What are the treatment options for renal artery aneurysm?

Treatment of Renal Artery Aneurysm

Surgical or endovascular intervention is indicated for renal artery aneurysms (RAAs) larger than 2 cm in diameter, regardless of symptoms, to reduce the risk of rupture and associated morbidity and mortality. 1

Indications for Treatment

• Treatment is indicated for RAAs ≥2 cm in diameter to prevent rupture and associated complications 1, 2
• Intervention is warranted for symptomatic RAAs regardless of size, with symptoms including hypertension, hematuria, flank pain, or renal infarction 3
• Women of childbearing age with RAAs should be considered for repair due to increased rupture risk during pregnancy 3
• RAAs with rapid growth (≥5 mm in 6 months or ≥10 mm per year) may warrant intervention, similar to the approach for other arterial aneurysms 4

Treatment Options

Open Surgical Repair

• Aneurysmectomy with arterial reconstruction is a safe and effective treatment for RAAs, particularly for complex aneurysm anatomy 5
• Surgical techniques include:
  • In-situ repair with patch angioplasty or primary repair for accessible aneurysms 1, 5
  • Ex-vivo reconstruction for complex hilar aneurysms involving multiple branches 5, 3
  • End-to-end anastomosis after aneurysm resection 3
• Open repair shows excellent technical success rates (100%) but is associated with longer hospital stays and higher perioperative morbidity 2, 3

Endovascular Treatment

• Endovascular coil embolization is indicated for narrow-necked, saccular, extraparenchymal aneurysms 1
• Advantages include shorter hospital stays (7.2 ± 6.9 days vs. 11.8 ± 6.7 days for open surgery) and lower morbidity rates 2, 3
• Technical success rates are slightly lower than open surgery (79.3% vs. 100%) 2
• Not suitable for all anatomical configurations, particularly complex hilar aneurysms with multiple branches 3

Minimally Invasive Approaches

• Robotic-assisted repair is emerging as a minimally invasive alternative when endovascular techniques are not suitable 6
• Allows for in-situ reconstruction with warm ischemia times ranging from 26-44 minutes 6
• Provides the benefits of minimally invasive surgery while enabling complex reconstructions 6

Factors Influencing Treatment Selection

• Aneurysm characteristics:
  • Size and growth rate 1, 2
  • Location (hilar vs. extraparenchymal) 3
  • Morphology (saccular vs. fusiform) 1, 3
• Patient factors:
  • Age and comorbidities 2
  • Presence of hypertension 5, 3
  • Renal function 3

Outcomes and Follow-up

• Mortality rates are low (1.7%) with both open and endovascular approaches 2
• Morbidity is higher with open surgical repair (50% vs. 7.7% for endovascular) 3
• Potential complications include bleeding, retroperitoneal hematoma, arterial thrombosis, and bowel obstruction 3
• Long-term follow-up imaging is essential to monitor for aneurysm exclusion and renal artery patency 2, 3
• RAA repair may reduce medication requirements for patients with concurrent hypertension 5

Special Considerations

• For patients with RAAs, evaluation for concomitant aneurysms in other vascular beds is recommended, similar to the approach for other arterial aneurysms 4
• Preservation of renal function is paramount; significant decreases in GFR may occur following intervention 3
• The choice between open and endovascular repair should be based on aneurysm anatomy, patient comorbidities, and institutional expertise 2, 3