J Korean Med Sci 2004; 19: 309-10 ISSN 1011-8934 Copyright The Korean Academy of Medical Sciences Experience of an Abdominal Aortic Aneurysm in a Patient Having Crossed Ectopia with Fusion Anomaly of the Kidney We report a case of surgically treated abdominal aortic aneurysm (AAA) in a patient having crossed ectopia with fusion anomaly of the kidney. One artery from the abdomi- nal aorta above the aneurysm supplies the right kidney while three renal arteries (two from the aneurysm itself and one from the left common iliac artery) supply the crossed ectopic kidney. Preoperative imaging to define the arterial and collecting systems along with a detailed planning of the operation is essential to prevent ischemic renal injury as well as ureteral injury during AAA repair. Key Words : Aortic Aneurysm, Abdominal; Renal Ectopia; Abnormrlities INTRODUCTION Crossed renal ectopia is the second most common renal fusion anomaly following horseshoe kidney. It may occur alone or in combination with fusion or malrotation of the usual two renal masses. Most important to the vascular sur- geon is the knowledge of the renal blood supply pertinent to aortic surgery. CASE REPORT A 73-yr-old male presented to us with a pulsating abdomi- nal mass. Abdominal computerized tomography (CT) scan showed an abdominal aortic aneurysm having crossed ectopia with fusion anomaly of the kidneys. His past medical histo- ry was positive for smoking, hypertension, benign prostatic hypertrophy, and parkinsonism. On physical examination, a pulsating non-tender abdominal mass of about 8 cm in dia- meter was palpable around the umbilicus. Lower extremity pulses were palpable without evidence of aneurysmal dilata- tion. Laboratory tests, chest radiography, and electrocardio- graphy were normal. The patient underwent a transfemoral aortogram (Fig. 1) to evaluate the renal arterial anatomy. One renal artery from the abdominal aorta for the upper (right) kidney, and two renal arteries from the aneurysm and one Tae Won Kwon, Kyu-Bo Sung*, Geun-Eun Kim Division of Vascular Surgery, Department of Surgery and Radiology*, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea Received : 10 January 2003 Accepted : 19 May 2003 Address for correspondence Tae-Won Kwon, M.D. Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea Tel : +82.2-3010-3492, Fax : +82.2-474-9027 E-mail : twkwon2@amc.seoul.kr *We have no financial support or commercial associa- tions that might pose a conflict of interest in connec- tion with the submitted manuscript. 309 renal artery from the left common iliac artery for the lower kidney (crossover left) were seen. One pelvis and one ureter for each kidney were also identified. Operation was conduct- ed. The retroperitoneal cavity was approached transperitoneal- ly. The ureter of the lower (crossover left) kidney crossed the midline at the level of the bifurcation and entered the blad- der. To minimize renal ischemic injury, we dissected the lower two renal arteries (one from the aneurysm itself and the other from the left common iliac artery) and anastomosed the low- est renal artery (from the left common iliac artery) to middle renal artery (from the aneurysm itself) in a side-to-end fashion before aneurysm resection. We administered mannitol before the aortic cross clamping. After clamping the abdominal aorta below the level of the right renal artery and bilateral inter- nal and external iliac arteries, the aneurysm was opened and two renal artery orifices were discovered. After the proximal anastomosis of the bifurcated graft, two renal arteries were individually reimplanted and blood flow was resumed to renal arteries. The renal arteries were reperfused within 20 min after the aortic cross clamping. Anastomosis of the two iliac limbs of the bifurcated graft to common iliac arteries was performed without concern of the time. The patient recov- ered uneventfully and was discharged on postoperative 7th day. Magnetic resonance (MR) angiogram (Fig. 2) was taken two weeks after the operation and showed patent renal arter- ies and well perfused kidneys.