Suprarenal Artery Research Articles

Retroperitoneal endoscopic release in the management of celiac artery compression syndrome

Celiac artery compression syndrome (CACS) can be treated successfully by division of the median arcuate ligament and celiac plexus fibers. The standard technique is the open approach by an upper midline or left subcostal incision. Only six single cases in which a laparoscopic transabdominal approach for CACS was used have been reported. We prospectively evaluated the feasibility of the endoscopic retroperitoneal approach for treatment of CACS. All patients with symptoms suggestive of CACS were evaluated using splanchnic duplex ultrasound scanning, gastric exercise tonometry (GET), and multiplane selective splanchnic angiography. The criteria for treatment were chronic abdominal symptoms, respiratory-dependent CA stenosis, and abnormal GET result. The release was performed by a retroperitoneal endoscopic approach. Anatomic success of the procedure was confirmed by angiography. The endoscopic retroperitoneal approach was used to treat 46 patients with CACS. One patient (2%) required conversion to an open procedure due to suprarenal artery bleeding. Release was ended prematurely in one patient due to a pneumothorax resulting in loss of working space. A postoperative pneumothorax developed in two patients, of which one needed treatment. No other complications were observed. Postoperative angiography during inspiration and expiration showed normal vessel anatomy in 36 of 46 patients. Six of 10 patients with persisting intraluminal stenoses were treated endovascularly. Five of these were successful, which brings the primary-assisted anatomic patency for the total group to 89% (41 of 46 patients). Three patients are being observed, and endovascular treatment remains an option in case of insufficient improvement. On median follow-up of 20 months (range, 2-42 months) 41 patients were free of symptoms or showed significant improvement. The endoscopic retroperitoneal approach for the release of the CA in CACS, with additional endovascular treatment of persistent stenosis, is feasible and effective. Short-term results were comparable with the open procedure.

Duplication of the inferior vena cava: anatomy, embryology and classification proposal

A case of a duplicated inferior vena cava (IVC) along with other anatomical vessel variations in a 72-year-old male cadaver is presented. The anomalous vessels involved, besides the IVC, were the left testicular vein and artery, the left suprarenal artery and a superior accessory left renal artery. Based on the gross appearance of the preaortic anastomotic trunk between the left and right IVC as well as on the underlying embryological features, a classification is proposed: incomplete bilateral duplication of the IVC and complete bilateral duplication of the IVC. The latter can be further divided into three types: major, minor and asymmetric.

Aortic, Celiac Axis, and Superior Mesenteric Artery Thrombosis Associated With Sigmoid Colon Adenocarcinoma and Hypercoagulable State

A patient with sigmoid colon adenocarcinoma and hypercoagulable state developed acute visceral ischemia secondary to thrombus involving the suprarenal aorta, celiac axis and superior mesenteric artery. A large, laminated fibrin thrombus was removed via supraceliac aortotomy. Attempts to clear thrombus from branches of the celiac axis and superior mesenteric artery by open and catheter-based techniques were of limited success. Extensive visceral infarction ensued and the patient died.

Unusual origin and course of the testicular arteries

The testicular arteries usually arise from the anterolateral aspect of the abdominal aorta just inferior to the renal arteries at the level of the second lumbar vertebra. However, they may also originate from the renal artery, middle suprarenal artery, one of the lumbar arteries, common or internal iliac artery, or the superior epigastric artery. An unusual origin of the right testicular artery and an unusual course of the left one were observed during routine dissection of the retroperitoneal space of a 43-year-old male cadaver. The right testicular artery originated from the inferior segmental branch of the right renal artery. After the left testicular artery originated from the anterolateral surface of the abdominal aorta just inferior to the left renal artery it was located between the left renal vein and the left renal artery and descended anterior to the renal vein. Thereafter it coursed on its normal route distally with the testicular vein. Awareness of variations of the testicular arteries, such as that shown in this case, is important during surgical and radiological procedures pertaining to kidney.

Treatment of Massive Retroperitoneal Hemorrhage from Adrenal Metastasis of Hepatoma

Spontaneous rupture of metastatic adrenal tumor with massive retroperitoneal hemorrhage and shock is an uncommon clinical event. Herein, we report a case of hepatocellular carcinoma (HCC), where left hepatic lobectomy and right adrenalectomy for metastatic HCC were performed in April and August 2002, respectively. Subsequently, the patient presented to the emergency room with acute-onset severe left flank and back pain in March 2004, accompanied by a falling hemoglobin level. Computed tomography revealed a 7-cm left adrenal tumor mass with retroperitoneal hemorrhage. The ruptured adrenal tumor was further confirmed by selective angiography, which demonstrated that the bleeder was supplied by the left suprarenal artery. Transarterial embolization (TAE) to stop tumor bleeding was performed successfully. The patient then underwent tumor resection with left adrenalectomy 5 days after the embolization, with pathology subsequently revealing metastatic HCC. The recurrent intrahepatic HCC was controlled with TAE, and the patient underwent hormone replacement therapy with prednisolone 10 mg/day. Metastatic adrenal tumor bleeding should be suspected in hepatoma patients who suffer abrupt flank pain and shock. Hemodynamically unstable patients require supportive transfusions and urgent surgical exploration. Angiographic embolization, if deemed feasible, may be a valuable adjunct for achievement of hemostasis prior to definite surgery.

A rare variation of the right middle suprarenal artery

According to general knowledge, the suprarenal gland is supplied by three sources: the phrenic artery, the abdominal aorta and the renal artery. Since the gland lacks a hilus, and particularly because of its clinical importance, anatomical arterial sources and branching is still not uniform and it needs to be determined by detail. In this study, the right middle suprarenal artery arising from the right renal artery was observed on the right side of a 45-year-old male cadaver.

Complex renal vascular variation: A case report

As the number of renal surgical interventions increase a better understanding of the anatomy of renal arteries and their branches gain in importance. Here we describe a common trunk from the right side of the aorta ramifying into suprarenal and two renal hilar arteries in a 40-year-old male cadaver detected during dissections performed in a routine gross anatomy course. The suprarenal branch is divided into several smaller branches to supply blood to the suprarenal gland. The superior renal hilar artery gave rise to the right testicular artery and an additional suprarenal artery. The inferior renal hilar artery gave rise to one more additional suprarenal artery. The superior renal hilar artery crossed the inferior renal hilar artery. On the same side renal veins were also doubled. For better outcome interesting variations such as in this case should be kept in mind before and during any interventions involving this region.

Multiple variations in the paired arteries of the abdominal aorta

Variations in the origin of arteries in the abdomen are very common. The arteries that show frequent variations include the celiac trunk, renal arteries, and gonadal arteries. We observed multiple variations in a 45-year-old male cadaver. The variations found on the left side were: one accessory renal artery, two testicular arteries, and middle suprarenal and inferior phrenic arteries that branched from the celiac trunk. On the right side, the inferior phrenic and middle suprarenal arteries arose from the right renal artery.

Laparoscopy-assisted reconstruction to treat severe aortoiliac occlusive disease: early and midterm results

Objectives The purpose of this study was to evaluate the consequences on patient selection and on early and midterm results of the learning curve of a surgical team performing laparoscopy-assisted surgery in the treatment of severe aortoiliac occlusive disease (AIOD). Patients and method Between January 1998 and June 2003, 58 patients (53 men, 5 women; mean age, 59.5 years [range, 37-76 years]) were included in a prospective study and underwent a laparoscopy-assisted aortofemoral reconstruction with graft implantation through a 5-cm to 8-cm minilaparotomy. Fifty-one patients (88%) had claudication (category 2 or 3, Rutherford classification), and seven patients (12%) had tissue loss; at presentation they had TransAtlantic Inter-Society Consensus C (n = 24, 41.4 %) or D (n = 32, 55.2%) iliac lesions, and the last 2 patients (3.4%) had severe aortic lesions. Perioperative data for the first 29 patients, obtained during the first 34 months of the study (group 1), were compared with data for the last 29 patients, obtained during the last 32 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomography before discharge and then every 2 years. Results One intraoperative surgical conversion (1.7%) was necessary, and two other patients (3.4%) died in the immediate postoperative period. With experience, initial contraindications such as obesity or suprarenal artery aortic clamping were eliminated, making it possible to increase the percentage of patients included, from 53.7% during the first 34 months to 90.6% during the last 32 months ( P = .003). The mean duration of the operative procedure decreased from 285 minutes in group 1 to 192 minutes in group 2 ( P < .001), and the mean duration of aortic clamping decreased from 76.4 minutes in group 1 to 31.8 minutes in group 2 ( P < .001). The number of early repeat interventions was reduced from three (10.3%) in group 1 to 2 (6.9%) in group 2 ( P = NS), and the clinical recovery period decreased from 7 days to 4.5 days ( P = .05). During a mean follow-up of 26.7 months (range, 1-66 months) there were 5 repeat surgeries (9%) to treat late graft occlusion, establishing midterm primary and secondary patency rates of 89.3% and 91%, respectively. No aortic false aneurysms were detected, and no major amputations were performed. Conclusion These preliminary results assess the feasability and the safety of this minimally invasive video-assisted technique. A short period of postoperative recovery and good midterm patency rate are the two main benefits of this new surgical option.

Morphological aspects of the inferior suprarenal artery.

The study was performed on 120 cases, and evaluated the origin, caliber at the origin, course, place of termination and distribution of the inferior suprarenal arteries, together with their point of entry into the glandular parenchyma. Most often, the inferior suprarenal artery originated from the trunk of the renal artery, prior to its terminal division. Other possible origins were: as a terminal branch of the renal artery, from one of the terminal branches of the renal artery (most often from the anterior division and rarely from the posterior one), as a common trunk with the superior polar renal artery, from a supplementary renal artery (more often from the superior and rarely from the inferior one), directly from the aorta, either as an individual branch, as a common trunk with the superior polar renal artery or as a common trunk with the middle suprarenal artery. Rarely the inferior suprarenal artery may originate from the genital artery or, also very rarely, from the celiac trunk, either individually or as a common trunk with the middle suprarenal artery. Usually, the inferior suprarenal arteries originating from the aorta or the renal artery have a larger caliber than those from other arterial sources. Most often, we found two or three arterial branches as inferior suprarenal arteries, so we may speak of inferior suprarenal arteries or an inferior suprarenal arterial pedicle.

Aortic dissection precedes formation of aneurysms and atherosclerosis in angiotensin II-infused, apolipoprotein E-deficient mice.

We sought to define the temporal characteristics of angiotensin II (AngII)-induced abdominal aortic aneurysms (AAAs) and to provide mechanistic insight into the development of this vascular pathology in apolipoprotein E-deficient (apoE-/-) mice. Male apoE-/- mice were infused with AngII for 1 to 56 days. Suprarenal arteries were sequentially sectioned, and cellular features were defined by histologic and immunocytochemical techniques. The initial identified event was medial accumulation of macrophages in regions of elastin degradation. Subsequent medial dissection was associated with luminal dilation and thrombus formation. Thrombi were usually constrained by adventitial tissue, although approximately 10% of mice died due to rupture. Thrombi led to profound inflammation that was characterized by infiltration of macrophages and T and B lymphocytes. Remodeling of the tissues was associated with regeneration of elastin fibers and reendothelialization of the dilated luminal surface. Aneurysmal tissue underwent profound neovascularization. Atherosclerotic lesions were only detected after development of the aneurysms. The initial event in AngII-induced AAA is a focal dissection in the suprarenal region. The progression of AAA precedes the development of overt atherosclerotic lesions.

Routine Use of Intravascular Ultrasound for Endovascular Aneurysm Repair: Angiography is not Necessary

Introduction: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography.Materials/methods: eighty consecutive patients (median age 69 years (range 25–90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference.Results: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190ml (range: 20–350) for angiography versus 0ml for IVUS (p<0.01). Median X-ray exposure time 24min (range 9–65min) versus 8min (range 0–60min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures.Conclusions: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.

Anatomical variations of the human suprarenal arteries

This is on anatomical study of the suprarenal arteries and their variations in 30 cadavers aimed at providing in a subsequent article the anatomical basis of arterial segments of the gland. The suprarenal glands were supplied by 3 main groups of suprarenal arteries: superior, middle and inferior. Only the superior and the inferior groups were present in all cases, since the middle vessels appeared in only 93.3% +/- 4.6 of the cases. The superior group included on each side 4 arteries in males and 5 in females; the middle group presented only 1 artery on each side in both males and females, and the inferior group exhibited on each side 2 arteries in males and 1 artery in females. The most variable group was the middle one, the aortic origin being the most frequent but with a relatively low incidence (53.3% +/- 9.1 on the right and 46.7% +/- 9.1 on the left). The superior group originated from the posterior branch of the ipsilateral inferior phrenic artery in 83.3% +/- 6.8 on the right and 80% +/- 7.3 on the left. The arteries of the inferior group were branches of the ipsilateral renal artery in 70% +/- 8.4 on the right and 50% +/- 9.1 on the left. The origin of the middle suprarenal arteries from the trunk of the inferior phrenic artery on both sides (26.7% +/- 8.1 on the right and 36.7% +/- 8.8 on the left) should be considered relevant. The anatomical findings warrant a further investigation for the identification, illustration and nomenclature of arterial anatomicosurgical segments.

Induction of experimental proteinuria in vivo following infusion of human plasma hemopexin

The human plasma constituent hemopexin (Hx), following incubation with renal tissue, is able to induce glomerular alterations in vitro that are similar to those seen in minimal change disease (MCD). Whether this acute phase reactant is also able to induce proteinuria and minimal change-like alterations in vivo is questioned. In the first set of experiments, Hx (4.0 mg in 5.0 mL saline) or equal amounts of control fraction, that is, heat-inactivated Hx (HI-Hx), were infused into conscious rats (N = 6) that had been surgically equipped with a cannula inserted into the suprarenal artery (SRA), enabling direct contact of the infusate and the renal microvasculature. Each animal received HI-Hx at day 1 for 15 minutes (flow rate 20.0 mL/h), subsequently followed by saline for seven hours (Flow rate 5.0 mL/h), after which the cannula was disconnected. At day 2, identical infusions in the same rat were carried out, using native Hx. Urine samples collected every 30 minutes during the experiments were monitored for protein content using standard methods. In the second set of experiments, unilateral perfusion was done ex vivo in anesthetized rats with Hx (N = 5) or HI-Hx (N = 3; 1.5 mg/mL; 4.0 mL during 6 min). After reconnection of the circulation, urine samples of both kidneys were collected every 30 minutes during five hours via ureter cannulation. Urinary protein (expressed as the difference in excretion between perfused and nonperfused kidney) was calculated in mg/24 h. In additional experiments, rats were sacrificed two hours after perfusion of Hx or heat-inactivated (control) Hx (first set of experiments) or after five hours (second set of experiments), and kidneys were processed for immunohistochemical and ultrastructural examination. The results of experiment 1 show a significant increase of proteinuria after Hx infusion versus HI-Hx (means +/- SD, 41.91 +/- 16.01 mg/24 h vs. control, 21.22 +/- 5.69 mg/24 h; P </= 0.03). Histochemical and electron microscopical examination of kidney tissue fragments taken at the time of proteinuria showed diminished expression of glomerular ecto-ATPase and enhanced effacement of epithelial foot processes at the ultrastructural level. In the second set of experiments, the results show significant urinary protein excretion peaking one hour after perfusion (6.63 +/- 7.06 mg/24 h), exclusively in Hx-perfused animals (analysis of variance, P < or = 0.001). It is concluded that Hx is able to induce proteinuria associated with MCD-like alterations in rat kidney in vivo.

Studies on the vasa vasorum of the human renal artery

The transplantation of a donor kidney is currently the treatment of choice for terminal renal insufficiency. However, major postoperative problems may be caused by vascular complications. It was therefore decided to look for possible correlations between these vascular problems and the arterial wall supply. The following methods were used to elucidate the origin and distribution of nutrient vessels: 1. Injection of the abdominal aorta with resin in three fresh cadavers. 2. The precise microscopic location of the branches originating from the renal arteries in eighteen autopsy subjects. 3. Abdominal angiography and selective angiography of the first left lumbar artery and left renal artery in one patient. It was found that the renal artery receives its blood supply from both internal and external nutrient vessels. The external vascular supply of the renal arterial wall originates from the aorta itself, from the inferior suprarenal artery (which sometimes has connections with the first and/or second lumbar artery) or from the diffuse vascular system of the retroperitoneal space. Because of the variety in number, course and origin of these nutritional vessels, an ideal point for the anastomosis of the renal artery cannot be indicated.

Angioarchitecture of the coeliac sympathetic ganglion complex in the common tree shrew (Tupaia glis).

The angioarchitecture of the coeliac sympathetic ganglion complex (CGC) of the common tree shrew (Tupaia glis) was studied by the vascular corrosion cast technique in conjunction with scanning electron microscopy. The CGC of the tree shrew was found to be a highly vascularised organ. It normally received arterial blood supply from branches of the inferior phrenic, superior suprarenal and inferior suprarenal arteries and of the abdominal aorta. In some animals, its blood supply was also derived from branches of the middle suprarenal arteries, coeliac artery, superior mesenteric artery and lumbar arteries. These arteries penetrated the ganglion at variable points and in slightly different patterns. They gave off peripheral branches to form a subcapsular capillary plexus while their main trunks traversed deeply into the inner part before branching into the densely packed intraganglionic capillary networks. The capillaries merged to form venules before draining into collecting veins at the peripheral region of the ganglion complex. Finally, the veins coursed to the dorsal aspect of the ganglion to drain into the renal and inferior phrenic veins and the inferior vena cava. The capillaries on the coeliac ganglion complex do not possess fenestrations.

Angioarchitecture of the coeliac sympathetic ganglion complex in the common tree shrew (Tupaia glis)

The angioarchitecture of the coeliac sympathetic ganglion complex (CGC) of the common tree shrew (Tupaia glis) was studied by the vascular corrosion cast technique in conjunction with scanning electron microscopy. The CGC of the tree shrew was found to be a highly vascularised organ. It normally received arterial blood supply from branches of the inferior phrenic, superior suprarenal and inferior suprarenal arteries and of the abdominal aorta. In some animals, its blood supply was also derived from branches of the middle suprarenal arteries, coeliac artery, superior mesenteric artery and lumbar arteries. These arteries penetrated the ganglion at variable points and in slightly different patterns. They gave off peripheral branches to form a subcapsular capillary plexus while their main trunks traversed deeply into the inner part before branching into the densely packed intraganglionic capillary networks. The capillaries merged to form venules before draining into collecting veins at the peripheral region of the ganglion complex. Finally, the veins coursed to the dorsal aspect of the ganglion to drain into the renal and inferior phrenic veins and the inferior vena cava. The capillaries on the coeliac ganglion complex do not possess fenestrations.

Extraorganic vascular system of adrenal glands in human fetuses

The injection method was used to study the origin and variability of the blood vessels forming the extraorganic vascular system of the adrenal glands. Studies were carried out on 40 human fetuses of a crown-rump length between 113 and 280 mm (14 to 28 weeks of fetal age). It was proved that the arterial blood supply during the fetal period is extremely variable in both the origin and the number of adrenal arteries, as well as in the asymmetry of the blood supply between the left and right adrenal glands. The three main origins of the suprarenal arteries are from the inferior phrenic artery, the abdominal aorta and the renal artery. The inferior phrenic artery is the main one supplying the suprarenal glands during the fetal period. A characteristic feature of the extraorganic venous system in fetal adrenal glands is the constant presence of the adrenal vein, including number, orifice and the main tributaries.

Right-sided pedunculated hepatocellular carcinoma: A form of adrenal metastasis

Pedunculated hepatocellular carcinoma (HCC) or extrahepatic growth of HC C is an uncommon but not rare pathological form, but its genesis is unknown. Right-sided adrenal metastases of HCC that were abutting on or about to fuse with the right hepatic lobe were resected in three patients. The masses seemed to have originated in the para-adrenal tissue, leaving the adrenal gland intact. They were partially supplied by the hepatic artery as well as by the suprarenal artery. Four cases of autopsied pedunculated HCC of the right lobe were also studied. The mass was protruding caudad from the noncancerous parenchyma of the right lobe. Postmortem angiography carried out on one liver showed that only a small portion of the mass toward the liver was supplied from the hepatic artery. These observations suggest that some, perhaps most, of the right-sided pedunculated HCCs represent fusion of the right lobe and para-adrenal or adrenal metastatic HCC. This phenomenon may be explained by possible transport of cancer cells toward the right adrenal gland through the so-called adrenohepatic fusion, a relatively common anatomical change in advanced age.

Ruptured Suprarenal Artery Aneurysm: Angiographic Diagnosis and Treatment by Selective Embolization

Ruptured Suprarenal Artery Aneurysm: Angiographic Diagnosis and Treatment by Selective Embolization