Open abdominal aortic aneurysm repair in a patient with horseshoe kidney

Abstract

Introduction Abdominal aortic aneurysm (AAA) associated with a horseshoe kidney (HSK) is a rare clinical entity, reported in less than 0.12% of AAA cases, that presents significant technical challenges due to variable renal arterial anatomy and the presence of a renal isthmus overlying the aneurysm. Careful preoperative planning is essential to ensure adequate renal perfusion and to minimize perioperative complications, particularly renal dysfunction, which has been reported in complex AAA repairs involving HSK (1–3). Case Presentation A 66-year-old patient presented with abdominal pulsations lasting two months. CTA demonstrated a 74 × 73 mm fusiform pararenal AAA extending from below the superior mesenteric artery into both common iliac arteries, in association with a horseshoe kidney and atypical renal artery anatomy. Due to the short and tapered proximal neck and the complex renal arterial pattern, endovascular repair would have required a technically demanding fenestrated or hybrid approach, therefore, open surgical repair was selected. The aneurysm was repaired using a prosthetic bifurcated aorto-bi-iliac graft with suprarenal aortic cross clamping. Postoperative renal function remained preserved. The postoperative period was complicated by paralytic ileus, which was resolved with conservative management. Discussion Both open and endovascular techniques have been reported for the treatment of AAA in patients with HSK when detailed preoperative imaging is used to identify renal and accessory arteries (1–3). Endovascular repair may be limited by unfavourable aneurysm morphology, short proximal necks, and aberrant renal arteries, frequently necessitating complex fenestrated or branched techniques (1,4). Open repair, although more invasive, allows direct exposure of the aneurysm and renal vasculature and remains a reliable option in anatomically complex cases. Therefore, treatment selection should be individualized based on aneurysm characteristics, renal anatomy, and technical feasibility. Conclusions The coexistence of AAA and HSK poses unique structural challenges that demand thorough understanding of renal anatomy, and flexible surgical planning. In this case, a short proximal neck and aberrant renal arteries precluded endovascular repair, so open surgery was performed, preserving renal function.