Aneurysm of the renal artery in a patient with the Marfan syndrome, treated by stenting and coils implantation

Renal artery aneurysm is rare but is being increasingly encountered due to the wider use of CT scan. The aneurysms are usually discovered incidentally. The etiology included atherosclerosis, fibromuscular disease, and Ehlers–Danlos syndrome [1]. Although the natural history of renal artery aneurysms is not known with certainty, potential complications including embolization and rupture have been reported especially in pregnant women [2]. Indications for treatment remains unclear but current indications include symptomatic or enlarging aneurysms, renal embolization, aneurysms in pregnant females or those considering pregnancy, renovascular hypertension, and aneurysms > 2.5 cm. Surgery, and even autotransplantation have been described and used in most of the cases [3]. More recently percutaneous approaches using covered stents have been reported [4]. Although elegant, the use of covered stents may be associated with a risk of late thrombosis and in some cases are not adapted for anatomical reasons. We report the case of a 38-year-old woman with the Marfan syndrome. Her father had aortic dissection and she had mild hypertension treated with β-blockers. She came to the hospital because of severe and sudden back pain. Clinical examination was unremarkable (BP 130/80; pulse 76). Cardiac and pulmonary auscultation was normal. ECG and blood tests were also normal. Because of the Marfan syndrome, CT scan was performed and showed aneurysm of the primary branch of the left renal artery (Fig. 1A and B). Back pain was considered to be due to the aneurysm, and cure with percutaneous intervention was decided. Implantation of a covered stent was not chosen for the reasons mentioned before. We, thus, decided to implant a conventional stent in the primary branch (Fig. 2) and release coils within the aneuvrysm to close the cavity. The stent is scaffolding that protect the vessel wall from the intrusion of coils. The intervention was performed in local anesthesia. Through a 7 Fr guiding catheter, a 0.014-in. wire (Persuador, Medtronic, Minneapolis, MN, USA) was inserted in the primary branch of the renal artery. A 3.5/16 mm Coroflex (Braun, Tüttlingen, Germany) stent was implanted at a pressure of 12 atm. Then, the stent struts were crossed with a 0.014 wire and a Transit catheter (Cordis, Miami Lakes, FL, USA) was used to deliver the coils. Several different coils (Boston Scientific, Minneapolis, MN, USA) in length and diameter were implanted up to a final length of 90 cm (Figs. 3 and 4). At the end of the procedure the aneurysm was completely closed. A control CT scan the day after the procedure confirmed the patency of the renal artery and of the stented branch as well as the complete occlusion of the aneurysm (Fig. 5A and B). Two months after the intervention the patient was in a good shape and had no complications. She reported a complete cessation of the pain and tension of the back. CT scan or angiography was not performed because of the irradiation induced by these procedures in a young women and the absence of clinical indication. Abdominal ultrasound showed a normal flow in the renal artery and a kidney with a normal size. This case shows that the Marfan syndrome can be associated with aneurysm of the renal artery. This should not be forgotten in the screening of these patients. Percutaneous intervention is certainly a very attractive therapeutic option for renal artery aneurysm. Its place compared to surgery remains to be determined, but randomized trials seem difficult to conduct due to the rarity of the disease. The final decision to choose surgery or percutaneous treatment should be based on the anatomy and the experience of the surgical and interventional cardiologist team. The size of the aneurysm is also important, large aneurysms being probably bettered treated by surgery. A: 3D CT scan image showing the aneurysm of the branch of the left renal artery (arrow). B: 2D CT scan image of the aneurysm (arrow). [Color figure can be viewed in the online issue, which is available at www.interscience.wiley. com.] Selective angiogram of the renal artery with the aneurysm (arrow). Image during coil deployment. The stent is already deployed in the artery and the coils are release through the struts of the stent. Angiogram immediately after closure of the aneurysm. A: CT scan showing the stent. The kidney is well perfused. B: CT scan showing the coils in the closed aneurysm.