Ruptured renal artery aneurysm managed with autotransplantation

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

This patient presented to the ED with left loin pain, having collapsed 3 hours earlier. On arrival, all vital signs were within normal limits. Urinalysis was positive for blood (++). Past medical history: Poorly functioning right kidney following infection in childhood; PCOS.

Patient Data

Age: 25 years
Gender: Female

Woking diagnosis: Left renal colic.

There is left-sided renal ptosis secondary to a large amount of intermediate attenuation material in the left retroperitoneum, predominantly in the left posterior pararenal space and left perinephric space. The appearances are in keeping with acute haemorrhage. There is no evidence of urinary tract calculus.

At the time of the CTKUB, the patient's symptoms had subsided, and all vital signs remained within normal limits. Haemoglobin was 10g/dl. Creatinine was 487micromol/l (this patient's baseline was 100 micromol/l).

The patient became hypotensive.

Appearances are in keeping with a ruptured left renal artery aneurysm with active haemorrhage. 

Urology in conjunction with the Renal Transplant Team performed autotransplantation following ex-vivo reconstruction.

3 months later. The patient's creatinine is 115 micromol/l (100 micromol/l pre-rupture).

The autotransplanted left renal kidney is seen in the right iliac fossa. A ureteric stent is in situ.

Case Discussion

In most cases of renal artery aneurysm rupture, nephrectomy is necessary due to haemodynamic instability. Left nephrectomy was to be avoided at all costs in this patient with an effectively solitary kidney (see past history). Emergency endovascular treatment with a covered stent was considered, but not attempted due to the position of the aneurysm at a branching point. 

Autotransplantation following extracorporeal reconstruction is a recognised treatment for complex hilar or intrarenal aneurysms that involve multiple arterial segments where in situ exposure of the renal hilum can be difficult.  Autotransplantation has also been reported in selected emergency cases over the years.

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Case information

rID: 22091
Case created: 10th Mar 2013
Last edited: 18th Feb 2016
Inclusion in quiz mode: Included

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