Renal artery aneurysms (RAA), particularly hilar and saccular types, are rare and challenging to manage, especially in the context of kidney transplantation. Here, we report on a 61-year-old male kidney donor identified with a 1.8 cm saccular RAA during a pre-donation evaluation. The case involved nephrectomy with ex vivo RAA repair followed by successful kidney transplantation to his wife. Through a multidisciplinary approach, the kidney was removed via open flank surgery to secure adequate vascular length. The renal artery was then microsurgically repaired on the surgical table. Two anterior branches were retained within the native artery as the upper renal artery, while the two posterior branches were anastomosed to a cadaveric iliac artery graft as the lower renal artery. The kidney was transplanted with the renal vein anastomosed to the recipient’s right external iliac vein, and the upper and lower renal arteries connected to the proximal and distal right external iliac arteries, respectively. Intraoperative Doppler ultrasound revealed reduced blood flow in the lower renal artery, showing that atherosclerotic plaque was causing an intimal flap obstruction. After removing the compromised section, anastomosis was performed, restoring arterial flow and kidney perfusion. The procedure also involved Lich-Gregoir ureteroneocystostomy, which was uneventful.
The surgery took a total of eight hours, with a cold ischemia time of 14 minutes and a warm ischemia time of 55 minutes, plus an additional 40 minutes for anastomosis. The estimated blood loss was 600 ml, with no transfusion required. The recipient maintained excellent graft function postoperatively, avoiding dialysis. Imaging at two months post-surgery showed patent vasculature and good perfusion, and at seven months, the recipient’s eGFR was 54 mL/min/1.73 m². This case demonstrates that renal artery allotransplantation after ex vivo RAA repair can yield favorable outcomes, but it is critical to address vascular challenges associated with atherosclerosis during the procedure.
