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Congenital Arteriovenous Aneurysm of the Kidney
Vol. 103, Mar. Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © Ja70 by The Williams & Wilkins Co.,
COXGENITAL ARTERIOVENOUS ANEURYS:vr OF THE KIDNEY ALBERT J. SALZMAN
HERBERT D. AXILROD
AND
From the Departments of Radiology ancl Urology, Atlantic City Hospital, Atlantic City, New Jersey
Arteriovenous aneurysms of the kidney may be congenital or acquired. We found 13 cases in the literature-6 were congenital1- 6 and 7 were acquired. 1- 13 vVe herein present a patient with a congenital arteriovenous aneurysm of the kidney. CASB RBPOR'l'
A 62-year-old white man was admitted to Atlantic City Hospital on May 26, 1968, because of difficulty in urination. Symptoms started 1 month earlier and were associated with frequency of urination. There had been no pain or gross hematuria. There was no history of previous Accepted for publication April 2, 1969. Varela, M. E.: Aneurisma arteriovenoso de los vasos renales y asistolia consecutiva. Rev. Med. Latino-Am., 14: 3244, 1923. 2 Pearse, R. and MacMillan, R. L.: Congenital aneurysm of the renal artery. J. Urol., 58: 235, 1947. 3 Schulze-Bergmann, G.: Uber das arterioveniise aneurysma der Niere. Ztschr. Urol., 47: 661, 1954. 4 Slominski-Laws, M. D., Kiefer, J. H. and Vermeulen, C. W.: Arteriovenous aneurysm of the kidney: case report. J. Urol., 75: 586, 1956. 5 Bohne, A. W. and Henderson, G. L.: Intrarenal arteriovenous aneurysm: case report. J. Urol., 77: 818, 1957. 6 Love, L., Moncada, R. and Lescher, A. J.: Renal arteriovenous fistulae. Amer. J. Roentgen., 95: 364, 1965. 7 Rieder, W.: Sonderstellung arterio-veniiser Aneurysmen der Nierengefasse in Rahmen operativer Behandl ung schwerer Herz-Kreislaufschaden beim arterio-veniisen Aneurysma. Der Chirurg., 14: 609, 1942. 8 Hamilton, G. R., Getz, R. J. and Jerome, S.: Arteriovenous fistula of the renal vessels: case report and review of the literature. J. Urol., 69: 203, 1953. 9 Kirby, C. K., Nichols, W. G., Garritano, A. P., Wohl, G. T. and Pietroluongo, A. L.: Arteriovenous fistula of renal vessels. Surgery, 37: 267, 1955. 10 Schwartz, J. W., Borski, A. A. and Jahnke, E. J.: Renal arteriovenous fistula. Surgery, 37: 951, 1955. 11 Bennett, A. R. and Wiener, S. N.: Intrarenal arteriovenous fistula and aneurysm. A complication of percutaneous renal biopsy. Amer. J. Roentgen., 95: 372, 1965. 12 Bosniak, M. A.: Radiographic manifestations of massive arteriovenous fistula in renal carcinoma. Radiology, 85: 454, 1965. 13 Painter, W. E., DiDonato, R. R. and White, R.: Renal arteriovenous aneurysm causing hydronephrosis and renal atrophy. Amer. J. Roentgen., 104: 306, 1968. 1
trauma to the flanks or abdomen. The patient had been taking antihypertensive medication for several years for mild hypertension. Physical examination revealed a healthy-looking man with a blood pressure of 155/80. His heart was enlarged and there was a grade 2 systolic murmur audible over the precordium. Chest x-ray showed left ventricular enlargement and an electrocardiogram showed evidence of left ventricular hypertrophy. Hemoglobin was 12.9, blood urea nitrogen was 17 mg. per cent and urinalysis showed a specific gravity of 1.018 with 10 to 15 white blood cells per high power field. An excretory urogram (IVP) revealed a mass in the upper two-thirds of the left kidney (fig. 1, A). N ephrotomography revealed calcifications within the mass which were believed to represent renal carcinoma (fig. 1, B). A retrograde aortogram showed a large arteriovenous malformation of the upper and mid-portion of the left kidney associated with marked hypertrophy of the left renal artery and rapid shunting of contrast material into a large left renal vein and inferior vena cava (fig. 2). Auscultation over the left upper abdomen was now performed and a loud, contiirnous, to-and-fro murmur was audible. On June 8 exploration of the left renal area revealed the hilus and kidney occupied by a large pulsatile mass. Nephrectomy was performed and examination of the specimen confirmed the presence of a large arteriovenous malformation composed of dilated and tortuous renal vessels. DISCUSSION
Congenital arteriovenous aneurysms are less common than acquired ones. 6 Acquired aneurysms may be the result of previous injury, 9 nephrectomy, 10 renal biopsy, 11 rupture of an arterial aneurysm into a renal vein 5 • 6 • 13 or a manifestation of a highly vascular adenocarcinoma of the kidney. 8 • 12 Patients, including the one reported on herein, have ranged in age from 13 to 63 years at the time of initial diagnosis. A characteristic murmur over the involved kidney was the most common clini290
:F'rG. J. A, TVP shows mass in upper two-thirds of left kidney, displacing upper and middle calyces. B, nephrotomogram shows mass equal in density to kidney. (Calcification seen on origina.J films is not visible iu reproduction.)
:F'w. 2. A, arterial phase of retrograde aortogram demonstrates markedly enlarged renal artery feedrng prominent arteriovenous malformation in upper two-thirds of kidney. B, venous phase of retrograde aortogram demonstrates rapid filling of large renal vein (open arrows) which opacifi.es inferior venn cava, (large arro\-vs) 291
292
SALZMAN AND AXILROD
cal sign and occurred in 5 patients. Hypertension and cardiac decompensation were the next most common manifestations. Two patients had gross hematuria. A renal mass and renal calcification were found by IVP in 2 patients in addition to our own. Aortography is usually diagnostic. A highly vascular neoplasm with extensive arteriovenous
shunting may occasionally present some clifficulty in differential diagnosis. 12 SUMMARY
A case of large arteriovenous aneurysm of the kidney has been reported. This is the seventh case to be reported of congenital origin. Clinical manifestations and diagnosis have been reviewed.
THE JOURNAL OF UROLOGY
Copyright © Ja70 by The Williams & Wilkins Co.,
COXGENITAL ARTERIOVENOUS ANEURYS:vr OF THE KIDNEY ALBERT J. SALZMAN
HERBERT D. AXILROD
AND
From the Departments of Radiology ancl Urology, Atlantic City Hospital, Atlantic City, New Jersey
Arteriovenous aneurysms of the kidney may be congenital or acquired. We found 13 cases in the literature-6 were congenital1- 6 and 7 were acquired. 1- 13 vVe herein present a patient with a congenital arteriovenous aneurysm of the kidney. CASB RBPOR'l'
A 62-year-old white man was admitted to Atlantic City Hospital on May 26, 1968, because of difficulty in urination. Symptoms started 1 month earlier and were associated with frequency of urination. There had been no pain or gross hematuria. There was no history of previous Accepted for publication April 2, 1969. Varela, M. E.: Aneurisma arteriovenoso de los vasos renales y asistolia consecutiva. Rev. Med. Latino-Am., 14: 3244, 1923. 2 Pearse, R. and MacMillan, R. L.: Congenital aneurysm of the renal artery. J. Urol., 58: 235, 1947. 3 Schulze-Bergmann, G.: Uber das arterioveniise aneurysma der Niere. Ztschr. Urol., 47: 661, 1954. 4 Slominski-Laws, M. D., Kiefer, J. H. and Vermeulen, C. W.: Arteriovenous aneurysm of the kidney: case report. J. Urol., 75: 586, 1956. 5 Bohne, A. W. and Henderson, G. L.: Intrarenal arteriovenous aneurysm: case report. J. Urol., 77: 818, 1957. 6 Love, L., Moncada, R. and Lescher, A. J.: Renal arteriovenous fistulae. Amer. J. Roentgen., 95: 364, 1965. 7 Rieder, W.: Sonderstellung arterio-veniiser Aneurysmen der Nierengefasse in Rahmen operativer Behandl ung schwerer Herz-Kreislaufschaden beim arterio-veniisen Aneurysma. Der Chirurg., 14: 609, 1942. 8 Hamilton, G. R., Getz, R. J. and Jerome, S.: Arteriovenous fistula of the renal vessels: case report and review of the literature. J. Urol., 69: 203, 1953. 9 Kirby, C. K., Nichols, W. G., Garritano, A. P., Wohl, G. T. and Pietroluongo, A. L.: Arteriovenous fistula of renal vessels. Surgery, 37: 267, 1955. 10 Schwartz, J. W., Borski, A. A. and Jahnke, E. J.: Renal arteriovenous fistula. Surgery, 37: 951, 1955. 11 Bennett, A. R. and Wiener, S. N.: Intrarenal arteriovenous fistula and aneurysm. A complication of percutaneous renal biopsy. Amer. J. Roentgen., 95: 372, 1965. 12 Bosniak, M. A.: Radiographic manifestations of massive arteriovenous fistula in renal carcinoma. Radiology, 85: 454, 1965. 13 Painter, W. E., DiDonato, R. R. and White, R.: Renal arteriovenous aneurysm causing hydronephrosis and renal atrophy. Amer. J. Roentgen., 104: 306, 1968. 1
trauma to the flanks or abdomen. The patient had been taking antihypertensive medication for several years for mild hypertension. Physical examination revealed a healthy-looking man with a blood pressure of 155/80. His heart was enlarged and there was a grade 2 systolic murmur audible over the precordium. Chest x-ray showed left ventricular enlargement and an electrocardiogram showed evidence of left ventricular hypertrophy. Hemoglobin was 12.9, blood urea nitrogen was 17 mg. per cent and urinalysis showed a specific gravity of 1.018 with 10 to 15 white blood cells per high power field. An excretory urogram (IVP) revealed a mass in the upper two-thirds of the left kidney (fig. 1, A). N ephrotomography revealed calcifications within the mass which were believed to represent renal carcinoma (fig. 1, B). A retrograde aortogram showed a large arteriovenous malformation of the upper and mid-portion of the left kidney associated with marked hypertrophy of the left renal artery and rapid shunting of contrast material into a large left renal vein and inferior vena cava (fig. 2). Auscultation over the left upper abdomen was now performed and a loud, contiirnous, to-and-fro murmur was audible. On June 8 exploration of the left renal area revealed the hilus and kidney occupied by a large pulsatile mass. Nephrectomy was performed and examination of the specimen confirmed the presence of a large arteriovenous malformation composed of dilated and tortuous renal vessels. DISCUSSION
Congenital arteriovenous aneurysms are less common than acquired ones. 6 Acquired aneurysms may be the result of previous injury, 9 nephrectomy, 10 renal biopsy, 11 rupture of an arterial aneurysm into a renal vein 5 • 6 • 13 or a manifestation of a highly vascular adenocarcinoma of the kidney. 8 • 12 Patients, including the one reported on herein, have ranged in age from 13 to 63 years at the time of initial diagnosis. A characteristic murmur over the involved kidney was the most common clini290
:F'rG. J. A, TVP shows mass in upper two-thirds of left kidney, displacing upper and middle calyces. B, nephrotomogram shows mass equal in density to kidney. (Calcification seen on origina.J films is not visible iu reproduction.)
:F'w. 2. A, arterial phase of retrograde aortogram demonstrates markedly enlarged renal artery feedrng prominent arteriovenous malformation in upper two-thirds of kidney. B, venous phase of retrograde aortogram demonstrates rapid filling of large renal vein (open arrows) which opacifi.es inferior venn cava, (large arro\-vs) 291
292
SALZMAN AND AXILROD
cal sign and occurred in 5 patients. Hypertension and cardiac decompensation were the next most common manifestations. Two patients had gross hematuria. A renal mass and renal calcification were found by IVP in 2 patients in addition to our own. Aortography is usually diagnostic. A highly vascular neoplasm with extensive arteriovenous
shunting may occasionally present some clifficulty in differential diagnosis. 12 SUMMARY
A case of large arteriovenous aneurysm of the kidney has been reported. This is the seventh case to be reported of congenital origin. Clinical manifestations and diagnosis have been reviewed.