title: A novel approach to the management of an inflammatory abdominal aortic aneurysm associated with crossed-fused renal ectopia.
abstract: BACKGROUND
  Crossed-fused renal ectopia is a rare anomaly that poses a therapeutic challenge in the management of abdominal aortic aneurysms (AAAs). Such challenges include preservation of renal blood flow in the setting of multiple aberrant renal arteries and ureteral anomalies. Several surgical approaches to this dilemma, including the use of traditional surgical techniques, have been described in the literature. We describe a novel approach to the management of a 7-cm inflammatory AAA associated with crossed renal ectopia with fusion.
  
  
  METHODS
  During routine surveillance computed tomography angiography (CTA) in a 63-year-old man, a rapidly enlarging AAA with new inflammatory changes was detected. The aneurysm had increased in size from 4.8 to 7 cm over a period of 6 months. At the time of presentation, he was found to be hemodynamically stable. Findings from the laboratory tests conducted at the time of admission were normal, with a baseline glomerular filtration rate of 91.2 mL/min and creatinine of 1. The CTA revealed significant thickening of the aortic wall, suggestive of aortic inflammation, the presence of crossed renal ectopia with fusion, and numerous anomalous renal arteries. We identified two right renal arteries arising from the proximal aneurysm sac and three left renal arteries arising from the common iliac arteries. Given the aortic inflammation, an open repair approach was considered high risk compared with an endovascular aneurysm repair (EVAR). However, given the uncharacteristic arterial anatomy, a staged surgical and endovascular management option was selected. We performed an aortic debranching and renal artery revascularization, followed by an EVAR.
  
  
  RESULTS
  We preserved renal function and excluded the aneurysm. The patient was discharged on the postoperative day 6 without periprocedural complications. A CTA was performed at 1- and 6-month follow-up period. This revealed a type 2 endoleak, which was confirmed by MR angiography. However, the aneurysm diameter had decreased in size from 7 to 6.3 cm in 1 month, and from 6.3 to 5.5 cm in 6 months. No further intervention was performed.
  
  
  CONCLUSIONS
  Inflammatory AAAs associated with crossed-fused renal ectopia can be successfully managed with aortic debranching and renal artery revascularization followed by an EVAR. This epitomizes the growing role for advanced endovascular therapies in conjunction with open surgical techniques.
authors.affiliation: Division of Vascular Surgery, The Mount Sinai Medical Center, New York, NY 10029, USA. rami.tadros@mssm.edu
authors.forename: Rami O
authors.initials: RO
authors.lastname: Tadros
authors.forename: Rajesh K
authors.initials: RK
authors.lastname: Malik
authors.forename: Sharif H
authors.initials: SH
authors.lastname: Ellozy
authors.forename: Michael L
authors.initials: ML
authors.lastname: Marin
authors.forename: Peter L
authors.initials: PL
authors.lastname: Faries
authors.forename: Ageliki G
authors.initials: AG
authors.lastname: Vouyouka
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D001025:Aortitis / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D002828:Choristoma; D057867:Endoleak / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects; D006801:Humans; D007668:Kidney; D008297:Male; D008875:Middle Aged; D012077:Renal Artery / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome