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A. K. Natour and A. D. Shepard
from the proximal sigmoid colon cephalad toward the aortic hiatus (Fig.11.3). A
retroperitoneal plane is developed anterior to the left kidney with the spleen, tail of
the pancreas, and splenic exure of the colon retracted medially. A plane anterior to
the kidney is developed using a combination of blunt and sharp dissection taking
care not to injure the mesocolon medially; this plane is more difcult to develop
than a retrorenal plane. This approach provides a much better exposure of the RA
than from the midline through the mesocolon. Exposure of proximal and mid left
a
c
b
Fig. 11.3 Exposure of the left RA using limited left medial visceral rotation. (a) Dotted line is
incision in peritoneal reection used to mobilize the splenic exure and descending colon along
with the spleen, which are retracted medially. (b) The spleen and left colon are retracted medially
to expose the left kidney and left renal vasculature; left RV is anterior to left RA. (c) Left RA
aneurysm exposed by mobilizing and retracting RV cephalad after ligating and dividing its lumbar,
gonadal, and adrenal branches
11 Renal Aneurysm Repair
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RA aneurysms requires mobilization of the overlying left RV with ligation and division of its lumbar and gonadal branches. A retrorenal approach with elevation of the
left kidney can be helpful for aneurysms arising posteriorly off the RA. This
approach avoids the need for RV mobilization but often places the RA on signicant
stretch, which can complicate subsequent repair. A left ank oblique incision in the
tenth intercostal space is helpful if such an approach is chosen. Dissection of the left
RA follows the same steps as the ones described for the right RA.
Following proximal and distal control and aneurysm mobilization, the patient is
systemically heparinized to an activated clotting time of 250s. Until recently, we
also routinely administered 25g of mannitol 20min prior to clamping to induce an
osmotic diuresis. Recent studies, however, have shown that mannitol may not have
a specic renal protective effect, so we now just ensure that the patient is volume
loaded with a good urine output prior to clamping. We believe strongly in the utility
of cooling to reduce renal metabolic demands and minimize ischemic injury when
RA clamp times more than 30min are anticipated or in the presence of signicant
preoperative renal dysfunction. Some authors have favored mobilizing the entire
kidney and surrounding it with ice, a technique we nd quite cumbersome. We prefer cold renal perfusion with an iced Ringer’s lactate solution (4°C containing heparin, mannitol, and methylprednisolone). Following proximal RA clamping, the
distal RA is infused with 250–300 cc of this solution over 5–6 min. With large
aneurysms, a 16G angiocath or balloon-tipped irrigation catheter can be placed
directly in the aneurysm. Alternatively, individual branches can be perfused with a
pediatric feeding tube after opening the aneurysm, taking great care not to injure
them. Following completion of perfusion, the distal arteries are occluded with
microvascular clamps. For these small-caliber vessels, we prefer the use of Yasargil
(cerebral aneurysm) microclips. These low-prole clips reduce the clutter associated with larger clamps and provide a less-obstructed surgical eld. Conventional
clamps are suitable for the main renal artery. The aneurysm sac is next resected
leaving a small rim of aneurysmal tissue attached to the involved arteries. Care must
be taken to preserve all sizeable branches including those originating from the posterior surface of the aneurysm. Cutting across their origins may make subsequent
reconstruction difcult if not impossible.
Reconstruction Techniques
There are a variety of in situ reconstruction techniques available for RAA repair
including aneurysmorrhaphy (dened as excising only the aneurysmal portion of a
saccular RA aneurysm) and more commonly aneurysm resection with either bypass
or interposition vein grafting. Studies have chosen that there is little to no difference
in short- or long-term outcomes between these two types of reconstruction when
chosen appropriately. The technique chosen is thus dependent on the anatomy of the
patient’s RA and aneurysm.
134
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A. K. Natour and A. D. Shepard
For aneurysms of the main RA, aortorenal bypass or interposition grafting is
most commonly performed, but for saccular aneurysms, resection and primary closure or patch angioplasty, to avoid narrowing, are also suitable. When using primary
closure, it is important to leave a small (1–2mm) rim of aneurysmal wall attached
to the artery. This minimizes the risk of narrowing the lumen with vessel closure.
Closure with interrupted stitches as opposed to a running suture may also be helpful
(Fig.11.4). For RAA associated with FMD, aortorenal bypass reduces the risk of
future problems; it is also appropriate for main RAA associated with FMD or atherosclerosis. Extra-anatomic bypasses based on the hepatic or splenic arteries may
also be suitable. A description of these procedures is covered in the chapter on
RA bypass.
Fig. 11.4 Techniques for reconstructing aneurysms of the main RA. (a) Saccular aneurysms can
be treated with lateral aneurysmorraphy using either primary repair, or. (b) Longitudinal patch
closure. (c) For aneurysms involving the full circumference, interposition grafting, or. (d) Formal
aortorenal bypass is suitable
cd
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Fig. 11.4 (continued)
Aneurysms at branch points, most commonly the main RA bifurcation, are more
frequent than main RA lesions and require more complex repairs. For saccular
aneurysms, aneurysmorrhaphy with or without patching can be performed, but salvage of all branches frequently requires resection and grafting +/− branch reimplantation (Fig.11.5). Reimplantation of a segmental artery into the main RA is preferred
over bypass when possible. After aneurysm excision, separate branches near each
other can be conjoined to create a common orice for reimplantation or bypass
(Fig.11.5c). Saphenous vein grafts are preferred to prosthetic grafts; though in the
reconstruction of large-caliber main RAAs, prosthetic grafts are probably adequate,
and in young adults avoid the very-long-term risks of vein graft aneurysmal
136
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A. K. Natour and A. D. Shepard
degeneration. Regardless of repair method, meticulous technique with loupe magnication and ne (6-0 or 7-0) polypropylene suture is mandatory. For very small
branches, interrupted sutures as opposed to running may be more appropriate to
avoid “purse- stringing” the anastomosis. At the completion of the reconstruction,
technical adequacy is conrmed with intraoperative duplex scanning and any signicant defects xed immediately.
Fig. 11.5 Techniques for reconstructing aneurysms involving the RA bifurcation or segmental
arteries. (a) Primary closure or vein patch closure (not shown). (b) Interposition vein grafting to
larger RA branch with reimplantation (end to side) of smaller branch(es) into the vein graft. (c)
Sewing two large branches together to create a common channel for distal anastomosis for either a
redundant main RA or more commonly an interposition vein graft. RA, renal artery; RV, renal vein
11 Renal Aneurysm Repair
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137
c
Fig. 11.5 (continued)
Other Less Frequently Used Described Techniques
Aneurysm plication: Plication of small (<1cm in diameter) branch aneurysms has
been suggested when such are encountered during operations for larger, clinically
signicant aneurysms. The redundant arterial wall is oversewn with a running 6-0
or 7-0 polypropylene suture. Aneurysms of very distal branches supplying limited
parenchyma can be ligated in similar circumstances.
138
Ex vivo repair and auto-transplantation: This approach is helpful for some com-
plex distal branch aneurysms that were previously treated with nephrectomy. A full
description of this approach is beyond the scope of this chapter.
Nephrectomy: Nephrectomy is still required for non-reconstructible aneurysms,
in the presence of a nonfunctioning, atrophic kidney or with uncontrollable RAA
rupture.
A. K. Natour and A. D. Shepard
Endovascular Repair
Endovascular techniques can be used to treat anatomically appropriate RAAs particularly in patients with poor operative risk. Localized aneurysms of the main RA
can be repaired with a covered stent though there is no good data regarding longterm patency of such reconstructions. Inferring from contemporary experience with
small-caliber stent grafts in the performance of branched endograft repair of thoracoabdominal aneurysms, however, patency of these grafts is probably reasonable.
Embolization therapy is also appropriate for distal intraparenchymal aneurysms
where there is low risk for signicant loss of renal mass. The possibility of inducing
renovascular hypertension from a resulting small segment of ischemic parenchyma
must be weighed against the risk of the aneurysm. Small-necked saccular aneurysms, regardless of location, can also occasionally be treated with intra- sac coiling
using techniques like those used for cerebral artery aneurysms.
Post-operative Care
Patients with a prolonged renal ischemia time may experience a signicant diuresis
during the immediate post-op period that will require attention to intravenous uids
and close monitoring of potassium and magnesium levels. Acute thrombosis of the
reconstructed renal artery is a potential complication and may be heralded by a sudden drop in urine output. Small branch occlusions are usually well tolerated though
renovascular hypertension may result from ischemic renal parenchyma. A thin-cut
CTA is usually performed on post-operative day 4 or 5in patients with normal renal
function to ensure a technically adequate repair. Patients are maintained on aspirin
(or other antiplatelet medications) plus a statin for at least 6months. Follow-up in
the outpatient clinic includes regular measurement of blood pressure and renal function and surveillance renal duplex ultrasound every 6months for the rst 2 years.
Any detected abnormality should be further studied with a CTA or a catheterdirected arteriogram.
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Outcomes
Renal artery aneurysm repair is an uncommonly performed operation, which can be
quite challenging. Open repairs should only be undertaken in reasonable risk
patients by experienced surgeons. In centers of excellence, renal artery reconstructions have durable outcomes with good long-term patency (95%) and freedom from
recurrence.
Further Reading
Henke PK, Cardneau JD, Welling TH, etal. Renal artery aneurysms: a 35-year experience with 252
aneurysms in 168 patients. Ann Surg. 2001;234:454–62.
English WP, Pearce JD, Craven TE, etal. Surgical management of renal artery aneurysms. J Vasc
Surg. 2004;40:53–60. https://doi.org/10.1016/j.jvs.2004.03.024.
Klausner JQ, Lawrence PF, Harlander-Locke M, etal. The contemporary management of renal
artery aneurysms. J Vasc Surg. 2015;61:978–84. https://doi.org/10.1016/j.jvs.2014.10.107.
Coleman DM, Stanley JC.Renal artery aneurysms. J Vasc Surg. 2015;62(3):779–85. https://doi.
org/10.1016/j.jvs.2015.05.034.
Chaer RA, Abularrage CJ, Coleman DM, etal. The Society for Vascular Surgery clinical practice
guidelines on the management of visceral aneurysms. J Vasc Surg. 2020;72(1S):3S–39S. https://
doi.org/10.1016/j.jvs.2020.01.039.
Chapter 12
Femoral andFemoral Anastomotic
Aneurysms
SachinderSinghHans
Anatomy
Arterial aneurysms in the lower extremity have the potential to cause limbthreatening ischemia from thrombosis or embolization from the mural thrombus.
Rupture of the femoral and popliteal aneurysms is extremely rare. Most femoral and
popliteal aneurysms are degenerative in nature. Pseudoaneurysms are often related
to anastomotic, traumatic, and mycotic etiology.
True femoral artery aneurysms are more common in the common femoral artery
(CFA) than they are in the supercial femoral artery (SFA) or deep femoral artery
(DFA). Aneurysms conned to the CFA are classied as type 1, while those involving the origin of the DFA are type 2. Femoral aneurysms are asymptomatic in 40%
of patients and in another 40% present with signs of lower extremity ischemia, and
in the remaining 20%, patients may present with a groin mass, which may become
painful as the aneurysm enlarges and causes symptoms secondary to the pressure on
surrounding structures.
Indications
The common femoral artery measures 10.5mm in men and 8.5mm in women (AP/
Tr diameter). The guidelines for surgical repair of CFA aneurysms have recently
been increased from 2.5 to 3.5 cm for asymptomatic patients. All symptomatic
patients should undergo repair to prevent complications regardless of their size.
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_12
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S. S. Hans
Preoperative planning by imaging of the aorta, iliac, SFA, and popliteal arteries with
CT angiography should be performed to evaluate the presence of concurrent aneurysms. Patient should undergo lower extremity arterial Doppler study including segmental pressures in patients with suspected associated arterial occlusive disease.
The surgical treatment involves open repair as the aneurysmal segment is replaced
with Dacron or polytetrauoroethylene (PTFE) graft.
Operative Procedure
A hockey stick incision is made in the groin extending from the apex of the femoral
triangle (upper thigh) curving slightly laterally and upward toward the anterior
superior iliac spine (Fig.12.1). Dissection is continued into the subcutaneous tissue,
which is incised longitudinally by electrocautery or by a 15-blade scalpel.
Fig. 12.1 Hockey stick
incision in the left groin
for exposure of the femoral
and femoral anastomotic
aneurysm
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