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Multiple Aneurysms of the Right Renal Artery: A Case Report
THE JOURNAL OF UROLOGY
Vol. 87, No. 6 June 1962 Copyright© 1962 by The Williams & Wilkins Co. Printed in U.S.A.
MULTIPLE ANEURYSMS OF THE RIGHT RENAL ARTERY: A CASE REPORT EARLE D. ACKER, JAMES V. DOOLEY AND WINFIELD F. HERMAN Aneurysms of the renal arteries are relatively infrequent, and constitute approximately only 1 per cent of all aneurysms. The majority of patients who have renal artery aneurysms are middle aged and the cases are about equally divided between males and females. 1 After the aneurysm has developed, calcifications which may form can be identified by x-ray. Because of this radiopaque shadow, many unsuspected renal artery aneurysms have been detected on routine x-ray examination. Aneurysms of the renal artery are for the most part saccular in type, and are usually found at bifurcation points. The average size is from 1-4 cm. in diameter; and some are within the kidney and are called intrarenal aneurysms. Multiple aneurysms of the renal artery and bilateral renal artery aneurysms do occur, but are not common. A review of 169 cases by Ippolito and LeVeen1 revealed that 100 aneurysms were non-calcified and 69 were calcified. Harrow and Sloane2 reviewed 24 cases of ruptured aneurysms six of which occurred during pregnancy. Among these 24 cases, there were 20 fatalities. All of the ruptured aneurysms were of the non-calcified type. Harrow and Sloane2 also reported a series of 5 cases of renal artery aneurysms which were detected by identifying the calcific shadow of the aneurysm on x-ray examination. These particular patients had experienced no symptoms referable to the aneurysms. The symptoms of a renal artery aneurysm may be minimal, and as stated earlier, there may be no symptoms at all. A diagnosis of renal artery aneurysm must be considered when a patient complains of intermittent, or constant flank pain that cannot be explained by the usual diagnosis. Occasionally, one may feel an abnormal pulsation of the aorta with an abnormal pulsation drifting toward the flank. There may be a bruit of the aorta and of the renal artery Accepted for publication November 17, 1961. 1 lppolito, J. J. and LeVeen, H. H.: Treatment of renal artery aneurysms. J. Urol., 83: 10-16,
which can be heard in the abdomen and also over the renal artery into the flank. Frequently intermittent hematuria may be present. Many of these patients have been investigated multiple times because of hematuria and no definite renal disease found. Many times intermittent or constant hypertension may be found. Surgical intervention is indicated in those patients who have the above mentioned symptoms with a proven aneurysm as demonstrated by the calcific shadow, or, more directly now, by visualization of the renal artery by radiography. Non-calcified aneurysms are much more prone to rupture than calcified ones and these should be operated upon regardless of size. It has been reported that 25 per cent of all noncalcified renal artery aneurysms will rupture.' If the aneurysm is calcified in a younger patient, the patient should be operated upon, because the aneurysm may rupture in the future. Poutasse believes that surgical treatment is unnecessary in a patient who is asymptomatic, non-hypertensive and has a calcified renal artery of 1.5 cm. in diameter or less. 1 Pregnant patients with renal artery aneurysms should be operated upon because of the high mortality rate from ruptured renal aneurysms. Operations on renal artery aneurysms may consist of 1) excision of the saccular aneurysm with direct suture of the arterial wall, 2) excision of a single aneurysm with direct anastomosis, 3) excision of the aneurysm and grafting with either a vein or plastic prosthesis, or as in the case to be reported, 4) nephrectomy with excision of the portion of renal artery containing the aneurysm or aneurysms. The following is a case report of a patient who had mild hypertension associated with persistent right flank pain for over 15 years and intermittent hematuria. She had undergone an extensive investigation including laparotomy, which failed to uncover the pathological process. CASE REPORT
Mrs. K. S., a 40-year-old woman, was admitted to the hospital November 20, 1960 with a chief complaint of persistent right upper
1960.
Harrow, B. R. and Sloane, J. A.: Aneurysm of renal artery, report of 5 cases. J. Urol., 81: 35-41, 1959. 2
759
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ACKER, DOOLEY AND HERMAN
quadrant pain. The patient had a history of a dull, right upper quadrant pain for approximately 15 years. Although the pain was persistent, its severity increased 3 to 4 times a year. These exacerbations lasted approximately 3 days. In 1946 an exploratory laparotomy was done because of persistent pain, and an appendectomy performed. However, no specific diagnosis was made and the patient continued to have pain, which was confined to the right upper quadrant and right flank, and was somewhat relieved by flexing the right thigh onto the abdomen. The pain was relieved to some extent following urination, but bowel movements made the pain worse. Diagnostic studies included a complete gastrointestinal series, a gallbladder series, several excretory urograms, cystoscopy and multiple laboratory tests. At one point, a question of hyperparathyroidism was entertained, but eventually not substantiated. She stated that her blood pressure had been elevated in the region of 160, and that occasionally blood had been found in the urine. In 1952 a hysterectomy was clone. She had also been investigated urologically several times because of the pain and hematuria. It was believed that a tumor of the
Fm. 1. Translumbar aortogram visualizes right renal artery with aneurysmal dilatations. (Photograph reversed. Editor.)
kidney or renal calculus might be responsible for the pain. However, the findings were all essentially negative except for persistent hematuria, pain and hypertension. The pulse was 85, temperature 98.6, respirations 16 and the blood pressure 160/100. The heart rate was slightly increased, the rhythm was normal and no murmurs were present. The lungs were clear to percussion and auscultation. The abdomen was not distended, and bowel sounds were normal. The patient was moderately tender in the right upper quadrant and right flank, and on auscultation of the abdomen over the aorta, a bruit, heard in the epigastric region in the midline, could be traced through the right upper quadrant to the right flank. No abnormal pulsations, however, could be felt. The liver, spleen and kidneys could not be palpated, and no abdominal masses were felt. The extremities were essentially normal. The peripheral pulses were good, and the reflexes equal and active. Urinalysis showed the urine to be hazy, pH 5, specific gravity 1.020, albumin and acetone negative, and a trace of sugar; pus 0-1 and red blood cells 5-8. The hemoglobin was 13.9 gm., or 87 per cent. The white count was 12,500 with 71 per cent polymorphonuclears, 2 eosinophiles, 27 lymphocytes. The latex globulin was 600-1200 mg. per cent which is within the normal range. The sedimentation rate was 3, and the fasting blood sugar was 134 mg. per cent. Two hours postprandially the blood was 111 mg. per cent. A lupus erythematosus test on November 25 sho,ved no LE cells. The thymol
FIG. 2. Specimen demonstrates aneurysm.
MULTIPLE ANEURYSMS OF THE RIGHT RENAL ARTERY
turbidity was 1 Maclagen unit, and the serum calcium was 9.1 mg. per cent. Febrile antigen agglutination for Brucella abortus showed no antibodies. On November 21 an aortogram (fig. 1) revealed a right renal artery which was longer than usual because of the slightly lower position of the right kidney. The peculiar appearance of the proximal 4 cm. was due partly to tortuosity, but also partly to the presence of small aneurysmal dilatations. There also appeared to be an aneurysmal dilatation at the bifurcation of the right renal artery at the renal pelvis. On November 22 x-rays showed that the dorsal and lumbosacral spine areas were normal. On November 27, cephalin flocculation was 1 plus in 24 hours, 2 plus in 48 hours; potassium was 4.3 meq. per liter. Examination of porphyrins showed only a slight trace of porphobilinogen. An electrocardiogram was normal. On December 5 another urinalysis showed occasional red blood cells microscopically. On December 6 catecholamines were 5 micrograms/100 cc, protein bound iodine was 8 micrograms/100 cc, and the blood urea nitrogen 12 mg. per cent. On December 7, a chest x-ray showed no lesion. On December 8, the right renal artery and right kidney were explored through a right subcostal and flank incision. The renal vessels were exposed by performing a Kocher maneuver to reflect the duodenum and pancreas toward the midline, and by mobilizing the hepatic flexure of the colon. The inferior vena cava and renal veins appeared to be normal. Exposure of the renal artery revealed that it was involved from the aorta to the kidney with small aneurysmal dilatations. There were 4 aneurysms in this vessel. The largest dilatation was at the bifurcation of the right renal artery at the kidney hilus,
761
and in the aneurysm was a very hard plaque (fig. 2). There was no possibility of grafting this vessel because of the distal aneurysm. The only alternative was to remove the renal artery at the aorta, and to do a right nephrectomy. Convalescence was uneventful. The pathologist reported that the specimen was saccular aneurysm of the renal artery, with multiple saccular diverticula of the renal artery and congestion of the kidney. The patient's blood pressure during hospitalization remained in the neighborhood of 160/100, but subsequently has dropped and is now stabilized in the region of 130/85. The pain in the right upper quadrant and right flank has disappeared and the patient considers that she is much improved. DISCUSSION
This case report demonstrates the difficulty one has in diagnosing non-calcified renal artery aneurysms. This patient had been thoroughly studied many times, and it was not until an aortogram was done, following a careful physical examination at which time the bruit was heard, that the correct diagnosis was finally made. She had many criteria for a diagnosis of renal artery aneurysm: flank pain, hypertension, and negative urological findings except for hematuria. The operation has been successful. This case is of interest in that four distinct aneurysmal dilatations were present in the right renal artery, none of which were calcified, thereby precluding diagnosis by routine x-ray examination. The importance of auscultation of the abdomen as part of a complete physical examination is well demonstrated. 633 N. Central Ave., Glendale 3, Cal. (E. D. A.)
Vol. 87, No. 6 June 1962 Copyright© 1962 by The Williams & Wilkins Co. Printed in U.S.A.
MULTIPLE ANEURYSMS OF THE RIGHT RENAL ARTERY: A CASE REPORT EARLE D. ACKER, JAMES V. DOOLEY AND WINFIELD F. HERMAN Aneurysms of the renal arteries are relatively infrequent, and constitute approximately only 1 per cent of all aneurysms. The majority of patients who have renal artery aneurysms are middle aged and the cases are about equally divided between males and females. 1 After the aneurysm has developed, calcifications which may form can be identified by x-ray. Because of this radiopaque shadow, many unsuspected renal artery aneurysms have been detected on routine x-ray examination. Aneurysms of the renal artery are for the most part saccular in type, and are usually found at bifurcation points. The average size is from 1-4 cm. in diameter; and some are within the kidney and are called intrarenal aneurysms. Multiple aneurysms of the renal artery and bilateral renal artery aneurysms do occur, but are not common. A review of 169 cases by Ippolito and LeVeen1 revealed that 100 aneurysms were non-calcified and 69 were calcified. Harrow and Sloane2 reviewed 24 cases of ruptured aneurysms six of which occurred during pregnancy. Among these 24 cases, there were 20 fatalities. All of the ruptured aneurysms were of the non-calcified type. Harrow and Sloane2 also reported a series of 5 cases of renal artery aneurysms which were detected by identifying the calcific shadow of the aneurysm on x-ray examination. These particular patients had experienced no symptoms referable to the aneurysms. The symptoms of a renal artery aneurysm may be minimal, and as stated earlier, there may be no symptoms at all. A diagnosis of renal artery aneurysm must be considered when a patient complains of intermittent, or constant flank pain that cannot be explained by the usual diagnosis. Occasionally, one may feel an abnormal pulsation of the aorta with an abnormal pulsation drifting toward the flank. There may be a bruit of the aorta and of the renal artery Accepted for publication November 17, 1961. 1 lppolito, J. J. and LeVeen, H. H.: Treatment of renal artery aneurysms. J. Urol., 83: 10-16,
which can be heard in the abdomen and also over the renal artery into the flank. Frequently intermittent hematuria may be present. Many of these patients have been investigated multiple times because of hematuria and no definite renal disease found. Many times intermittent or constant hypertension may be found. Surgical intervention is indicated in those patients who have the above mentioned symptoms with a proven aneurysm as demonstrated by the calcific shadow, or, more directly now, by visualization of the renal artery by radiography. Non-calcified aneurysms are much more prone to rupture than calcified ones and these should be operated upon regardless of size. It has been reported that 25 per cent of all noncalcified renal artery aneurysms will rupture.' If the aneurysm is calcified in a younger patient, the patient should be operated upon, because the aneurysm may rupture in the future. Poutasse believes that surgical treatment is unnecessary in a patient who is asymptomatic, non-hypertensive and has a calcified renal artery of 1.5 cm. in diameter or less. 1 Pregnant patients with renal artery aneurysms should be operated upon because of the high mortality rate from ruptured renal aneurysms. Operations on renal artery aneurysms may consist of 1) excision of the saccular aneurysm with direct suture of the arterial wall, 2) excision of a single aneurysm with direct anastomosis, 3) excision of the aneurysm and grafting with either a vein or plastic prosthesis, or as in the case to be reported, 4) nephrectomy with excision of the portion of renal artery containing the aneurysm or aneurysms. The following is a case report of a patient who had mild hypertension associated with persistent right flank pain for over 15 years and intermittent hematuria. She had undergone an extensive investigation including laparotomy, which failed to uncover the pathological process. CASE REPORT
Mrs. K. S., a 40-year-old woman, was admitted to the hospital November 20, 1960 with a chief complaint of persistent right upper
1960.
Harrow, B. R. and Sloane, J. A.: Aneurysm of renal artery, report of 5 cases. J. Urol., 81: 35-41, 1959. 2
759
760
ACKER, DOOLEY AND HERMAN
quadrant pain. The patient had a history of a dull, right upper quadrant pain for approximately 15 years. Although the pain was persistent, its severity increased 3 to 4 times a year. These exacerbations lasted approximately 3 days. In 1946 an exploratory laparotomy was done because of persistent pain, and an appendectomy performed. However, no specific diagnosis was made and the patient continued to have pain, which was confined to the right upper quadrant and right flank, and was somewhat relieved by flexing the right thigh onto the abdomen. The pain was relieved to some extent following urination, but bowel movements made the pain worse. Diagnostic studies included a complete gastrointestinal series, a gallbladder series, several excretory urograms, cystoscopy and multiple laboratory tests. At one point, a question of hyperparathyroidism was entertained, but eventually not substantiated. She stated that her blood pressure had been elevated in the region of 160, and that occasionally blood had been found in the urine. In 1952 a hysterectomy was clone. She had also been investigated urologically several times because of the pain and hematuria. It was believed that a tumor of the
Fm. 1. Translumbar aortogram visualizes right renal artery with aneurysmal dilatations. (Photograph reversed. Editor.)
kidney or renal calculus might be responsible for the pain. However, the findings were all essentially negative except for persistent hematuria, pain and hypertension. The pulse was 85, temperature 98.6, respirations 16 and the blood pressure 160/100. The heart rate was slightly increased, the rhythm was normal and no murmurs were present. The lungs were clear to percussion and auscultation. The abdomen was not distended, and bowel sounds were normal. The patient was moderately tender in the right upper quadrant and right flank, and on auscultation of the abdomen over the aorta, a bruit, heard in the epigastric region in the midline, could be traced through the right upper quadrant to the right flank. No abnormal pulsations, however, could be felt. The liver, spleen and kidneys could not be palpated, and no abdominal masses were felt. The extremities were essentially normal. The peripheral pulses were good, and the reflexes equal and active. Urinalysis showed the urine to be hazy, pH 5, specific gravity 1.020, albumin and acetone negative, and a trace of sugar; pus 0-1 and red blood cells 5-8. The hemoglobin was 13.9 gm., or 87 per cent. The white count was 12,500 with 71 per cent polymorphonuclears, 2 eosinophiles, 27 lymphocytes. The latex globulin was 600-1200 mg. per cent which is within the normal range. The sedimentation rate was 3, and the fasting blood sugar was 134 mg. per cent. Two hours postprandially the blood was 111 mg. per cent. A lupus erythematosus test on November 25 sho,ved no LE cells. The thymol
FIG. 2. Specimen demonstrates aneurysm.
MULTIPLE ANEURYSMS OF THE RIGHT RENAL ARTERY
turbidity was 1 Maclagen unit, and the serum calcium was 9.1 mg. per cent. Febrile antigen agglutination for Brucella abortus showed no antibodies. On November 21 an aortogram (fig. 1) revealed a right renal artery which was longer than usual because of the slightly lower position of the right kidney. The peculiar appearance of the proximal 4 cm. was due partly to tortuosity, but also partly to the presence of small aneurysmal dilatations. There also appeared to be an aneurysmal dilatation at the bifurcation of the right renal artery at the renal pelvis. On November 22 x-rays showed that the dorsal and lumbosacral spine areas were normal. On November 27, cephalin flocculation was 1 plus in 24 hours, 2 plus in 48 hours; potassium was 4.3 meq. per liter. Examination of porphyrins showed only a slight trace of porphobilinogen. An electrocardiogram was normal. On December 5 another urinalysis showed occasional red blood cells microscopically. On December 6 catecholamines were 5 micrograms/100 cc, protein bound iodine was 8 micrograms/100 cc, and the blood urea nitrogen 12 mg. per cent. On December 7, a chest x-ray showed no lesion. On December 8, the right renal artery and right kidney were explored through a right subcostal and flank incision. The renal vessels were exposed by performing a Kocher maneuver to reflect the duodenum and pancreas toward the midline, and by mobilizing the hepatic flexure of the colon. The inferior vena cava and renal veins appeared to be normal. Exposure of the renal artery revealed that it was involved from the aorta to the kidney with small aneurysmal dilatations. There were 4 aneurysms in this vessel. The largest dilatation was at the bifurcation of the right renal artery at the kidney hilus,
761
and in the aneurysm was a very hard plaque (fig. 2). There was no possibility of grafting this vessel because of the distal aneurysm. The only alternative was to remove the renal artery at the aorta, and to do a right nephrectomy. Convalescence was uneventful. The pathologist reported that the specimen was saccular aneurysm of the renal artery, with multiple saccular diverticula of the renal artery and congestion of the kidney. The patient's blood pressure during hospitalization remained in the neighborhood of 160/100, but subsequently has dropped and is now stabilized in the region of 130/85. The pain in the right upper quadrant and right flank has disappeared and the patient considers that she is much improved. DISCUSSION
This case report demonstrates the difficulty one has in diagnosing non-calcified renal artery aneurysms. This patient had been thoroughly studied many times, and it was not until an aortogram was done, following a careful physical examination at which time the bruit was heard, that the correct diagnosis was finally made. She had many criteria for a diagnosis of renal artery aneurysm: flank pain, hypertension, and negative urological findings except for hematuria. The operation has been successful. This case is of interest in that four distinct aneurysmal dilatations were present in the right renal artery, none of which were calcified, thereby precluding diagnosis by routine x-ray examination. The importance of auscultation of the abdomen as part of a complete physical examination is well demonstrated. 633 N. Central Ave., Glendale 3, Cal. (E. D. A.)