Background: Renal autotransplantation is an alternative for treating rare renal artery aneurysm.1 We report the challenging anaesthetic management of ex vivo complex Aneurysmorrhaphy with Autotransplantation (AA) after a laparoscopic nephrectomy.

Case Report: A 73-year-old woman, American Society of Anaesthesiology (ASA) physical status 3 (hypertension, diabetes mellitus, multinodular goiter, dyslipidemia) was presented for elective ex vivo AA (aneurism with 28 mm of diameter). After premedication with intravenous (IV) midazolam 1mg, low thoracic epidural catether was placed at T11-T12 for postoperative (PO) analgesia. General anaesthesia was induced with IV fentanyl 150mcg, propofol 70 mg, rocuronium 50 mg and maintained with desflurane, O2 and air. ASA standard, invasive blood pressure (BP), central venous pressure (CVP), neuromuscular block, depth of anaesthesia and cerebral oximetry monitoring were used. Urine output (UOP) and arterial blood gas were measured hourly. Crystalloids were given to maintain UOP > 1ml/Kg/h, high CVP and systolic blood pressure (SBP) >120 mmHg before nephrectomy. During the bench surgery a CVP of 6-7 cmH2O was obtained. After kidney transplantation and before unclamping, mannitol 0,25g/kg and furosemide 100mg were administrated. CVP and SBP were increased to 15 cmH2O and 140mmHg, respectively, with adequate UOP. The surgery lasted 8 hours, with total ischemia time of 3 hours. Analgesia was attained using continuous epidural infusion of ropivacaíne 0.2%, epidural bolus of morfine and IV acetaminophen. The patient was hemodynamically stable, without significant metabolic or electrolytic abnormalities and minimal blood loss throughout the intra and PO period. She was discharged on the 8th PO day with well-preserved renal function.

Discussion: Ex-vivo AA demands proper intraoperative management according to the surgery phase with maintenance of adequate UOP. Invasive monitoring is required to achieve this goal. Mannitol and furosemide are given to protect the kidney and improve graft viability. Colloids and drugs that may cause renal lesion should be avoided.

References:
1.	Min E-K et al. Renal autotransplantation in open surgical repair of suprarrenal abdominal aortic aneurysm. Ann Surg Treat Res. 2015; 89(1): 48-50.

Learning points: Success of the autotransplanted kidney depends on preoperative optimization, intra operative hemodynamic stability and invasive monitoring during perioperative period.

Anaesthesia for renal autotransplantion and ex vivo renal artery aneurysm repair - a case report