 58.9 min in this group and the average time to manage the crossing vessel was 8.0 ± 3.5 min, 5.9 ± 1.4 min in the suspension group, and 11.7 ± 3.0 min in the transposition group. The dilation of the affected side was 4.8 ± 1.5 cm before operation and 1.2 ± 1.3 cm 3 months after operation. The difference was statistically significant (P < 0.05). Follow-up to February 2020 showed no significant changes in the kidney size in all patients and hydronephrosis was relieved. CONCLUSION: For UPJO patients with crossing vessel compression, the method of Hem-o-lok suspension or vascular transposition can be used to relieve crossing vascular compression and improve the success of pyeloplasty.

A rare case of thoracic renal artery.

Identifying of variations of renal vascular anatomy is important for radical surgery, endovascular intervention, and renal transplantation. While there are common normal variations of renal vascular anatomy, such as accessory renal arteries, a main renal artery that originates from the thoracic aorta (thoracic renal artery) is remarkably rare. The majority of reported cases of thoracic renal artery were right side, except two cases reported on 1980 and 2016. The author reports a rare case of left renal artery originating from the thoracic aorta.

Endovascular management of a patient with massive renal arteriovenous fistula: challenges and tricks.

We describe the endovascular management of a patient with a massive renal arteriovenous fistula and a huge venous aneurysmal sac, who presented with features of cardiac failure and fever. The challenges faced and the outcomes are discussed with relevant literature review.

Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms.

Renal arteriovenous fistula with renal artery aneurysms and dilated renal veins presents as an infrequent lesion. Endovascular therapy has recently been considered the first-line treatment for these conditions. We report a case of a patient with idiopathic renal arteriovenous fistula concomitant with multiple renal artery aneurysms that was successfully treated by the placement of a covered stent.

Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes.

BACKGROUND: In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs). PATIENTS AND METHODS: In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated. RESULTS: The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05). CONCLUSION: MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.