Obstructive uropathy associated with endovascular repair of an inflammatory abdominal aortic aneurysm

Stewart H. Lambie1, Mario De Nunzio2, J. Huw Williams3 and Christopher W. McIntyre1

1Department of Renal Medicine and 3Department of Urology Derby City General Hospital and 2Department of Radiology, Derbyshire Royal Infirmary, Derby, UK

Correspondence and offprint requests to: Dr C. W. McIntyre, Department of Renal Medicine, Derby City General Hospital, Uttoxeter Road, Derby DE22 3NE, UK. Email: Chris.McIntyre{at}sdah-tr.trent.nhs.uk

A 72-year-old male presented with claudication in the right leg. Clinical examination suggested an abdominal aortic aneurysm (AAA). Computed tomography (Figure 1) demonstrated an infrarenal AAA with a maximum diameter of 7 cm, and appearances suggestive of peri-aortic inflammation. The left kidney was normal, but the right was hydronephrotic. At this stage, the serum creatinine was 145 µmol/l. The patient was not fit for open surgical repair of the aneurysm, and therefore endovascular aortic repair was performed.



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Fig. 1. CT scan with i.v. contrast demonstrating an abdominal aortic aneurysm with a dilated ureter (arrow A) and inflammatory mass (arrow B).

 
Subsequently renal function deteriorated and the patient was referred to the renal services with a serum creatinine of 218 µmol/l. Ultrasound again demonstrated a hydronephrotic right kidney. Formal renal angiography revealed a small atrophic right kidney, but no renal artery stenosis on this side. The left renal artery had a <50% stenosis, and a DTPA renogram indicated that the smaller right kidney was contributing only 36% of overall function.

Therapy was commenced using oral prednisolone. At cystoscopy, the right ureter was cannulated and retrograde ureterography carried out. This demonstrated narrowing of the ureter related to inflammatory tissue at the level of the endovascular graft in the common iliac artery (Figure 2). In view of the proximity of this blood vessel, and the relative lack of function on that side, the ureter was not stented.



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Fig. 2. Retrograde ureterogram of the right ureter demonstrating dilatation of the ureter with narrowing at the common iliac artery, outlined by the endovascular graft.

 
Management of inflammatory AAA is empirical and controversial due to the lack of controlled trials [1]. Recently, treatment has been attempted using endovascular stenting, with varying success. One study suggested that endovascular repair halts progression of perianeurysmal fibrosis in most patients [1], and there has been at least one report of regression of both periaortic fibrosis and ureteric obstruction following endovascular repair [2]; however, others have found that endovascular repair failed to treat periaortic fibrosis [3]. In our case, obstruction clearly has not resolved following endovascular repair.

Conflict of interest statement. None declared.

References

  1. Hinchliffe R, Macierewicz J, Hopkinson B. Endovascular repair of inflammatory abdominal aortic aneurysms. J Endovascular Ther 2002; 9: 277–281[CrossRef][ISI][Medline]
  2. Rehring T, Brewster D, Kaufman JA, Fan C, Geller S. Regression of perianeurysmal fibrosis and ureteral dilation following endovascular repair of inflammatory abdominal aortic aneurysm. Ann Vasc Surg 2001; 15: 591–593[CrossRef][ISI][Medline]
  3. Barrett JA, Wells IP, Rowbottom CA et al. Progression of peri-aortic fibrosis despite endovascular repair of an inflammatory aneurysm. Eur J Vasc Endovasc Surg 2001; 21; 567–568[CrossRef][ISI][Medline]




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