Ruptured renal artery aneurysm managed with autotransplantation

Case contributed by Jan Frank Gerstenmaier

Presentation

Acute left loin pain, having collapsed 3 hours earlier. On arrival in ED, 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

Working diagnosis (pre-CT): 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 hemorrhage. 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. Hemoglobin was 10 g/dL. Creatinine was 487 μmol/L (this patient's baseline was 100 μmol/L).

The patient became hypotensive, an emergent CT with arterial, PV and delayed phases was performed.

There is a left renal artery aneurysm. There has been progression of retroperitoneal hemorrhage since the CTKUB. Active extravasation of contrast into the left posterior pararenal space on PV and delayed phases. Atrophic right kidney.

2.2 cm left renal artery aneurysm at a branching point of renal arteries.

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

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

3 months later, the patient's creatinine is 115 μmol/l (100 μmol/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 hemodynamic 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 recognized 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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