Descripción anatómica de la arteria polar renal accesoria y su relación con la hipertensión arterial / Anatomical description of accessory renal polar artery and its relationship with arterial hypertension

La irrigación renal incluye la arteria renal y las arterias renales accesorias. Uno de estos vasos accesorios es la arteria polar renal superior o inferior. Estos vasos tienen un desarrollo embrionario y un origen anatómico similar a la arteria renal, tanto en la aorta abdominal como en sus ramas. Irrigan los segmentos renales correspondientes y se ha observado que su obliteración puede ser causa de aumento de la presión arterial, al estimular un aumento de renina circulante. El objetivo de este trabajo, es presentar un reporte de caso clínico de paciente masculino de 24 años, sin antecedentes mórbidos. Consulta por un cuadro de cefalea y mareos de 2 semanas de evolución. Clínicamente se pesquisó aumento de presión arterial y obesidad, sin fiebre ni otros hallazgos significativos. Los exámenes complementarios arrojan las siguientes alteraciones: triglicéridos (aumentados), presión arterial (aumentada), renina (aumentada) y AngioTac de abdomen evidenció una arteria renal polar accesoria superior izquierda, con estenosis vascular. La literatura indica que la hipertensión arterial esta correlacionada con la obstrucción parcial o total de una arteria renal o de una rama accesoria. Esta alteración en la disminución del flujo sanguíneo podría estimular la liberación de renina al torrente sanguíneo, afectando la presión arterial. Nuestros hallazgos concuerdan con lo descrito en la literatura y requieren ser considerados en el diagnóstico de hipertensión arterial. Este caso evidencia la necesidad de realizar una revisión exhaustiva de la base anatómica de la medicina con un enfoque integrativo, lo que permitirá mejorar el diagnóstico, el tratamiento y el pronóstico de patologías donde esta información es poco clara o inexistente.

The kidney irrigation includes the renal artery and the accessory renal arteries. One of these accessory vessels is the superior or inferior renal polar artery. These vessels have an embryonic development and an anatomical origin similar to the renal artery, both in the abdominal aorta but also of its branches. Irrigate the corresponding renal segments and it has been observed that their obliteration may cause increased blood pressure, by stimulating an increase in circulating renin. The objective of this work is to present a clinical case report of a 24year-old male patient, with no morbid history. Consultation due to headache and dizziness symptoms with 2 weeks of evolution. Clinically increased blood pressure and obesity, without fever or other significant findings. Corresponding exams showed the following changes: triglycerides (increased), blood pressure (increased), renin (increased) and abdominal AngioTac showed a left upper accessory polar renal artery with vascular stenosis. The literature indicates that arterial hypertension is correlated with partial or total obstruction of a renal artery or an accessory branch. This alteration in the decrease in blood flow could stimulate the release of renin into the bloodstream, affecting blood pressure. Our findings agree with what is described in the literature and need to be considered in the diagnosis of arterial hypertension. This case demonstrates the need for an exhaustive review of the anatomical basis of medicine with an integrative approach. This would improve diagnosis, treatment and prognosis of pathologies where this information is unclear or non-existent.

Variaciones vasculares en cavidad abdominal y de vías urinarias: presentación de caso / Vascular variations in urinary tract and abdominal cavity: case report

Se presenta un raro caso de múltiples variaciones en la cavidad abdominal de un espécimen cadavérico de 50 años de género masculino, del laboratorio de anatomía de la Universidad Industrial de Santander (Bucaramanga-Colombia). Se observó variaciones arteriales (arteria renal adicional derecha y origen de la rama hepática derecha desde la arteria mesentérica superior), venosa (vena renal derecha adicional) y de vía urinaria (doble uréter en el lado derecho). Estas diversas variantes anatómicas además de suscitar interés académico, deben ser consideradas y descritas correctamente por los clínicos durante la realización de procedimientos quirúrgicos, radiológicos y de imágenes diagnósticas en la cavidad abdominal.

Here we present a rare case of multiple abdominal cavity variations in a 50-year-old male cadaveric specimen of the anatomy laboratory of the Universidad Industrial de Santander (Bucaramanga, Colombia). The anatomical dissection revealed arterial variations (right additional renal artery and origin of the right hepatic branch from the superior mesenteric artery), venous (right additional renal vein) and urinary tract (duplicated ureter on the right side). These multiple anatomic variations in addition to raising academic interest, should be considered and described correctly by clinicians while performing surgical, radiological and imaging procedures in the abdominal cavity.

Safety and Efficacy of Transarterial Nephrectomy as an Alternative to Surgical Nephrectomy

OBJECTIVE: To evaluate the safety and efficacy of transarterial nephrectomy, i.e., complete renal artery embolization, as an alternative to surgical nephrectomy. MATERIALS AND METHODS: This retrospective study included 11 patients who underwent transarterial nephrectomy due to a high risk of surgical nephrectomy or their refusal to undergo surgery during the period from April 2002 to February 2013. Medical records and radiographic images were reviewed retrospectively to collect information regarding underlying etiologies, clinical presentations and embolization outcomes. RESULTS: The underlying etiologies for transarterial nephrectomy included recurrent hematuria (chronic transplant rejection [n = 3], arteriovenous malformation or fistula [n = 3], angiomyolipoma [n = 1], or end-stage renal disease [n = 1]), inoperable renal or ureteral injury (n = 2), and ectopic kidney with urinary incontinence (n = 1). The technical success rate was 100%, while clinical success was achieved in eight patients (72.7%). Subsequent surgical nephrectomy was required for three patients due to an incomplete nephrectomy effect (n = 2) or necrotic pyelonephritis (n = 1). Procedure-related complications were post-infarction syndrome in one patient and necrotic pyelonephritis in another patient. Of four patients with follow-up CT, four showed renal atrophy and two showed partial renal enhancement. No patient developed a procedure-related hypertension. CONCLUSION: Transarterial nephrectomy may be a safe and effective alternative to surgical nephrectomy in patients with high operative risks.

Irrigación renal: multiplicidad de arterias / Renal irrigation: multiplicity of arteries

Generalmente, el riñón consta de una arteria renal originada en la aorta abdominal, que luego se divide en una rama anterior y posterior, sin embargo no es raro encontrar más de una emergiendo de la parte abdominal de la aorta o de alguna arteria ilíaca. El incremento en el uso de la nefrectomía laparoscópica ha llevado a la necesidad de un conocimiento detallado de la anatomía vascular renal. Por la importancia de las variaciones arteriales renales, se presenta una disposición de irrigación múltiple, que fue observada en un individuo adulto de 54 años de edad y de sexo masculino, a través de una tomografía computarizada multidetectores, con reconstrucción tridimensional. En el lado derecho, se observaron cuatro arterias renales (AR), con origen independiente desde la parte abdominal de la aorta, donde la AR1 y AR4 ingresan en la parte inferior del seno renal y la AR2 y AR3 en la parte superior del mismo. En el lado izquierdo, se observaron dos arterias renales, donde la más superior (AR1) es la de mayor calibre. Casos con más de tres arterias son raros, de tal modo que la variación presentada en este artículo es de interés anatómico y clínico, por la presencia de cuatro arterias en el lado derecho y de dos en el lado izquierdo en un mismo individuo.

Generally, the kidney has a one renal artery originating from the abdominal aorta, which is then divided into an anterior and posterior branches, however not uncommon to find more than one emerging from the abdominal aorta or iliac artery some. The increased use of laparoscopic nephrectomy has led to the need for detailed knowledge of renal vascular anatomy. Given the importance of the renal artery variations, we present a multiple irrigation of the kidney, which was observed in an adult man of 54 years old, through multidetector computed tomography with three-dimensional reconstruction. On the right side, there were four renal arteries (RA), with an independent origin from the abdominal aorta, where RA1 and RA4 entering the bottom of the renal sinus and RA3 and RA2 at the superior part of this sinus. On the left, we observed two renal arteries where the most superior (RA1) is the largest size. Cases with more of three arteries are rare, so that the variation presented in this article had anatomical and clinical interest for the presence of four arteries on the right side and two on the left side in an individual.

Doppler de arterias renales: parte 3 / Renal artery doppler: part 3

En esta última parte del artículo se describe el uso de doppler en patología venosa renal y trombosis venosa renal.

Doppler de arterias renales: parte 2 / Renal artery doppler

En esta parte del artículo se describen la fisiopatología y etiología de la estenosis renal, así como metodología y técnicas para su idenficación por ultrasonido...

Estudo do padrão arterial de 200 pedículos renais por meio de angiotomografias / Study of arterial pattern of 200 renal pedicle through angiotomography

OBJETIVO: Verificar a prevalência e a distribuição das artérias renais e de seus ramos in vivo, relacionando as particularidades encontradas nas artérias renais com o sexo e sua lateralidade. MÉTODO: Duzentos pedículos renais foram estudados por meio de angiotomografias e suas artérias analisadas de acordo com número, posição de origem, calibre, comprimento e trajeto em relação aos segmentos renais. Sua frequência e lateralidade foram pesquisadas quanto ao sexo e idade. RESULTADOS: Foram observadas múltiplas artérias em 61,5 por cento dos pedículos (56 por cento à direita e 67 por cento à esquerda), ocorrendo em 65 por cento dos homens e 58 por cento das mulheres. A origem aórtica para as múltiplas artérias foi mais frequente à direita e, com maior frequência, as artérias renais se originaram entre as vértebras L1 e L2 como divisões pré-hilares da artéria principal. O comprimento médio da artéria principal foi maior em rins direitos com artéria única. Não houve diferença entre o diâmetro da artéria renal principal. CONCLUSÃO: Existe maior prevalência das múltiplas artérias renais do que aquela descrita na literatura, sem diferença entre os sexos ou lateralidade. As artérias renais originaram-se com maior frequência entre as vértebras L1 e L2, como divisões pré-hilares da artéria principal e com trajeto ao hilo do rim. O comprimento médio da artéria principal é maior à direita e nos rins com artéria única. Não houve diferença no diâmetro da artéria renal principal entre rins com artérias únicas e múltiplas.

OBJECTIVE: To investigate the prevalence and distribution of renal arteries and their branches in vivo, correlating the particularities found in them with sex and laterality. METHODS: Two hundred renal pedicles were studied by CT angiography and its arteries analyzed according to number, position of origin, size, length and trajectory in relation to renal segments. Its frequency and laterality were surveyed regarding gender and age. RESULTS: There were multiple arteries in 61.5 percent of the pedicles (56 percent in the right and 67 percent in the left), occurring in 65 percent of men and 58 percent of women. The aortic origin to the multiple arteries was more frequent on the right and, more often, the renal arteries originated between vertebrae L1 and L2 as pre-hilar division of the main artery. The average length of the main artery was higher in right kidneys with a single artery. There was no difference between the diameters of the main renal arteries. CONCLUSION: There is a higher prevalence of multiple renal arteries than the one described in the literature, with no difference for gender or laterality. The renal arteries originated more frequently between vertebrae L1 and L2, with divisions of the pre-hilar route and main artery to the hilum of the kidney. The average length of the main artery is greater on the right and in kidneys with single artery. There was no difference in diameter between the main renal artery between kidneys with single and multiple arteries.

Doppler de arterias renales: parte 1 / Renal artery doppler: part 1

El doppler de arterias renales es una herramienta para valorar la presencia de estenosis en éstas arterias, de las que permite una evaluación anatómica completa. Se describen distintas técnicas de estudio, y aspectos anatómicos de las arterias.

Outcomes of laparoscopic donor nephrectomy in the presence of multiple renal arteries

Data of laparoscopic donor nephrectomy [LDN] with multiple renal arteries for donor and recipient outcomes were reviewed, with the aim of clarifying whether the laparoscopic approach is safe in the presence of multiple renal arteries. All donor nephrectomies performed at our institution from 2004 to 2008 were reviewed retrospectively. Results were compared between LDN kidneys with multiple arteries and those with a single renal artery. Out of 171 donor nephrectomies, 21 [12%] were performed for kidneys with multiple renal arteries. All of the 150 [88%] donor nephrectomies in the single vessel group were performed laparoscopically. In the multiple artery group, 9 [43%] underwent an open procedure while 12 [57%] underwent a laparoscopic procedure. The warm ischemia time was longer in the multiple artery group than the single artery group, but the difference was not statistically significant [4.25 +/- 0.87 min vs. 4.12 +/- 0.95 min, respectively]. Regarding transplant recipients, the vascular anastomosis time was similar in both groups [30 +/- 4.6 min vs. 29.5 +/- 3.7 min]. The operative blood loss in the transplant recipients was significantly more in the multiple artery group compared to the single artery group [339 +/- 292 ml and 130.7 +/- 44.8 ml, respectively; P=0.03]. The recipient renal function was similar for both the groups at postoperative day 7, 1 month, and at 1 year. The data support the fact that the laparoscopic approach to donor nephrectomy in the presence of multiple renal arteries can be performed safely with adequate laparoscopic experience

The Utility of 64 Channel Multidetector CT Angiography for Evaluating the Renal Vascular Anatomy and Possible Variations: a Pictorial Essay

The increased use of laparoscopic nephrectomy and nephron-sparing surgery has prompted the need for a more detailed radiological evaluation of the renal vascular anatomy. Multidetector CT angiography is a fast and accurate modality for assessing the precise anatomy of the renal vessels. In this pictorial review, we present the multidetector CT angiography appearances of the normal renal vascular anatomy and a spectrum of various anomalies that require accurate vascular depiction before undergoing surgical treatment.

Morphometric study of a horseshoe kidney

To describe a horseshoe kidney, a congenital anomaly of the upper urinary tract. A case study of horseshoe kidney harvested from a 62-year-old cadaver at Gazi University Medical School is presented. The right and left kidneys were fused at their lower poles by a parenchymal isthmus located ventral to the abdominal aorta and formed a U-shape with two unequal arms. The isthmus of the ectopic kidney was placed obliquely to the left at the level of the fourth and fifth lumbar vertebra. The left kidney was larger and longer than the right one. The kidneys were supplied by three renal arteries arising from the abdominal aorta. Two arteries on the right side supplied blood of the two kidneys, while the third artery that directly originated from the aorta, above the origin of inferior mesenteric artery, supplied the isthmus. Venous drainage of the both kidneys and the isthmus were drained by three veins that opened independently into the inferior vena cava. The right ureter was duplicated in origin. This report shows that knowledge of anomalies such as this is very important in planning and conducting surgical procedures

[Report of the frequency of normal renal vascular variants in 62 patients by use of abdominal CT angiography]

In most individuals, each kidney is supplied by a single renal artery and a vein, however multiple renal arteries and veins is not uncommon. In comparison to conventional angiography computed tomographic [CT] angiography is a new and less aggressive measure used for detection of normal renal vascular anatomy and diagnosis of vascular variants. To evaluate the frequency of normal vascular variants in 62 patients [124 Kidneys], underwent abdominal CT Angiography [Aortography]. During a period of one year, abdominal CT angiography was performed in 62 patients, 48 male and 14 female between 7-74 years of age [Mean 25.68 years]. The angiographic images were studied after being reconstituted by use of a computer. There was no complication and all patients tolerated the procedure without any reaction and/or discomfort. One forth of the patients felt some warmness during contrast injection. In 98 [79%] kidneys only one renal artery, in 20 kidneys [16.1%] two arteries, in 4 kidneys three arteries, and in two kidneys four arteries were detected. In 109 kidneys [88%] only one vein and in 15 kidneys [12%] two renal veins were detected and circum-aortic renal vein or renal collar was found only in one case. In this study the frequency of multiple renal vascular variants was less common than those of other studies. By use of spiral CT angiography and reconstitution of images by a computer, renal arteries and veins can be investigated in a short time avoiding invasive sequela or any complication for the patients

Tratamento endovascular de aneurisma da artéria renal por embolização com micromolas preservando o fluxo sangüíneo renal: relato de caso / Endovascular treatment of renal artery aneurysm using microcoil embolization and renal blood flow preservation: case report

O tratamento endovascular da doença aneurismática da artéria renal tem sido, cada vez mais, aceito como uma alternativa à cirurgia convencional, especialmente em casos de aneurismas complexos intra-parenquimatosos ou que comprometam a bifurcação da artéria renal. Os autores relatam a experiência do tratamento endovascular de uma paciente com aneurisma sacular da bifurcação da artéria renal direita, associado à hipertensão renovascular de difícil controle. Foi realizada a cateterização seletiva da artéria renal, com a inserção de micromolas no saco aneurismático. O aneurisma foi completamente ocluído com preservação total do fluxo sanguíneo renal. A evolução clínica foi satisfatória com redução significativa das medicações anti-hipertensivas. A angio-tomografia de controle, após o oitavo mês do procedimento, confirmou o sucesso do tratamento.

Endovascular treatment of renal artery aneurysmal disease has been increasingly accepted as an alternative to conventional surgery, especially in cases of renal artery bifurcation or complex intrarenal aneurysms. The authors report a case of endovascular treatment of a saccular aneurysm of the right renal artery bifurcation associated with poorly controlled renovascular hypertension. Selective catheterization of the renal artery was performed and microcoils were inserted into the aneurysmal sac. The aneurysm was completely obliterated with total preservation of renal blood flow. Clinical evolution was satisfactory with significant reduction in anti-hypertensive drugs. Control tomographic angiography, after eight months, confirmed treatment success.

Bilateral prehilar multiple branching of renal arteries: a case report and literature review.

Proper knowledge of variations of the arteries supplying the kidney is essential not only to the anatomists but also to the surgeons. In the present paper we are reporting a case of bilateral early and multiple branching of the renal arteries. The origin of the 2 renal arteries was normal but soon after their origin they ended by giving rise to multiple branches. Most of these branches entered the kidney through the hilum. However, on both sides, one of the branches (superior polar artery) passed superolaterally to reach the upper pole of the kidney. The superior polar artery also gave rise to the inferior suprarenal artery. Further, related literature review is done and the urological implications of these variations in renal surgeries are discussed.

Direct percutaneous embolization of renal pseudoaneurysm

To describe and evaluate a novel method of direct ultrasound [US] guided percutaneous embolization of renal pseudoaneurysm. Elevn patients with severe hematuria were included in this study during the period from February 2005 to February 2006. They included five patients with penetrating renal trauma, two patients post-renal biopsy and four patients after percutaneous nephrolithotripsy. Diagnostic duplex US of the pseudoaneurysm was performed. The size of the pseudoaneurysm and its neck were determined. A solution of Gelfoam particles was prepared in sterile saline solution and under US guidance, the tip of the needle was inserted into the aneurysm and slowly Gelfoam particles solution was injected. During the injection of Gelfoam, the pseudoaneurysm initially filled with an echo genic thrombus, decreasing thereby the color flow detected by US. The needle was removed when no flow in the pseudoaneurysm was detectable. The patient was kept for 30 minutes in the department and then discharged home. Follow up by color Doppler US every 2 to 4 weeks. In 10 patients bleeding was effectively controlled with direct embolization in a single session and did not need any further intervention, while one patient needed endovascular embolization due to recurrent severe hematuria after 24 hours. The amount of the injected Gelfoamn particles [1-2 mm diameter] was from 1 to 3 ml, according to the size of the pseudoaneurysm. No complication was observed secondary to embolization procedure. Re-bleeding did not occur in any patient during their follow-up period that ranged from 3-12 months. Direct ultrasound guided percutaneous embolization of renal pseudoanureysm is a new method for treating renal pseudoaneurysm. It avoids the side effects of contrast media, hazards of irradiation and complications of angiographic catheterization. Moreover, it saves the patient the risk of surgical interference to control bleeding by partial or total nephrectomy specially in patients with solitary kidney. it has been proved to be a rapid, effective, feasible, tissue preserving, and likely to reduce morbidity and mortality. Therefore, it is recommended to be a first line of treatment of actively bleeding renal pseudoaneurysms

Oclusão tardia das artérias renais após a correção endovascular dos aneurismas da aorta abdominal com próteses de fixação supra-renal / Late occlusion of renal arteries after endovascular repair of abdominal aortic aneurysms by suprarenal fixation of stent grafts

Objetivo: Apresentar três casos em que se observaram complicações tardias nas artérias renais. Casuística e método: No período de novembro de 1998 a fevereiro de 2005, foram operados, pelo Centro Paulista de Cirurgia Vascular, 121 pacientes com aneurima de aorta abdominal pelo método endovascular. Em 81 pacientes, a endoprótese foi fixada na posição supra-renal e, em 40, a fixação foi infra-renal. Os pacientes foram acompanhados no pós-operatório com tomografia abdominal realizada com 1, 6 e 12 meses anualmente, a partir do primeiro ano. Noventa e sete pacientes (80,1 por cento) foram acompanhados dentro desse protocolo, sem perda do seguimento. Destes, 33 (34 por cento) apresentavam fixação infra-renal e 64 (66 por cento) fixação supra-renal...