Lower Polar Artery Research Articles

Current practice with grafts with multiple renal arteries in kidney transplantation: role of the methylene blue in the lower pole.

Kidneys with multiple renal arteries (MRAs) from different patches, may provide to the surgeon additional technical difficulties that make kidney transplants very challenging. MRAs have been largely debated over the years whether to be anastomosed or not due to the disappointing outcomes when it comes to inappropriate ligation or anastomosis. Some authors empirically reassure that smaller branches can be safely ligated and dissected without intraoperative and postoperative complications or compromising the functional recovery of the graft. Literature is poor about the possible differences in the management of superior and inferior polar arteries. Inferior polar arteries represent a topic of great interest as they may also supply the proximal ureter. The aim of this article is to merge the current knowledge about the management of inferior polar arteries and to highlight if there is any role of the methylene blue dye (MB) in the study of the ureteral vascularization in kidney transplantation. MB can be considered a safe and simple tool of vascular perfusion assessment in kidney transplantation. By injecting the dye-solution into the inferior MRA hidden ureteral branches can be unmasked and guide the surgeon to preserve important vessels. In view of their fundamental role in the vascularization of the ureter, the lower polar arteries of the graft, should be invariably studied by MB. It provides an objective, simple and fast tool for the evaluation of the ureteral vascularization when injected through the inferior MRA of the graft. (www.actabiomedica.it)

Interventional Radiology Management of Renal Pseudoaneurysms: Experience at a Tertiary Care Hospital

Abstract Objectives Renal pseudoaneurysms are multifactorial in origin, and angioembolization remains the mainstay of treatment. Few case reports have also described percutaneous embolization using glue or thrombin. Our study aimed to evaluate the predictors of active bleed by analyzing their etiology, morphology, imaging features, and treatment adopted. To the best of our knowledge, this is the largest such study done in India. Methods This was a retrospective study of patients treated for renal pseudoaneurysms between 2014 and 2019. We reviewed their clinical data, treatment modalities used, and clinical outcomes. We also assessed computed tomography angiography (CTA) and conventional angiography images. Results A total of 79 patients (54 males and 25 females) were included in the study. The mean age was 39.5 years (range 15–83 years). The most common cause was renal biopsy, followed by surgery. Of these, three patients (3.9%) had more than one lesion and 57% of pseudoaneurysms were seen in lower polar arteries. Active contrast extravasation was seen in 15.2% (n = 12) of the patients and 21.5% (n = 17) showed lobulations in CT and digital substraction angiography. The mean size of the pseudoaneurysms was 1.17 cm (SD 0.7); 22.8% of pseudoaneurysms were wide necked. The embolization was approached by endovascular (89.9%), percutaneous (10.1%), or both (1.3%) routes. Embolization was performed using microcoils (78.5%), gel foam (12.7%), N-butyl cyanoacrylate glue (8.9%), polyvinyl alcohol (8.9%), and thrombin (5.1%) either as a single agent or in combination. The technical success was achieved in all cases after the first procedure. Pseudoaneurysms with a wide neck (p = 0.03) and lobulations (p = 0.002) were associated with active contrast extravasation. Episodes of rebleeding were seen at a younger age (p-value = 0.02). Conclusion Minimally invasive methods remain the cornerstone in the management of renal pseudoaneurysms with high success rates. The morphology of pseudoaneurysms can help predict the risk of active bleeding and decide the type of intervention. Direct percutaneous injection into the aneurysm sac is an alternate technique and should be considered when an endovascular approach is challenging.

Analysis of Intra Renal Arterial Pattern in Kidney Donors using 64-Slice Computed Tomography Angiography

The renal artery when it reaches close to the hilum of kidney where it cleaves into anterior and posterior divisions were receives around 75% and 25% of blood respectively. Further these branches divide into many segmental branches. These segmental arteries does not have collateral system, so when there is any occlusion of these arteries which results in the ischemia of the particular segment of kidney. Anatomists believe that knowledge of presence of lower polar artery is essential for polar nephrectomy. Prior knowledge of variations in the renal vessels is required for urological surgery for preoperative investigations as there are reports of surgical complications which include enormus haemorrhage. In this study we analyzed the different variations in the intra renal branch of inferior segmental artery.

Urine Leak Following Kidney Transplantation: An Evidence-based Management Plan

Care of kidney transplant recipient remains complex and long-term graft survival is not seen in every transplant recipient. Due to reduced supply and increased demand of human organs, more transplants are carried out using marginal grafts on emergency lists. Transplant recipients have altered physiology due to known end-stage renal disease, recent surgery and the use of potent analgesic and immunosuppressive medications. Amongst the known surgical complications, urine leak remains the most common. It can result from poor graft preparation due to excessive peri ureteric or lower pole dissection or damage to lower polar artery resulting in ischemic necrosis. In addition, poor surgical technique, bladder outflow obstruction, iatrogenic injury to bladder or renal pelvis may contribute to urine leak. On-going urine leak may manifest itself as swelling, pain, high drain output, sepsis, ileus and eventual graft loss. Early identification, localisation and quantification of leak remain essential in management of these patients. In addition, sepsis should be identified and treated promptly as these patients are highly susceptible to infections. Early recognition of this complication can significantly reduce hospital stay, improve quality of life, reduce graft loss and mortality. In this article, we aim to develop an evidence-based management approach to a patient with urine leak using a clinical scenario.

Re-Implantation and Boari Flap Reconstruction for the Management of Ureteric Stricture Following Renal Transplant: A Single Centre Experience.

Purpose: This study aims to review the outcomes of patients with ureteric strictures and reconstruction following renal transplantation in a single centre. Methods: All patients who developed ureteric stricture and subsequently underwent ureteric reconstruction between December 2003 and November 2013 were included in this study. Results: 1560 renal transplants were performed during the study period. 42 ureteric reconstructions were performed in this period. Two reconstructions were performed at the time of transplant for high ureteric injury, the remaining 40 for ureteric stricture, giving an incidence of 2.5%. There were 25 male and 15 female recipients with a median age of 48 (range 14-78). Of these, 18 (45%) received a DBD, 12 (30%) received a DCD (including one dual transplant) and 10 (25%) received a living donor (LD) graft. 5 were re-transplant (2nd or 3rd). The median time to stricture was 78 days (range 41-1016 days) from transplant. The median cold and warm ischaemia times were 14:38hr (32m-24:30hr) and 33 minutes (20m-42m) respectively. 7 kidneys had multiple arteries, 3 with a lower polar artery that was anastomosed. The majority of patients underwent nephrostomy insertion and antegrade stenting prior to surgical repair. 19 patients were reconstructed by re-implantation to the bladder, 18 utilized a Boari flap, 2 used an ileal conduit and 1 an anastomosis to a native ureter. All ureteric anastomoses were stented. In one patient, reconstruction was deemed impossible and was subsequently managed with an extra-anatomic stent. Two patients (5%) required re-operation for re-stricture and kinking. Median serum creatinine at 12 months following surgery was 148 (84-508) μmol/l. There was no 90 day mortality and 11 grafts were lost with a median time of 323 days (27-3103 days) from reconstruction. Conclusions: The incidence of ureteric stricture following renal transplant in our centre is low. Most strictures occur early following transplant. Re-implantation of transplant ureter or short Boari flap reconstruction was successfully employed in most cases. Native ureter is useful in reconstruction of strictures in dual renal transplants. None of the strictures requiring reconstruction after 2006 were associated with positive BK virus serology.

MORPHOLOGICAL FEATURES OF THE SPLENIC VESSELS

By means of corrosion method the splenic artery has been found to be divided in 92, 0% of cases into two branches of the first order. Bifurcation of the vessel was conducted at an acute angle in 47, 5% of cases and at a blunt angle in 52,5% of cases. Trifurcation of the arterial trunk (6, 8% of cases) and magistral type of splenic artery division (1, 2% of cases) was found rarely. Polar arteries were determined in 50, 6% of cases. Lower polar artery was detected more frequently – 59, 15% of cases and rarely – upper polar artery in 18, 2% of cases. The presence of both polar arteries was observed in 22, 7% of cases. The venous drainage from the spleen was conducted through a single splenic vein which is formed near the hilum in 82, 6% of cases, and only in 17, 4% of cases the junction of the first order veins was observed at a distance of 1,0 to 3,0 cm from the hilum.

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.

Ureteropelvic junction obstruction by aberrant lower pole artery

Obstruction of the ureteropelvic junction (UPJ) is one of the causes of obstruction uropathy and it may be either congenital or acquired. Aberrant lower pole crossing vessels is one of the congenital causes. In order to determine the exact cause of UPJ obstruction, imaging examinations are performed. Computed tomography (CT) with reformatted three-dimensional images is the best imaging examination for demonstrating the aberrant crossing vessels in the case of UPJ obstruction. Because the aberrant crossing vessels may aggravate, but is not the primary cause of UPJ obstruction, dismembered pyeloplasty with anterior transposition of the collecting system and preservation of the aberrant crossing vessels are usually performed to treat UPJ obstruction.

The new technique of using the epigastric arteries in renal transplantation with multiple renal arteries

The most common anatomic variant seen in the donor kidneys for renal transplantation is multiple renal arteries (MRA), which can cause an increased risk of complications. We describe the long-term outcomes of 16 years of experience in 76 kidney transplantations with MRAs. In a new reconstruction technique, we remove arterial clamps after anastomosing the donor to the recipient's main renal vessels, which cause backflow from accessory arteries to prevent thrombosis. By this technique, we reduce the ischemic times as well as the operating times. Both in live or cadaver donor kidneys, lower polar arteries were anastomosed to the inferior epigastric artery and upper polar arteries were anastomosed to the superior epigastric arteries. Injection of Papaverine and ablation of sympathic nerves of these arteries dilate and prevent them from post-operative spasm. Follow-up DTPA renal scan in all patients showed good perfusion and function of the transplanted kidney, except two cases of polar arterial thrombosis. Mean creatinine levels during at least two years of follow-up remained acceptable. Patient and graft survival were excellent. No cases of ATN, hypertension, rejection and urologic complications were found. In conclusion, this technique can be safely and successfully utilized for renal transplantation with kidneys having MRAs, and may be associated with a lower complication rate and better graft function compared with the existing techniques.

Anatomical Study of Variations in the Blood Supply of Kidneys

Each kidney is supplied by a single renal artery and a single renal vein, which accounts for about 20% of the cardiac output. However, variations in the form of level of origin and arrangement of renal arteries are so frequent. The present study aimed to note the vascular anatomy of kidneys with respect to the variations in their origin, course and any aberrant vessels which were present. The study material comprised of 15 formalin fixed human cadavers. During routine abdominal dissection for undergraduate students, the kidneys were exposed and the blood supply, along with its variations, were noted. The following anatomical findings are observed in this study: (i) Accessory renal arteries (ii) Presegmental arteries (iii) Upper polar arteries (iv) Lower polar arteries (v) Inferior suprarenal artery from accessory renal artery and (vi) Accessory renal vein. Awareness of the normal as well variational anatomy is mandatory for the surgeons, radiologists and urologists, for doing any uroradiological procedures or angiographic studies. Hence, this study will serve a useful guideline for the above mentioned procedures.

2273 FATE OF THE ACCESSORY RENAL ARTERIES OF GRAFTS WITH MULTIPLE RENAL ARTERIES DURING LIVE-DONOR RENAL ALLO-TRANSPLANTATION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery II1 Apr 20122273 FATE OF THE ACCESSORY RENAL ARTERIES OF GRAFTS WITH MULTIPLE RENAL ARTERIES DURING LIVE-DONOR RENAL ALLO-TRANSPLANTATION Ahmed Harraz, Ahmed Shokeir, Ibrahim Shalaby, Shady Soliman, Ahmed El-Hefnawy, Mohamed Kamal, Ahmed Kamal, and Mohamed Ghoneim Ahmed HarrazAhmed Harraz Mansoura, Egypt More articles by this author , Ahmed ShokeirAhmed Shokeir Mansoura, Egypt More articles by this author , Ibrahim ShalabyIbrahim Shalaby Mansoura, Egypt More articles by this author , Shady SolimanShady Soliman Mansoura, Egypt More articles by this author , Ahmed El-HefnawyAhmed El-Hefnawy Mansoura, Egypt More articles by this author , Mohamed KamalMohamed Kamal Mansoura, Egypt More articles by this author , Ahmed KamalAhmed Kamal Mansoura, Egypt More articles by this author , and Mohamed GhoneimMohamed Ghoneim Mansoura, Egypt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2451AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Donor grafts with multiple arteries are accepted alternative with equivalent outcome to grafts with single renal arteries. We aim at determining the effect of occlusion of the accessory artery on early graft function and delineating factors predicting occlusions of the accessory artery. METHODS A retrospective review of 731 consecutive live-related renal transplants was conducted between November 2002 and January 2011. A total of 105 consecutive grafts with multiple renal arteries were identified. The patency of the accessory artery was evaluated using Doppler US and MRA done at postoperative period. The frequency of patency was correlated with renographic clearance to delineate the effect on graft function. Factors predicting occlusion of the accessory artery were studied using univariate and multivariate analyses. RESULTS Doppler US diagnosed occlusion of the accessory arteries in 11 (10.5%) out of 105 grafts at a mean and median (range) of 8 and 9 (1-21) days post-transplantation, respectively. Mean ± SD and median (range) of renographic clearance of grafts with occluded accessory arteries were 50.5 ± 26 and 40 (21-92) ml/min while those of grafts with patent accessory arteries ware 68.6 ± 18.9 and 67.2 (21-117) (p<0.01). The percentage change of renographic clearance before and after transplantation has increased for grafts with patent arteries and decreased for grafts with occluded arteries (p=0.03). On multivariate analysis, factors predicting the occlusion of the accessory artery were delayed graft function (OR= 9.9, 95% CI= 1.6-58.6, p=0.01) and upper polar location of the accessory artery (OR=8.9, 95% CI= 1.8-43.4, p<0.01). On the other hand, the site of anastomosis (to major or inferior epigastric arteries) or anastomosing the artery to the main artery (bench surgery) had not affected the patency. Further analysis showed that the mean ± SD of the diameter of the upper polar arteries was 0.14 ± 0.09 cm and those of the hilar and lower polar arteries were 0.2 ± 0.06 and 0.2 ± 0.08, respectively (p=0.03). CONCLUSIONS Occlusion of the accessory renal artery has a negative impact on the early graft function. When considering grafts with accessory arteries, grafts with upper polar arteries should be paid the greatest attention and efforts should be exerted to avoid delayed graft function. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e917 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Harraz Mansoura, Egypt More articles by this author Ahmed Shokeir Mansoura, Egypt More articles by this author Ibrahim Shalaby Mansoura, Egypt More articles by this author Shady Soliman Mansoura, Egypt More articles by this author Ahmed El-Hefnawy Mansoura, Egypt More articles by this author Mohamed Kamal Mansoura, Egypt More articles by this author Ahmed Kamal Mansoura, Egypt More articles by this author Mohamed Ghoneim Mansoura, Egypt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Unilateral Hydronephrosis and Renal Damage after Acute Leukemia

A 14-year-old boy presented with asymptomatic right hydronephrosis detected on routine yearly ultrasound examination. Previously, he had at least two normal renal ultrasonograms, 4 years after remission of acute myeloblastic leukemia, treated by AML-BFM-93 protocol. A function of the right kidney and no damage on the left was confirmed by a DMSA scan. Right retroperitoneoscopic nephrectomy revealed 3 renal arteries with the lower pole artery lying on the pelviureteric junction. Histologically chronic tubulointerstitial nephritis was detected. In the pathogenesis of this severe unilateral renal damage, we suspect the exacerbation of deleterious effects of cytostatic therapy on kidneys with intermittent hydronephrosis.

Lumbotomy for multicystic dysplastic kidney: A trap for the unwary

This is a report of a case of multicystic dysplastic half of a horseshoe kidney (HSK) at surgery for multicystic kidney. During the surgery, through a lumbotomy approach, there was inadvertent injury to a lower polar artery and the pelvis of the normal contralateral half of the HSK, leading to a stormy postoperative course. This report emphasizes the need for accurate preoperative diagnosis before embarking on a lumbotomy, and also reviews the entity of multicystic dysplasia in one half of a HSK.

Percutaneous Cyanoacrylate Glue Injection into the Renal Pseudoaneurysm to Control Intractable Hematuria After Percutaneous Nephrolithotomy

We report a case of a 43-year-old man who developed intractable hematuria after percutaneous nephrolithotomy. Angiography detected a pseudoaneurysm arising from the lower polar artery; however, embolization could not be performed because of unfavorable vascular anatomy. A percutaneous thrombin injection under ultrasound guidance initially controlled the bleeding, but hematuria subsequently recurred as a result of recanalization of the aneurysm. The case was successfully managed with ultrasound- and fluoroscopic-guided direct injection of cyanoacrylate glue into the pseudoaneurysm.

A case of hydronephrosis caused by a precaval right lower polar artery

A case of hydronephrosis caused by a precaval right lower polar artery

Anatomy of renal arterial supply

A thorough knowledge of the variations of the renal artery has grown in importance with the increasing numbers of renal transplants, vascular reconstructions, and various surgical and radiologic techniques. The literature indicates that multiple renal arteries are found in 9- 76% of cadavers. The purpose of this study is to establish the incidence and characteristics of variations of renal arteries in Thais. A total of 267 Thai cadavers were dissected in the anatomy laboratory. The anatomical findings included: a single hilar artery in 82% of cases; double renal arteries in 17% of cases (one hilar artery with an upper polar artery occurred in 7%; two hilar arteries in 7%, and one hilar artery combined with one lower polar artery in 3%); and triple renal arteries occurred in 1% (two hilar arteries with one upper polar artery in 0.4% and two hilar arteries with one lower polar artery in 0.6%). In preparation for interventions, such as living renal donation, vascular reconstruction, renovascular hypertension, or radical nephrectomy, the results indicate that preoperative renal imaging is necessary and that operative techniques with attention to multiple renal arteries should be considered.

Anatomie und Physiologie bei milzerhaltenden Eingriffen

Anatomy and Physiology in Spleen-Preserving Surgery The basis for a successful partial splenectomy is the blood supply of each splenic segment and a high frequency of upper and lower polar arteries. The compartments of the spleen are the red pulp, the white pulp, and the marginal zone. Recent functional and immunohistological studies have documented major species differences. Furthermore, the spleen only attains its typical structure at a certain age. The development of this organ and its functional relevance for pediatric surgery are largely unknown. In splenic remnants the function of the red pulp might be sufficient to prevent Howell-Jolly bodies in the blood, but the white pulp and the marginal zone are inadequate in septicemia. The spleen plays a major role in lymphocyte recirculation, but the adhesion molecules involved are largely unknown. The immune function of the spleen is also regulated by nerves that might be involved in the regeneration of autotransplanted splenic tissue. The extrapolation from the structure and function of the spleen in adults to that in young children or from animal experiments to the human situation should only be undertaken with great caution.

Vascular Complications in Allogeneic Renal Transplantations

Background. The incidence of vascular complications during allogeneic renal transplantations ranges from 5% to 15%. They may be donor related (additional polar arteries, multiple renal arteries, multiple renal veins, injured arteries or veins), recipient related (severe atherosclerosis, venous thrombosis, previous transplantation), or technical. In a retrospective study of 666 kidney transplantations, the incidence and treatment of vascular complications were analyzed. Patients/Results. All transplantations were performed in end-to-side technique with aortic patch if available; all kidneys were obtained from brain-dead donors. A total of 89 operations included vascular complications (13.4%). In 46 patients (6.9%), the problem arose intraoperatively, 33 complications (5%) occurred within three weeks, and another 10 (0.3%) were seen later after successful transplantation. In 17 kidneys, major additional polar arteries were encountered, 7 of which were reanastomosed, 10 were ligated. Three kidneys were lost owing to insufficient blood supply to the ureter. In 7 patients, intraoperative vascular service operations had to be carried out owing to stenosis of the iliac artery or massive kinking. Early postoperative complications included bleeding after biopsy, anastomotic leakage, and arterial or venous thrombosis (1 successful venous thrombectomy; 18 of 33 organs were removed). As for late complications, the authors observed 9 transplant renal artery stenoses (TRAS); 8 were treated by percutaneous transluminal angioplasty. One patient developed an iliac aneurysm owing to chronic patch rupture. Conclusion. The majority of intraoperative complications were due to injury of the kidney during donor nephrectomy (21/46). Polar arteries should be reconstructed if possible, especially lower polar arteries, because of the danger of ureteral necrosis. In times of increasing donor organ shortage, only experienced surgeons should perform explantation and transplantation of kidneys to avoid technical faults in a considerable number of organs.

Unusual relationship of multiple renal arteries

An unusual cross relationship of two left renal arteries was demonstrated angiographically during the investigation of a young man presenting with painless, total hematuria after a traffic accident. The upper pole artery arose from the aorta caudal to the lower pole artery. In the absence of a malrotation a possible embryologic cause has been advanced. It also highlights the advantage of combining selective renal arteriography with aortography when multiple renal arteries are encountered.