Multiple Renal Artery Aneurysms Research Articles

Kidney autotransplantation for multiple renal artery aneurysms: A case report

Kidney artery aneurysms are a rare phenomenon with a prevalence of 0.01%-1% in the general population. Although historical series describe rupture rates of 14% to 30% with a mortality rate of 80%, the natural history of kidney artery aneurysms is currently characterized by a low risk of rupture and a slow to nonexistent growth rate. Criteria for repair have been controversial for decades and currently include aneurysm size > 2 cm, female sex, and symptoms such as drug-refractory hypertension, pain, and hematuria. In this article, we report a successful kidney autotransplantation for multiple renal artery aneurysms (8 to 9 mm) in a 37-year-old woman who had suffered from arterial hypertension for 19 years. The clinical case described demonstrates the efficacy of surgical treatment of renal artery aneurysms with malignant hypertension.

Anatomic characteristics and natural history of renal artery aneurysms during longitudinal imaging surveillance

Renal artery aneurysms (RAAs) are uncommon, and rates of growth and rupture are unknown. Limited evidence therefore exists to guide clinical management of RAAs, particularly small aneurysms that are asymptomatic. To further characterize the natural history of RAAs, we studied anatomic characteristics and changes in diameter during imaging surveillance. Patients evaluated for native RAAs at a single institution during a 5-year period (July 2008 to July 2013) were identified and analyzed retrospectively. Patients with two or more cross-sectional imaging studies (computed tomography or magnetic resonance imaging) more than 1 month apart were included. Demographic and clinical data were collected from medical records, and anatomic data (including aneurysm diameter, calcification, and location) were obtained from electronic images. Changes in RAA diameters over time were evaluated by plots and Wilcoxon signed rank tests. Sixty-eight RAAs in 55 patients were analyzed. Median follow-up was 19.4 months (interquartile range, 11.2-49.0 months). Mean age at presentation was 61.8 ± 9.8 years, and 73% of patients were women. Hypertension was prevalent among 73% of patients. Multiple RAAs were present in 18% of patients, and 24% also had arterial aneurysms of other splanchnic or iliac vessels. The majority of RAAs were calcified and located at the main renal artery bifurcation. Mean initial aneurysm diameter was 16.0 ± 6.4 mm. Median annualized growth rate was 0.06 mm (interquartile range, -0.07 to 0.33 mm; P = .11). No RAA ruptures or acute symptoms occurred during surveillance, and 10.3% of RAAs were repaired electively. Risk of short-term RAA growth or rupture was low. These findings suggest that annual (or less frequent) imaging surveillance is safe in the majority of patients and do not support pre-emptive repair of asymptomatic, small-diameter RAAs.

Anatomic Characteristics and Natural History of Renal Artery Aneurysms During Longitudinal Imaging Surveillance

Renal artery aneurysms (RAA) are uncommon and rates of growth and/or rupture are unknown. Limited evidence, therefore, exists to guide clinical management of RAA, particularly those that are small and asymptomatic. To further characterize the natural history of RAA, we studied anatomic characteristics and changes in diameter during imaging surveillance. Patients evaluated for native RAA at a single institution over a three-year period (July 2010-July 2013) were identified and analyzed retrospectively. Patients with two or more cross-sectional imaging studies (computed tomography or magnetic resonance imaging) more than 1 month apart were included. Demographic and clinical data were collected from medical records and anatomic data (including aneurysm diameter, calcification, and location) were obtained from images. Aneurysm growth over time was analyzed using plots and Wilcoxon signed rank tests. Fifty-two aneurysms in 44 patients were analyzed. Median follow-up was 17.5 months (IQR, 8.1, 34.2 months); 70.5% of patients were female and mean age at initial presentation was 60.4 ± 9.5 years; and 75.0% of patients had hypertension. Imaging studies demonstrated a 20.5% prevalence of nonrenal abdominal aneurysms and 18.2% had multiple RAA. Most RAA were located at the main renal artery bifurcation and had some degree of calcification. Mean initial aneurysm diameter was 16.3 ± 6.3 mm. Median annualized growth rate was 0.03 mm (IQR, −0.16, 0.42 mm) (P = .34). 13.5% of RAA were repaired electively and no RAA ruptures occurred. Risk of short-term RAA growth or rupture was low. These findings suggest that annual (or less frequent) imaging surveillance is safe in the majority of patients and do not support pre-emptive repair of asymptomatic, small diameter RAA.

Spontaneous perirenal hematoma due to multiple renal artery aneurysms in a patient with presumed polyarteritis nodosa

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that involves the renal and visceral arteries.1 PAN typically presents with systemic symptoms and signs such as fatigue, weight loss, weakness, fever, arthralgia, skin lesions, hypertension, renal insufficiency, neurologic dysfunction and abdominal pain.2 Despite the common involvement of the kidney, spontaneous perirenal hemorrhage from a renal vasculitic aneurysm is a rare complication. A 72-year-old man was admitted to the hospital with complaints of dyspnea and generalized edema that had persisted for 2 weeks. Physical examination revealed coarse and decreased breath sounds with moist rales. His serum potassium and creatinine level were 9.5 mEq/L and 10.6 mg/ dL, respectively. Viral makers and autoantibodies, including anti-neutrophil cytoplasmic antibodies, were negative. His erythrocyte sedimentation rate was 18 mm/h and high sensitive C-reactive protein was 21.4 mg/L. We performed emergency hemodialysis via femoral vein catheterization under the impression of acute kidney injury and uncontrollable potassium levels. After emergency dialysis, the patient’s condition slowly improved. On the 15th hospital day, he complained of a sudden onset of right flank pain accompanied by a hypotensive episode. Abdominal computed tomography showed massive perirenal hematoma around the right kidney (Panel A: arrow). Renal angiography showed multiple aneurysmal dilatations of the interlobar arteries of the right kidney, and we performed coil embolization (Panel B: arrows; Panel C). Polyarteritis nodosa was diagnosed according to the radiologic findings of aneurysmal dilatation of the interlobar arteries of the right kidney. Images in vascular medicine

Favorable outcomes with in situ techniques for surgical repair of complex renal artery aneurysms

The optimal method of operative management of complex branch renal artery aneurysms (RAAs) remains unclear, with recent reports predominantly espousing endovascular and ex vivo repair. We sought to determine the long-term outcome of RAA repair performed with autogenous in situ techniques. This was a cohort study of patients undergoing surgical repair of RAAs identified from our prospective vascular division registry (1984-2009). Twenty-six RAAs were repaired in 24 patients (17 women, 7 men; mean age, 52 ± 16 years). Mean size was 2.3 ± 0.7 cm (range, 0.7-4.0 cm). Twenty RAAs were repaired based on size and six for hypertension alone. Multiple RAAs were present in 13 patients (54%). Associated conditions included hypertension in 24 (100%), fibromuscular dysplasia in 6 (25%), coexistent renal artery stenosis in 6 (25%), and aortic aneurysm in 3 (12.5%). Reconstruction of first- or second-order branches was required in 25 RAAs (96%). In situ techniques were used in 22 repairs and included resection combined with autogenous vein bypass and interposition in 11, primary anastomosis to conjoined outflow vessels in 3, and aortic reimplantation in 2. Aneurysmorrhaphy was combined with vein patch angioplasty in 6, exclusion in 2, tailored primary closure in 1, and autogenous bypass in 1. Four patients underwent ex vivo reconstruction. Perioperative mortality was 0% and morbidity was 11.5%, including one nephrectomy during ex vivo repair for immediate thrombosis. Renal function was preserved (preoperative creatinine, 0.94 ± 0.3 vs postoperative creatinine 1.06 ± 0.4 mg/dL; P = .11). Systolic (SBP) and diastolic blood pressure (DBP) control improved after operation: preoperative SBP 142 ± 18 vs postoperative SBP 130 ± 15 mm Hg (P = .007) and preoperative DBP 86 ± 14 vs postoperative DBP 78 ± 10 mm Hg (P = .01). Long-term patency was evaluated in 18 reconstructions (69%) by duplex imaging or contrast radiography at an average long-term follow-up of 99 months (range, 1-300 months) and was 94%. Five-year freedom from rupture and survival by the Kaplan-Meier method was 100%. In situ techniques allow repair of complex RAAs involving branch vessels with minimal morbidity, improved blood pressure control, and maintenance of renal function. This operative approach further provides excellent long-term patency and survival in this relatively young patient population.

Multiple renal artery aneurysms diagnosed by three-dimensional CT angiography

Renal artery aneurysm is a relatively rare disease that is found in 0.3–1.0% of patients examined by renal angiography. We report a case of multiple renal artery aneurysms that were accurately diagnosed by three-dimensional CT angiography (3D-CTA) using volumetric data sets of spiral CT.

Color Photography in Open Urological Surgery

The quality of intraoperative color slide photography can be improved by 1) orienting the viewer with landmark outline and constant camera position during the procedure, 2) brown gloves to avoid contrast within the operative field, 3) blue sponges to absorb blood, 4) contrasting stay sutures or tapes and 5) taking multiple pictures at different exposures. These points are illustrated with the photographic record of the repair of multiple renal artery aneurysms to provide the urologist with helpful hints in the recording of his interesting or challenging operative procedures.