Endovascular aneurysm repair for abdominal aortic aneurysm: Overcoming anatomical challenges related to horseshoe kidney

A 70-year-old high-risk male with an asymptomatic 64 mm infrarenal abdominal aortic aneurysm (AAA) and an Eisendrath Type IV horseshoe kidney (HSK) underwent endovascular aneurysm repair (EVAR). Preoperative computed tomography angiography (CTA) revealed accessory renal arteries (ARAs) originating from the iliac arteries and aneurysm sac, necessitating selective preservation. EVAR successfully excluded the aneurysm while maintaining perfusion through a right common iliac artery-derived ARA supplying the renal isthmus. Smaller ARAs (<3 mm) were excluded to reduce endoleak risk. Postoperative imaging confirmed aneurysm exclusion without endoleak, though asymptomatic isthmus infarction occurred due to occlusion of a left iliac ARA. Renal function remained stable at three-year follow-up (2022–2025). This case supports EVAR as a feasible option for complex AAA-HSK anatomy, emphasizing meticulous preoperative planning and selective vessel preservation to balance aneurysm exclusion and renal perfusion. Individualized strategies are critical in anatomically challenging scenarios.