Systemic Review of Renal Artery Aneurysm Management

A Qualitative Systematic Review of Endovascular Management of Renal Artery Aneurysms

Clinical question

How does endovascular management of renal artery aneurysms fare in a qualitative systemic review of the literature?

Take away point

Systematic review of 454 renal artery aneurysms management demonstrated that endovascular approaches were associated with high technical success (96%), a low rate of moderate-to-severe adverse events (6.7%; the most common being renal infarction, but only 16% were clinically evident), and no periprocedural mortality (0%).

Reference

Sheahan, K.P., Alam, I., Pehlivan, T., Pasqui, E., Briody, H., Kok, H.K., Asadi, H. and Lee, M.J., 2024. A systematic review of endovascular management of renal artery aneurysms. Journal of Vascular and Interventional Radiology.

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Study design

Systemic review

Funding Source

None

Setting

Academic

Figure

Figure. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart showing the search, review, and selection process. RAA = renal artery aneurysm.

Summary

Renal artery aneurysms (RAAs) are increasingly detected incidentally, with rupture rates of 3%–5% and associated mortality, especially in nonpregnant patients. Key risk factors include aneurysm size over 20 mm, progressive enlargement, and hypertension, with treatment recommended for aneurysms larger than 2-3 cm, progressive growth, or in pregnant women due to the high mortality risk during peripartum rupture (peripartum rupture is associated with mortality rates of up to 100% for the baby and 80% for the mother). Although there is limited prospective data comparing operative or endovascular repair with surveillance, endovascular techniques have emerged as the preferred treatment for most RAAs due to advancements in technology, quicker recovery times, and high success rates. This study reviews the evidence on endovascular treatment of RAAs, focusing on technical success, adverse events, treatment options, and intermediate to long-term outcomes to guide optimal management strategies.

This systematic review, registered with the PROSPERO database and conducted following Cochrane and PRISMA guidelines, aimed to evaluate the safety and effectiveness of endovascular treatment for renal artery aneurysms (RAAs). A comprehensive search of multiple databases identified studies published between 2000 and 2022, focusing on those with at least five patients undergoing endovascular treatment. Two authors independently selected and reviewed studies, with disagreements resolved through consensus. The review assessed RAA-related mortality, rupture rates, and secondary outcomes such as renal infarction and reintervention. Data analysis included descriptive statistics on outcomes, and a quality and risk-of-bias assessment was performed using the Risk of Bias in Nonrandomized Studies of Interventions tool. The study sought to provide clarity on optimal RAA management by reviewing technical success, adverse events, and long-term outcomes of endovascular techniques.

The systematic review included 26 single-center, retrospective observational studies published between 2007 and 2022, encompassing 13 cross-sectional studies, 6 cohort studies, and 7 case series. A total of 371 patients were reviewed, with a mean age of 53.8 years and a female predominance of 62%. Fibromuscular dysplasia was noted in 26% of cases, though its type was not specified. The majority (53%) of renal artery aneurysms (RAAs) were asymptomatic and most commonly located at the hilar bifurcation.

Endovascular management of renal artery aneurysms (RAAs) employed various techniques, each contributing to the high technical success rate of 96.69% observed across studies. The primary technique used was coil embolization, which accounted for 42% (n=191) of the procedures. This method involves the insertion of coils into the aneurysm to promote clot formation and vessel occlusion. Stent-assisted coiling was the next most common approach, used in 21.5% (n=98) of cases, where a stent is placed to maintain vessel patency while coils are deployed to occlude the aneurysm. Other techniques included the use of flow-diverting stents, liquid embolics, and covered stents, each chosen based on the aneurysm's characteristics and location. Despite the variety of methods, the overall complication rate was 22.9%, with severe adverse events occurring in 6.7% of cases. Mild complications, such as minor renal infarctions and postembolization syndrome (PES), were relatively common, while severe complications, including significant renal impairment, were rare. The need for reintervention was low, at 3%, typically due to issues like incomplete occlusion or reperfusion of the aneurysm sac.

Endovascular treatment of renal artery aneurysms (RAAs) is favored due to its reduced invasiveness, offering better outcomes compared to open surgery, especially for elderly patients and those with comorbidities. Techniques like coil embolization, stent grafts, and flow-diverting stents are employed based on aneurysm characteristics, with coil embolization being the most common but also associated with the highest number of mild adverse events. The study highlights the need for careful patient selection, particularly when dealing with complex aneurysms or when considering younger patients for stent grafts. Despite the technical success and low severe adverse event rate (6.7%), the risk of delayed aneurysm reperfusion necessitates ongoing surveillance. The discussion underscores the challenges of comparing different endovascular techniques and the need for standardization in adverse event reporting, antiplatelet therapy, and follow-up protocols to further refine treatment approaches.