Accessory Renal Arteries Research Articles

Inhabitation of an accessory renal artery in a cratered hilum of a malrotated kidney

Structural variations of the kidney and its abnormal vascular architecture make the kidney unsuitable for transplantation. We report here a case of malrotated left kidney with cratered hilum and presence of an accessory renal artery. A lumbar vein was seen to loop under the accessory renal artery on the way of its termination into the left renal vein. The kidney appeared to have failed to rotate from its fetal position. Thus, the hilum was placed ventrally. The hilum was crater-like in shape, wide, and allowed passage of the hilar structures. The shape of the kidney itself had undergone slight modification as it appeared more ovoid than its typical bean shape. The poles, but not the surface or borders were distinguishable. The variations described in the current observation are of a unique pattern of congenital malformation having surgical, urological, and radiological implications.

Unilateral multiple variations of renal, phrenic, suprarenal, inferior mesenteric and gonadal arteries

Knowledge of the branching pattern of the abdominal aorta is clinically important for any abdominal surgeon operating on parts of the gut or neighboring structures. Variations of these vessels may influences urological, renal transplantation and laparoscopic surgeries. We present an unreported case of multiple variations of branching pattern of abdominal aorta. It includes double renal arteries for left kidney, a common trunk with right and left phrenic, right and left superior suprarenal and left middle supra renal arteries, and a common trunk originate 2.5 cm above the bifurcation of abdominal aorta gave off inferior mesenteric, accessory renal artery to the left kidney and left testicular arteries in the middle-aged normal male cadaver. The embryogenesis of such multiple variations of branches of abdominal aorta is not clear, but the anatomic consequences may have important clinical implications. Knowledge of these variations is important for urologists, radiologists and surgeons in general.

Variation in the Arrangement of Structures at Hilum of Human Kidney

Context: There is a variation in the arrangement of structures at hilum which may create problem for the surgeon during dissection of hilum of kidney. Moreover, developmental anomalies like, constriction at pelviureteric region, double renal pelvis, accessory renal arteries etc are not uncommon. So, adequate anatomical knowledge of kidney specially at hilum is required for successful surgery of this reason. Objective: To study the variation in the arrangement of renal vessels and renal pelvis at hilum. Study design: Descriptive type. Place and period: Department of Anatomy, Mymensingh Medical College, Mymensingh, Bangladesh from January 2004 to June 2005. Materials and methods: A total of 100 fresh human kidneys of both sexes and sides were collected from the morgue of Mymensingh Medical College at postmortem. The selected cases were between 5 to 60 years of age. The samples were preserved to observe the variations in the arrangement of main structures at hilum of kidneys regardless of age groups. Results: When hilum of the kidneys viewed before backwards, anteriorly and at the middle, there was 1% variation in the arrangement of renal vessels but posteriorly renal pelvis was found in variably and it was double in 2% of kidneys. Posterior division of renal artery was present behind the renal pelvis in 12% of kidneys. Conclusion: Variation in the arrangement of structures at hilum was observed in 1% of kidneys. DOI: http://dx.doi.org/10.3329/bja.v10i2.17322 Bangladesh Journal of Anatomy, July 2012, Vol. 10 No. 2 pp 76-79

A Horseshoe Kidney From a Live Donor as a Renal Transplant: Case Report

This case report presents our experience regarding a horseshoe kidney from live donor to be used as a renal transplant. The recipient was a 48-year-old man with chronic renal failure owing to hypertension who had been on hemodialysis for 2 years. The donor was his 43-year-old sister who had an uncomplicated horseshoe kidney with negative results on a urinalysis. An aortogram showed that the arterial supply to the kidney consisted of 2 superior arteries (1 on each side) and 1 inferior accessory artery that was divided to feed the lower fused parenchyma of the kidney. Surgery was performed via a retroperitoneal lumbotomy incision; the left half of the kidney was mobilized. The left kidney was procured by clamping the inferior accessory renal artery, transecting the parenchyma within the demarcation boundary. The transplant kidney was placed in the recipient's contralateral iliac fossa. The graft vein was anastomosed to the recipient's external iliac vein, the artery to the external iliac artery, and the ureter to the bladder. After perfusing the graft, no urine leakage was detected from the transacted surfaces, and the graft began producing urine. There were no complications after surgery. The patient was discharged on the 10th day after surgery with a creatinine level of 0.07 μmol/L. Maintenance immunosuppressive treatment included tacrolimus, mycophenolate mofetil, and prednisolone. We believe using a horseshoe kidney as a renal allograft after a detailed preoperative evaluation may help expand the donor pool.

Does the Presence of Accessory Renal Arteries Affect the Efficacy of Renal Denervation?

This study sought to assess the efficacy of catheter-based renal sympathetic denervation in patients with accessory renal arteries and to compare the blood pressure (BP)-lowering effect with that observed in patients with bilateral single renal arteries after renal denervation. Catheter-based renal sympathetic denervation causes significant BP reductions in patients with resistant hypertension. Seventy-four patients were included in this study. Patients were assigned to 2 main groups: a bilateral single renal arteries group I (n = 54) and an accessory renal arteries group II (n = 20). Group II consisted of 9 patients whose accessory renal arteries were all denervated (group IIa), and 11 patients whose accessory renal arteries were not, or only incompletely, denervated (group IIb). The primary endpoint was the change in office systolic BP after 6 months. The procedure was successful in all patients. Group I: mean BP at baseline was 166.2/89.4 ± 20.5/14.6 mm Hg and decreased by -16.6 (p < 0.001)/-6.7 (p = 0.016) ± 16.4/11 mm Hg at 6-month follow-up. Group II: mean BP at baseline was 164.2/89.1 ± 19.9/15.4 mm Hg and decreased by -6.2 (p = 0.19)/-0.2 (p = 0.5) ± 19.7/11.3 mm Hg at 6-month follow-up. Patients in group IIa had an office BP reduction of -8.8 (p = 0.2)/1.1 ± 17.9/10.8 mm Hg and patients in group IIb of -4.1 (p = 0.55)/-1.3 ± 20.8/11.6 mm Hg. Similarly, significant improvements in 24-h mean systolic BP were seen in group I (-8.3 ± 17.4 mm Hg, p < 0.01), whereas none were seen in group II (-3.7 ± 8.3 mm Hg, p = 0.38). BP reduction achieved after renal denervation in patients with accessory renal arteries is less pronounced than in patients with bilateral single renal arteries.

Renal sonography with Doppler for detecting suspected pediatric renin-mediated hypertension – is it adequate?

Renal Doppler US is used to evaluate suspected vascular causes of hypertension in children, despite mostly unknown diagnostic performance characteristics. To evaluate renal Doppler US for detecting vascular causes of hypertension in children with high clinical suspicion of aortic or renal artery narrowing. We identified pediatric renal Doppler US examinations performed for hypertension between January 1995 and June 2010 at our institution. We excluded children without follow-up angiography (CT-, MR-, or catheter-based). Two pediatric radiologists reviewed imaging studies and documented relevant findings. Intrarenal spectral Doppler resistive index measurement <0.5 or tardus parvus waveform constituted a positive examination. Thirty-five boys and 13 girls underwent renal Doppler US and confirmatory imaging (mean age = 9.0years). Nineteen US examinations were truly negative, two were falsely negative, 18 were truly positive (16 involved narrowing of the aorta or main renal artery) and nine were falsely positive. Sonography had a sensitivity and specificity of 90% and 68%, respectively, for detecting a vascular cause of hypertension. Renal Doppler sonography reliably detects renin-mediated hypertension caused by aortic or main renal artery narrowing in children. More studies are needed to determine its ability to detect intrarenal and accessory renal artery stenoses.

Accessory renal arteries in a Caribbean population: a computed tomography based study

IntroductionThe commonest variation to the classic anatomic description of renal arterial supply is the presence of accessory renal arteries. The incidence varies widely according to ethnicity. There is no data on the prevalence of these anomalies in persons of Caribbean ethnicity.MethodsAll CT scans done over two years from July 1, 2010 to June 30, 2012 were retrospectively evaluated. The anatomy of the renal arterial supply was reported from these studies and the anatomy of accessory renal arteries was documented.ResultsThere were 302 CT scans evaluated and accessory renal arteries were present in 109/302 (36.1%) CT scans, 95% confidence interval 30.6%, 41.4%. There were 71/309 (23.5%) patients with accessory arteries on the left and 54/309 (17.9%) had them on the right (p 0.087). Of these, 16 (14.7%) patients had bilateral accessory renal arteries present. The most common origin for the accessory arteries was the abdominal aorta in 108 (99.1%) cases and in 1 case the accessory artery arose from the coeliac trunk. There were 80 left sided accessory renal arteries: 17 (21.3%) upper polar and 27 (33.8%) lower polar arteries. Of 62 right sided accessory arteries, 14 (22.6%) were upper polar and 26 (42%) were lower polar arteries.ConclusionThis is the first population-based report of anatomic anomalies in renal arterial supply in a Caribbean population. These are important findings that may affect vascular and urologic procedures on persons of Caribbean ethnicity.

Multiple renal arteries with renal cell carcinoma: Preoperative evaluation using computed tomography angiography prior to laparoscopic nephrectomy

To investigate anatomical variations in the renal arteries of patients with renal cell carcinoma (RCC) using computed tomography angiography (CTA). Patients diagnosed with RCC were evaluated using CTA prior to undergoing laparoscopic nephrectomy. Any anatomical variations of the renal arteries on the side affected by the RCC were recorded. The CTA results were compared with the observations made during surgery and those produced by conventional digital subtraction angiography. A total of 107 patients with RCC were enrolled in the study. Multiple renal arteries were found in 11 patients (10.3%). Accessory renal inferior polar arteries were the most common type of multiple renal arteries. Multiple renal arteries acting as the feeding arteries to the RCC were found in five patients (4.7%). CTA can be used as part of the preoperative evaluation prior to laparoscopic nephrectomy to provide anatomical information about the presence of multiple renal arteries in the affected kidney of patients with RCC. This could help with planning the surgery and reducing surgical complications.

Can an accessory renal artery be safely covered during endovascular aortic aneurysm repair?: Table 1:

A best evidence topic was constructed according to a structured protocol. The question addressed was whether coverage of an accessory renal artery (ARA) in patients undergoing endovascular aortic aneurysm repair (EVAR) is associated with increased risk of renal impairment. Altogether, 106 papers were located using the reported searches, of which 5 represented the best evidence to answer the question. The authors, journal, date and country of publication, study type, patient group studied, relevant outcomes parameters and results of these papers are tabulated. Our best evidence analysis included 116 patients who had one or more ARA excluded during EVAR. Segmental renal infarction occurred in varying numbers of patients (ranging from 0 to 84%). The authors consistently demonstrate that loss of renal mass is not associated with functional renal impairment, expressed by various outcome parameters such as serum creatinine, glomerular filtration rate (GFR), renal failure requiring dialysis and worsening hypertension. Comparisons of groups of patient with covered or preserved ARAs by one of the selected studies showed no difference in any of these renal outcome parameters, apart from a significantly higher renal infarct volume in the former group (P < 0.001). Subgroup analysis of patients with pre-existing renal dysfunction (GFR < 60 ml/h/m(2)) showed no difference in GFR change when comparing covered with uncovered ARA patient cohorts. No type II endoleak related to the covered ARA was reported in any of these studies. In conclusion, current evidence supports the safety of coverage of ARAs located in the proximal fixation zone to achieve seal in EVAR.

Cadaveric renal anatomic study of partial nephrectomy with segmental renal artery clamping

Objective To study the anatomic characteristics of the renal artery and segmental renal artery and their relationship with the renal hilum in order to provide a theoretical basis for partial nephrectomy with segmental renal artery clamping.Methods From 2010 to 2012,22 pairs of adult cadaveric renal specimen via conventional anti-corrosion were adopted for the research.The distance between the first branch of renal artery and the secondary branch to the line A (Line A connects upper and lower pole of the renal hilum) and the distance between the two branches were measured and comparison was made between left and right kidney respectively.The location and dominance of the accessory renal artery were analyzed.Results The average distance between the first branch and the line A was (1.0±0.7) cm,and the distance between the secondary branch and Line A was (0.4±0.3) cm,and there was no significant difference between left and right side (P＞0.05).The cases with the first branch outside the line A was 90.9％ (40/44).There were 23 cases with secondary branch outside the line A (52.3％,23/44),and 16 cases with secondary branch inside the line A (36.4％,16/44).31.8％ of the cases had accessory renal artery,among which one case had two accessory arteries.Eleven accessory arteries originated from the renal artery,while 13 accessory arteries dominated the upper pole of kidney.Conclusions The renal artery showed segmental distribution,and there was enough space between the renal artery and the renal hilum.This finding further clarifies that partial nephrectomy with segmental renal artery clamping could be safe and feasible.Accessory renal arteries arise with certain possibility,and most dominate in the upper pole of kidney.So intraoperative attention should be paid to avoid unnecessary nephron loss. Key words: Partial nephrectomy; Segmental renal artery; Renal hilum; Accessory renal artery; Anatomy, regional

A case-control study of intentional occlusion of accessory renal arteries during endovascular aortic aneurysm repair

The purpose of this study was to evaluate outcomes of patients treated by intentional coverage of accessory renal artery (ARA) during endovascular abdominal aneurysm repair (EVAR). The clinical data of 119 patients (110 male and nine female; mean age, 75years) from a cohort of 811 patients treated by EVAR from 1998 to 2009 was reviewed. Patients who had intentional coverage of at least one ARA (group A) were compared with two control groups, which included patients with no ARA (group B) and those who had ARA preserved during EVAR (group C). All three groups of patients were matched for age, gender, hypertension, and preoperative estimated glomerular filtration rate (eGFR). Paired pre- and postoperative computed tomography angiography was analyzed for the presence and volume of kidney infarction. End points were changes in eGFR, chronic kidney disease (CKD) stage, blood pressure measurements, presence and volume of kidney infarction, freedom from reintervention, and endoleak. There were 42 patients in group A, 42 in group B, and 35 in group C. Demographics, cardiovascular risk factors, and CKD classification were similar in all three groups. Among patients in group A, 44 ARAs were intentionally covered with ARAs originating from the proximal neck in 22 patients, the aneurysm sac in 20, and the iliac arteries in two. There was one (1%) early death in the entire study. Early morbidity was similar in all three groups, including four patients (9%) in group A, four (9%) in group B, and four (11%) in group C (P= .9). Six (5%) patients had >25% decrease in eGFR, including two who had ARA coverage. None of the patients required dialysis. After a mean follow-up of 37months, there were no differences in late renal function deterioration, changes in eGFR, CKD stage, or blood pressure measurements among the three groups. Three of the 18 patients (17%) with ARA >3mm arising from the aneurysm sac developed a type II endoleak requiring coil embolization. Kidney infarction was noted in 28 patients (67%) in group A. Freedom from reintervention at 2years was similar in groups A (64%), B (80%), and C (96%; P= .09). Intentional ARA occlusion during EVAR was not associated with changes in renal function or blood pressure measurements, even when performed in patients with more advanced renal dysfunction. Type II endoleak may result from persistent outflow into large (>3mm) ARAs that arise from the aneurysm sac.

Non-contrast angiography of renal artery in 3T magnetic resonance in patients with refractory arterial hypertension before renal denervation

Introduction: Catheter-based renal sympathic denervation is a technique for treatment of resistant arterial hypertension. Planning this procedure magnetic resonance (MR) is a non-invasive method without any radiation to reliably image the anatomical conditions like diameters, possible stenosis or abnormalities of renal arteries. Impaired renal function (GFR<30 ml/min) is a known contraindication for gadolinium based contrast agent due to the risk of nephrogenic systemic fibrosis. To address the question if imaging of the anatomy of renal arteries in 3T MR may be feasible and reliable without using contrast agent the present prospective study was performed. Methods: 34 Patients with resistant hypertension (taking four antihypertensive drugs including diuretics and long term blood pressure measurement larger than 135/85mmHg) for whom renal denervation was planned were included prospectively. In 3T magnetic resonance 3D conventional contrast MR angiography (CMRA) was performed after antecubital injection of gadopentetat-dimeglumin during breath-hold. Additionally, an inflow inversion recovery steady state free precession sequence (Inhance) was used for non-contrast MR angiography (NCMRA). Diameters of renal artery were assessed 20 mm from aortic ostium. Furthermore, the aortic diameter was measured at height of renal artery orifice. Results: 34 patients (66±8 years) were included in both conventional contrast and non-contrast MR angiography and presented a total of 76 main and accessory renal arteries. In CMRA mean renal artery diameter was 6.2±1.8 mm, in NCMRA mean renal artery was determined with 6.0±2.0 mm. Mean aortic diameters were identified with 20.4±3.2 in CMRA and with 20.1±2.8 in NCMRA. Measurements of renal artery by NCMRA closely correlate to renal artery diameters assigned by CMRA (r=0.97). Furthermore, detection of aortic diameters showed also good correlation between both MRA (r=0.92). Bland-Altman-analysis did not present any signs of under- and overestimation of both measurement methods. Conclusion: At 3T CMR determination of renal artery and aortic diameter at the orifice of the renal arteries is possible by non-contrast MR angiography as well as by 3D contrast MR angiography. Both methods provide reliable estimates of the diameter of the vessel without relevant under- or overestimation. Non-contrast MR angiography should be regarded as a powerful completely non-invasive tool to image renal arteries without the need to use potentially nephrotoxic contrast media.

A case of spontaneous renal infarction secondary to an accessory renal artery thrombosis

Medical Journal of AustraliaVolume 199, Issue 3 p. 168-169 Letter A case of spontaneous renal infarction secondary to an accessory renal artery thrombosis Elizabeth C Travis, Corresponding Author Elizabeth C Travis House Officer [email protected] Waikato District Health Board, Hamilton, Waikato, New Zealand.Correspondence: [email protected]Search for more papers by this authorVicki A Quincey, Vicki A Quincey General Physician and Rheumatologist Waikato District Health Board, Hamilton, Waikato, New Zealand.Search for more papers by this author Elizabeth C Travis, Corresponding Author Elizabeth C Travis House Officer [email protected] Waikato District Health Board, Hamilton, Waikato, New Zealand.Correspondence: [email protected]Search for more papers by this authorVicki A Quincey, Vicki A Quincey General Physician and Rheumatologist Waikato District Health Board, Hamilton, Waikato, New Zealand.Search for more papers by this author First published: 05 August 2013 https://doi.org/10.5694/mja13.10468Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume199, Issue3August 2013Pages 168-169 RelatedInformation

English

Introduction Renal artery variations have gained importance in the last decade because of the widespread development in transplantation surgery. Variations in the renal vasculature are of importance not only for the surgeons, but for the radiologists, especially in the interventional radiological approaches. Post surgical complications and the risk of kidney loss is higher in the cases with multiple renal arteries when compared with the kidneys having a single renal artery. The aim of this study was to discuss the surgical importance of the inferior renal polar artery. Case report During routine dissection, a case of accessory right renal inferior polar artery was found. The main renal artery was arising from the aorta about 1.7 cm below the superior mesenteric artery extending laterally towards the hilum of the kidney. At about 1.3 cm below the origin of the inferior mesenteric artery from the anterolateral aspect of the aorta, an accessory renal artery measuring 5.1 cm in length, was seen coursing upwards, backwards and laterally and entered the right kidney through its lower pole. This inferior polar renal artery in our case passed superficial to the ureter and testicular vein on the right side and hence can lead to partial obstruction of ureter leading to hydronephrosis, or testicular vein predisposing to varicocele. Conclusion Surgeons should exclude the possibility of presence of such accessory renal arteries obstructing ureter or testicular vein prior to the surgical treatment of hydronephrosis and varicocoele. The awareness about the presence of such variations is important from the academic, surgical and radiological point of view.

English

The congenital anomalies of kidney are important as they may cause renal failure in middle age group. The horseshoe kidney is the most common congenital fusion anomaly in which both kidneys were fused at their lower poles by an isthmus in front of the inferior vena cava and the abdominal aorta. We present a case report of horseshoe kidney with long hilum opened anteriorly and extrarenal calyces in the left kidney along with an accessory renal artery arising from the aorta, supplied to lower pole of the left kidney and there was a separate renal vein opening into the inferior vena cava. The knowledge of horseshoe kidney with accessory renal vessels and extrarenal calyceal

Outcomes of endovascular aneurysm repair on renal function compared with open repair

Recent studies have shown that progressive renal dysfunction may develop in patients after endovascular aneurysm repair (EVAR). Data are conflicting about the effect of EVAR on renal function compared with open repair (OR). The purpose of this study was to compare the effects of EVAR, both with transrenal fixation (TRF) and infrarenal fixation (IRF), vs OR on renal function detected with renal perfusion scintigraphy (RPS). A prospective study was carried out from January 2003 to December 2007. Exclusion criteria included factors that could influence post-procedural renal function as: preoperative creatinine clearance level <65 mL/min for men and 60 mL/min for women, renal artery stenosis >60%, renal accessory artery planned to be covered by the endograft, single functioning kidney, hemodialysis, and kidney transplant. To evaluate renal function, an RPS was performed preoperatively, at 30 days, at 6 and 12 months, and then yearly. The glomerular filtration rate (GFR) was estimated with the Gates method. During the study period, 403 patients were enrolled; 243 (60%) had OR and 160 (40%) EVAR; among these, 83 (51%) had a TRF and 77 (48%) an IRF; 55 patients were excluded from the study. No statistical differences were observed between groups for demographics and risk factors. Statistically significant differences emerged between OR and EVAR for early postoperative death (4% vs 0%; P = .01). Follow-up ranged from 54 to 126 months (mean, 76 months) for OR and from 54 to 124 months (mean, 74 months) for EVAR (P = NS). Kaplan-Meier analysis survival rate at 9 years was 70% for OR and 58% for EVAR with a risk of secondary procedure of 9% and 34%, respectively (P < .0001). A deterioration of the GFR was observed during the follow-up in both groups with a decrease after 9 years of 11% in the EVAR group and 3% in the OR group respective to baseline (P < .001). A remarkable difference emerged on renal function between EVAR patients who required a secondary procedure compared with the other EVAR patients (P < .005). No significant differences emerged between TFR and IRF for GFR decline during the follow-up period. After EVAR, there is a continuous decline in renal function with respect to OR, regardless of fixation level and independently of pre-existing renal insufficiency. The risk of GFR impairment after EVAR should be taken into consideration in selecting patients with preoperative renal insufficiency.

An unusual renal accessory artery originating from the thoracic aorta and its potential clinical implications

We report a case of an unsual anatomical vascular blood supply to the right kidney. In an analysis of kidneys, by dissection of 39 foetuses, additional renal arteries were found in 18 cases (46.15%). In only one case (2.5%) was it noticed that the right kidney was supplied with blood by three renal arteries, one main and two additional arteries. One of the additional arteries, marked as the upper pole artery of aortic origin, separated from the thoracic aorta at the level of T11 (the eleventh thoracic rib), 1.5 cm above the truncus coeliacus. This artery, after passing through the diaphragm, entered the renal hilus at its upper part and served to vasculate that part of the kidney. The importance of this study is seen in the fact that anatomic knowledge of variations in the vascularization of the kidneys is of exceptional practical importance. Also, this information may concern transplant surgeons involved in living donor nephrectomies.

Customized fenestrated endovascular graft repair of abdominal aortic aneurysm with concomitant horseshoe kidney

The occurrence of an abdominal aortic aneurysm (AAA) with horseshoe kidney (HSK) is an uncommon but complex surgical problem. This report outlines three such cases, the particular issues encountered and how customized endovascular grafts were successfully used to overcome them. Case one shows an accessory renal artery arising from the left common iliac artery, case two shows a right accessory renal artery from the AAA sac and case three has the right renal artery coming off the distal abdominal aorta within the sac. Across three patients, each graft had a single custom fenestration, which preserved a total of three major vessels with no change in renal function. Customized endografts are a viable tool to preserve aberrant vessels and thus renal mass in AAA and HSK. Customized endografts require an extensive work-up and are currently expensive to fabricate. However they are rapidly evolving as a mainstream tool in vascular surgery and provide a solution in cases of aberrant visceral vasculature.

English

The renal vasculature was always a subject of variations both in the number and pattern of portal of entry into kidney and Perihilar placement of the artery, vein and pelvis. Good anatomical insight is an essential prerequisite besides the surgical expertise. The cadaveric dissection at Shadan Institute of Medical Sciences, Teaching Hospital and Research Centre, revealed superior / upper polar artery arising from the lateral aspect of the aorta just proximal to the origin of Main Renal Artery (MRA). The main renal artery and the accessory renal artery had almost a common point of origin. The peri-hilar segmentation of the main renal artery was a fork like pattern. One of the segmental arteries was long and had its portal of entry into the kidney by perforating the capsule of the anterior substance of the kidney. The remaining segmental branches had their portal of entry through the hilum. The lower two segmental branches were placed anterior to the main renal vein causing altered hilar anatomy. A thorough knowledge of the frequently to the rarely occurring wide range of variations of renal vasculature has significance in exploration and treatment of renal trauma, renal transplantation, renal artery embolization, surgery for abdominal aortic aneurysm and conservative or radical renal surgery. Such a rare variation including the combination of extra renal peri-hilar segmentation of MRA with superior polar artery is worthy of concern to the urologists harvesting kidneys from the live donors for performing transplantation procedures, partial nephrectomies for the hilar tumors and for Radiologists during interpretation of the

Spontaneously Resolving Lower Polar ATN in a Transplant Kidney With Dual Vascular Supply Demonstrated on 99mTc EC Renography

We report the presence of a differential acute tubular necrosis pattern on renography in a renal transplant recipient who had received a donor kidney with dual renal arterial supply. The proximal accessory renal artery was supplying the lower pole which had been demonstrated on CT angiography. This possibility should be kept in mind while reporting renography with tubular agents like 99mTc EC in transplant patients. Follow-up renography effectively demonstrated spontaneous resolution of the differential retention pattern and acute tubular necrosis. This case reiterates the usefulness of retention of tubular tracers like 99mTc EC for detection of tubular necrosis.