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Introduction. Horseshoe kidney (HSK) is a congenital anomaly of the embryonic kidneys, occurs early in gestation when they are in close proximity and is the result of abnormal migration of nephrogenic cells. The presence of HSK may complicate an anterior approach to reconstructive surgery of aorta and iliac vessels, because the isthmus of the HSK lies across the aorta. HSK is often associated with anomalous renal vessels. Case report . We report a 71 old female patient with MDCT seen 50 mm diameter of abdominal aortic aneurysm and HSK, and aberrant renal vessels with subocluded upper left renal artery. Open surgical treatment was applied. Endarterectomy of left upper renal artery, perfusion of right common bottom pole renal artery, and reimplantation of both bottom polar renal arteries were done. Isthmus was not divided. Coexistence of HSK and abdominal aortic aneurysm (AAA) is a rare entity that presents a technical challenge to vascular surgeons because surgical treatment of such an aneurysm is complicated due to the abnormal anatomy, difficulties in exposing the aneurysm, and a variable blood supply to the isthmus and lower poles of the HSK. Conclusion. Open surgical repair of AAA with HSK is the successful method and provides good exposure, possibility of preserve renal circulation and prevention of renal insuffiency.


Abstract
Introduction. Horseshoe kidney (HSK) is a congenital anomaly of the embryonic kidneys, occurs early in gestation when they are in close proximity and is the result of abnormal migration of nephrogenic cells. The presence of HSK may complicate an anterior approach to reconstructive surgery of aorta and iliac vessels, because the isthmus of the HSK lies across the aorta. HSK is often associated with anomalous renal vessels. Case report. We report a 71 old female patient with MDCT seen 50 mm diameter of abdominal aortic aneurysm and HSK, and aberrant renal vessels with subocluded upper left renal artery.
Open surgical treatment was applied. Endarterectomy of left upper renal artery, perfusion of right common bottom pole renal artery, and reimplantation of both bottom polar renal arteries were done. Isthmus was not divided. Coexistence of HSK and abdominal aortic aneurysm (AAA) is a rare entity that presents a technical challenge to vascular surgeons because surgical treatment of such an aneurysm is complicated due to the abnormal anatomy, difficulties in exposing the aneurysm, and a variable blood supply to the isthmus and lower poles of the HSK. Conclusion. Open surgical repair of AAA with HSK is the successful method and provides good exposure, possibility of preserve renal circulation and prevention of renal insuffiency.

Introduction
HSK is a congenital anomaly of the embryonic kidneys, occurs early in gestation when they are in close proximity and is the result of abnormal migration of nephrogenic cells (1). A HSK is found in approximately 0.1% of autopsy series, and in 0.1% to 0.6% of aortic operations (2). The presence of HSK may complicate an anterior approach to aorta, because the isthmus of the HSK lies across the aorta and often is associated with anomalous renal vessels (3). A medial fusion of the kidneys, mostly anteriorly to the aorta, is the main characteristic of this anomaly (4). HSK usually can be found preoperatively with MDCT angiography for abdominal aneurysm. Open surgical repair because of possible complications including renal infarction, neuralgia, and collecting system disruption presents a challenge. Endovascular aortic repair (EVAR) is considered for this pathology, allowing aneurysm repair without isthmus dissection, but, whether to sacrifice commonly presenting aberrant renal arteries during EVAR is a point of controversy. Some authors recommended a hybrid treatment. (5) We report one case of open repair AAA with HSK, with aberrant renal arteries and its reattachment without division of renal isthmus.

Case report
A 71 old female patient was admitted to our hospital with MDCT finding of 50 mm wide AAA and HSK. Isthmus of HSK was on the front side of aneurysm. Fig. 1. Near here  Left urether follows isthmus of HSK. Artery for right urether that was originate from right common iliac artery. Figure 4. Near here

Discussion
Coexistence of HSK and AAA is a rare entity that presents a technical challenge to vascular surgeons because surgical treatment of such an aneurysm is complicated due to the abnormal anatomy, difficulties in exposing the aneurysm, and a variable blood supply to the isthmus and lower poles of the HSK.(6) Abnormalities concerning the number and the origin of kidney vessels can be associated to ectopic and HSK. (7) Appropriate preoperative evaluation of the HSK by CT-angiography and renal function is mandatory for optimal planning of the treatment strategy (8). Horseshoe kidneys are frequently found in patients with other venous, and particularly inferior vena cava anomalies, which should be evaluated using MDCT as part of treatment planning (9). Transperitoneal approach provides the best exposure to the aneurysm and kidney, however, the presence of the renal isthmus affects both surgical exposure and proximal aortic control. Left retroperitoneal approach has the advantage of avoiding interference with the renal isthmus and urinary tracts; however, access to the right iliac artery is limited (10).

Conclusion
Open surgical repair of AAA with HSK is the successful method for experienced team and provides good exposure of aorta, kidneys, and vessels. Endarterectomy of renal arteries, reimplantation of accessory renal vessels, and preservation of isthmus of HSK is the challenge but best choice to prevent postoperative renal insufficiency.