High-Origin Visceral and Renal Arteries with a Symptomatic Right Renal Artery Aneurysm: A Case Report and Literature Review

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Abstract
Background: Renal artery aneurysms (RAAs) are uncommon visceral arterial lesions whose management depends on symptoms, patient-specific rupture risk, and arterial anatomy. Markedly high origin renovisceral arteries may further complicate endovascular access and reconstruction. This report describes the management of a symptomatic RAA in a young woman with multifocal aneurysmal disease and unusual renovisceral arterial origins at the 11th and 12th thoracic vertebral levels (T11–T12). Case presentation: A 35-year-old woman presented with intermittent right loin pain. Computed tomography angiography demonstrated multiple right renal artery aneurysms, the largest measuring 1.7 cm, together with a 0.6-cm left renal artery aneurysm and a 0.67-cm superior mesenteric artery aneurysmal dilatation. The celiac trunk, superior mesenteric artery, and both renal arteries originated unusually high at the T11–T12 level. An initial trial of right renal artery stenting through right brachial access was technically difficult. Selective angiography after difficult cannulation demonstrated contrast extravasation from a minute right renal artery perforation. The patient remained hemodynamically stable; heparin was reversed with protamine, and repeat angiography 5 min later demonstrated complete sealing without further extravasation. The procedure was therefore aborted with close inpatient observation. Definitive treatment was achieved by ligation of the right renal artery aneurysmal segment and a retrocaval aorta-to-right renal artery bypass using a reversed great saphenous vein graft. At six months, the graft remained patent with preserved renal perfusion and no recurrence of the presenting symptom. Conclusions: This case demonstrates how extreme renovisceral anatomical variation, multifocal aneurysmal disease, and adverse arterial characteristics can limit the feasibility of endovascular treatment. In selected patients in whom secure endovascular access or renal branch preservation cannot be achieved, open reconstruction remains an effective renal-preserving option. Long-term surveillance is important because of the remaining untreated aneurysmal lesions and the limited duration of follow-up in this report.

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