Endovascular repair of infrarenal abdominal aortic aneurysm associated with a horseshoe kidney and graft thrombosis in early follow-up

EVAR in Patients With Abdominal Aortic Aneurysm and Horseshoe Kidney: A Systematic Review

PURPOSE

A systematic review of all patients that have been reported in the literature with abdominal aortic aneurysm (AAA) concomitant with horseshoe kidney (HSK) treated electively by endovascular aneurysm repair (EVAR) is presented. A new grouping system for describing HSK vasculature is implemented.

MATERIALS AND METHODS

We searched for published manuscripts using the Medical Subject Headings terms "abdominal aortic aneurysm," "AAA," "EVAR," "endovascular aneurysm repair," and "horseshoe kidney" in PubMed, Google Scholar, Scopus, and National Center for Biotechnology Information databases. Inclusion criteria include all published material of patients with AAA with HSK treated electively by an endovascular approach. We excluded patients who were treated by a hybrid or open repair or patients with ruptured AAA. Statistical analysis was carried out using SPSS Statistics version 25 (IBM Corp, Armonk, New York) software.

RESULTS

A total of 50 patients from 30 studies were included for analysis. Males made up 88% (n=44) of the population. The median age for this cohort was 70 years (range: 47-86 years). Median aneurysmal diameter was 6.0 cm (range: 4.0-10.3 cm). The median operative time for endovascular repair was 84 minutes (range: 40-332 minutes). The most common graft used was Zenith, used in 40% (n=20) of the cases, followed by Endurant in 14% (n=7). The overall complication rate was 14% (n=7). The median follow-up was 19 months (range: 1-108 months). While comorbidities did not appear to impact outcomes significantly, median operative times for smokers were higher than those in nonsmokers, 84 versus 118 minutes, respectively (p=0.048). Univariate linear regression modeling of aneurysmal size with age, operative time, and length of stay revealed a significant coefficient association between aneurysmal size and operative times. After adjusting for comorbidities and aneurysmal size, prior history of chronic kidney disease significantly increased odds for renal infarction.

CONCLUSION

This review presents the most complete data set possible of patients with concomitant HSK and AAA treated by an endovascular approach. Furthermore, the A + B + C classification for grouping the HSK vasculature is implemented. This systematic review suggests EVAR to be an excellent option with low complication rates for the treatment of AAA in patients with HSK.

Endovascular infrarenal aneurysm repair in patients with horseshoe kidneys: case series and literature review

Horseshoe kidney may cause technical and access problems during open aortic aneurysm repair. The aim of this study is to report two cases from our institution and to review the world's literature on successful endovascular infrarenal aneurysm repair in patients with horseshoe kidneys. A retrospective review of a prospectively entered departmental computerized database was performed for the two patients from our institution. Articles were searched electronically from PubMed and Medline, using the terms ‘horseshoe kidney’ and ‘aneurysm’. Endovascular cases were reviewed from the world's literature. In addition to the two patients from our institution, there were 19 patients with infrarenal aneurysms and horseshoe kidneys in published literature who underwent successful endovascular aneurysm repair. The occlusion of lower-pole or accessory renal arteries does not seem to cause significant endoleak or renal impairment in the long run. In conclusion, our experience and current literature seem to suggest that endovascular repair of infrarenal aortic aneurysms for patients with horseshoe kidneys is safe. Renal impairment will depend on the area of kidney perfused by the accessory renal arteries. The endovascular treatment option is less invasive than open repair, and circumvents the problem of difficult exposure, especially in those patients with significant co-morbidity.