Suprarenal Fixation Induces Renal Artery Neointimal Hyperplasia In Endovascular Aortic Aneurysm Repair
Shree K Subedi, M.D., Andy M Lee, M.D., Gregg S Landis, M.D.
Renal artery occlusion following endovascular abdominal aortic aneurysm repair (EVAR) with suprarenal fixation is uncommon. We report one patient who was found to develop renal artery occlusion and parenchymal infarction six months after EVAR using the Zenith endovascular graft with suprarenal fixation. Our patient underwent urgent endovascular repair of a symptomatic 6 cm abdominal aortic aneurysm. The covered portion of the endograft was inadvertently deployed well below the renal artery orifices, but given the long length of the infrarenal neck, was felt to provide adequate fixation. At the completion of the procedure both renal arteries were confirmed to be patent. A one-month postoperatively a CT scan showed exclusion of the aortic sac and normal enhancement of both kidneys. Six months postoperatively, the patient was found to have increasing creatinine levels despite having no clinical symptoms. CT scanning revealed a non-enhancing left kidney and angiography demonstrated an occlusion of the left renal artery, with signs of severe intimal hyperplasia. A barb welded to the bare metal stent appeared to be impinging on the left renal artery. Angulation in the aortic neck may have also contributed to excessive metallic coverage of the renal ostium. This case illustrates that renal artery occlusion after EVAR can occur due to repetitive injury to the renal artery orifice, and that neointimal hyperplasia can be induced by the bare metal stent overlying the renal ostium. To our knowledge, this is the first reported case of renal artery intimal hyperplasia caused by repetitive injury from transrenal fixation systems