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Renal Artery Aneurysm
Vol. 105, Feb.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL ARTERY ANEURYSM JOHN F. RHODES*
GEORGE JOHNSON, JR.
AND
From the Divisions of Urology and Vascular and Traumatic Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Although aneurysms of the renal arteries are reported to be found in only 1 of 1,000 autopsies,1 recent increased use of angiographic studies has led to the discovery of many non-calcified renal artery aneurysms that otherwise would not have been detected. 2 The clinician is faced with the problem of whether to remove the kidney, excise the aneurysm and repair the artery or do nothing. Successful excision of a renal artery aneurysm with preservation of the kidney in our patient stimulated us to review the current results of treatment of this disease.
1969 and the left renal artery aneurysm was excised via a transperitoneal approach. The aneurysm measured 1 cm. in diameter and had a thin wall. It originated at the bifurcation of the main renal artery and was excised at its point of origin (fig. 1, B). The resulting opening in the renal artery was sutured transversely without compromising the lumen of the vessel. An angiogram 5 weeks postoperatively revealed excellent circulation to the left kidney (fig. 2). The patient remained mildly hypertensive (150/ 90) but this was controlled with diet and antihypertensive medication.
CASE REPORT DISCUSSION
E. S., a 45-year-old Negress, was seen in October 1968 for hypertension and recurrent lower urinary tract infection, 10 years in duration. There was no history of hematuria or flank pain. Physical examination was negative except for mild hypertension and obesity. There was no bruit audible in either flank and neither kidney was palpable. Excretory urography and cystography revealed a right renal mass and a diverticulum of the mid urethra containing stones. Angiography proved the renal mass to be a cyst. A non-calcified 1 cm. aneurysm of the superior branch of a double left renal artery was detected (fig. 1, A). There was no angiographic evidence of renal artery stenosis, arteriosclerotic disease or decreased renal perfusion. The urethral diverticulum was excised transvaginally and the urinary tract infection was treated with antibiotics. The urethra healed without stricture or fistula and there was no recurrence of infection for the next 3 months. The patient was readmitted to the hospital in January
There are more than 300 reported cases of aneurysm of the renal artery. Glass and Uson report that renal aneurysms occur equally in male and female individuals and the usual age of the patient at the time of diagnosis is 40 to 60 years. 3 They also report that 80 per cent of the aneurysms are unilateral and more involve the right renal artery than the left. There are no pathognomonic symptoms or signs of renal artery aneurysm. Hypertension is occasionally noted. However, Poutasse reports that hypertension is more likely due to an associated stenotic lesion of the renal artery or some cause other than the aneurysm itself.2 Glass and Uson report that about 20 per cent of patients present with gross hematuria and about 33 per cent present with flank pain. 3 Occasionally an asymptomatic patient has a bruit over the involved vessel. Many times the diagnosis is made incidentally by angiography performed for other reasons. 3 The first successful treatment of renal artery aneurysm without nephrectomy was reported in 1926 when the neck of the aneurysm was ligated. 4 Subsequently several reports on excision of an
0
Accepted for publication March 9, 1970.
* Requests for reprints: Division of Urology,
Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27514. 1 Popowniak, K. L., Gifford, R. W., Jr., Straffon, R. A., Meaney, T. F. and McCormack, L. J.: Aneurysms of the renal artery. An analysis of 51 cases. Postgrad. Med., 40: 255, 1966. 2 Poutasse, E. F.: Renal artery aneurysms: their natural history and surgery. J. Urol., 96: 297, 1966.
3 Glass, P. M. and Uson, A. C.: Aneurysms of the renal artery: a study of 20 cases. J. Urol., 98: 285, 1967. 4 Callahan, W. P. and Schiltz, F. H.: Aneurism of renal artery. Surg., Gynec. & Obst., 43: 724, 1926.
155
156
RHODES AND JOHNSON
Fm. 1. A, selective renal arteriogram with catheter placed in left superior renal artery reveals 1 cm. aneurysm at bifurcation of main renal artery. B, operative photograph of aneurysm arising at bifurcation of left renal artery. Renal vein is retracted inferiorly with tape around proximal vein and silk sutures about distal renal arteries.
aneurysm and angioplastic repair of the renal artery have appeared in the literature. 2 • 5 • 6 The primary indication for operative treatment of non-calcified aneurysms appears to be the threat of rupture. In 1959 Harrow and Sloane reviewed 100 cases of non-calcified aneurysm and found the incidence of rupture to be 24 per cent. 7 The mortality rate from rupture was 83 per cent. With the increased incidence of non-calcified aneurysm detected by the present use of angiography, the actual incidence of rupture is probably somewhat less than previously stated. Most investigators agree that
FIG. 2. Aortogram after removal of aneurysm of superior left renal artery.
5 Poutasse, E. F.: Renal artery aneurysm: report of 12 cases, two treated by excision of the aneurysm and repair of renal artery. J. U rol., 77: 697, 1957. 6 Siderys, H. and Shumacker, H.B., Jr.: Aneurysm of the renal artery: successful resection with reconstruction of the bifurcation. Amer. J. Surg., 105: 269, 1963. 7 Harrow, B. R. and Sloane, J. A.: Aneurysm of renal artery: report of five cases. J. Urol., 81: 35, 1959.
RENAL ARTERY ANEURYSM
non-calcified aneurysms should be treated surgically even if the patient is asymptomatic. 1- 3 , s- 10 Indications for operation on calcified aneurysms are less clear. Partially calcified aneurysms have ruptured and probably should be surgically excised. 2· 8 However, there are no reports of rupture of a completely calcified aneurysm. 11 Most observers believe that asymptomatic, Burkett, J. A.: Sacciform aneurysm of renal artery. Amer. Surg., 18: 457, 1952. 9 Nesbit, R. M. and Crenshaw, W. B.: Aneurysm of the renal artery. J. Urol., 75: 380, 1956. 1 ° Kaufman, J. J.: Surgery of the renal vessels. In: Urologic Surgery. Edited by J. F. Glenn and W. H. Boyce. New York: Harper and Row, Publishers, p. 661, 1969. 11 McKiel, C. F., Jr., Graf, E. C. and Callahan, D. H.: Renal artery aneurysms: a report of 16 cases. J. Urol., 96: 593, 1966. 8
157
round, neatly calcified aneurysms less than 2 cm. in diameter do not require removal but can be treated expectantly with periodic plain roentgenograms to be sure the calcified wall remains intact.2, 7, 10, 12 SUMMARY AND CO="CLUSION
A patient with successful local excision of a non-calcified aneurysm of the renal artery is presented. Review of previous experience indicates that non-calcified or partially calcified aneurysms of the renal artery should be excised whereas completely calcified renal aneurysms, especially if small, may be treated conservatively. 12 Ippolito, J. J. and LeYeen, H. H.: Treatment of renal artery aneurysms. J. Urol., 83: 10, 1960.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
Printed in U.S.A.
RENAL ARTERY ANEURYSM JOHN F. RHODES*
GEORGE JOHNSON, JR.
AND
From the Divisions of Urology and Vascular and Traumatic Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
Although aneurysms of the renal arteries are reported to be found in only 1 of 1,000 autopsies,1 recent increased use of angiographic studies has led to the discovery of many non-calcified renal artery aneurysms that otherwise would not have been detected. 2 The clinician is faced with the problem of whether to remove the kidney, excise the aneurysm and repair the artery or do nothing. Successful excision of a renal artery aneurysm with preservation of the kidney in our patient stimulated us to review the current results of treatment of this disease.
1969 and the left renal artery aneurysm was excised via a transperitoneal approach. The aneurysm measured 1 cm. in diameter and had a thin wall. It originated at the bifurcation of the main renal artery and was excised at its point of origin (fig. 1, B). The resulting opening in the renal artery was sutured transversely without compromising the lumen of the vessel. An angiogram 5 weeks postoperatively revealed excellent circulation to the left kidney (fig. 2). The patient remained mildly hypertensive (150/ 90) but this was controlled with diet and antihypertensive medication.
CASE REPORT DISCUSSION
E. S., a 45-year-old Negress, was seen in October 1968 for hypertension and recurrent lower urinary tract infection, 10 years in duration. There was no history of hematuria or flank pain. Physical examination was negative except for mild hypertension and obesity. There was no bruit audible in either flank and neither kidney was palpable. Excretory urography and cystography revealed a right renal mass and a diverticulum of the mid urethra containing stones. Angiography proved the renal mass to be a cyst. A non-calcified 1 cm. aneurysm of the superior branch of a double left renal artery was detected (fig. 1, A). There was no angiographic evidence of renal artery stenosis, arteriosclerotic disease or decreased renal perfusion. The urethral diverticulum was excised transvaginally and the urinary tract infection was treated with antibiotics. The urethra healed without stricture or fistula and there was no recurrence of infection for the next 3 months. The patient was readmitted to the hospital in January
There are more than 300 reported cases of aneurysm of the renal artery. Glass and Uson report that renal aneurysms occur equally in male and female individuals and the usual age of the patient at the time of diagnosis is 40 to 60 years. 3 They also report that 80 per cent of the aneurysms are unilateral and more involve the right renal artery than the left. There are no pathognomonic symptoms or signs of renal artery aneurysm. Hypertension is occasionally noted. However, Poutasse reports that hypertension is more likely due to an associated stenotic lesion of the renal artery or some cause other than the aneurysm itself.2 Glass and Uson report that about 20 per cent of patients present with gross hematuria and about 33 per cent present with flank pain. 3 Occasionally an asymptomatic patient has a bruit over the involved vessel. Many times the diagnosis is made incidentally by angiography performed for other reasons. 3 The first successful treatment of renal artery aneurysm without nephrectomy was reported in 1926 when the neck of the aneurysm was ligated. 4 Subsequently several reports on excision of an
0
Accepted for publication March 9, 1970.
* Requests for reprints: Division of Urology,
Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27514. 1 Popowniak, K. L., Gifford, R. W., Jr., Straffon, R. A., Meaney, T. F. and McCormack, L. J.: Aneurysms of the renal artery. An analysis of 51 cases. Postgrad. Med., 40: 255, 1966. 2 Poutasse, E. F.: Renal artery aneurysms: their natural history and surgery. J. Urol., 96: 297, 1966.
3 Glass, P. M. and Uson, A. C.: Aneurysms of the renal artery: a study of 20 cases. J. Urol., 98: 285, 1967. 4 Callahan, W. P. and Schiltz, F. H.: Aneurism of renal artery. Surg., Gynec. & Obst., 43: 724, 1926.
155
156
RHODES AND JOHNSON
Fm. 1. A, selective renal arteriogram with catheter placed in left superior renal artery reveals 1 cm. aneurysm at bifurcation of main renal artery. B, operative photograph of aneurysm arising at bifurcation of left renal artery. Renal vein is retracted inferiorly with tape around proximal vein and silk sutures about distal renal arteries.
aneurysm and angioplastic repair of the renal artery have appeared in the literature. 2 • 5 • 6 The primary indication for operative treatment of non-calcified aneurysms appears to be the threat of rupture. In 1959 Harrow and Sloane reviewed 100 cases of non-calcified aneurysm and found the incidence of rupture to be 24 per cent. 7 The mortality rate from rupture was 83 per cent. With the increased incidence of non-calcified aneurysm detected by the present use of angiography, the actual incidence of rupture is probably somewhat less than previously stated. Most investigators agree that
FIG. 2. Aortogram after removal of aneurysm of superior left renal artery.
5 Poutasse, E. F.: Renal artery aneurysm: report of 12 cases, two treated by excision of the aneurysm and repair of renal artery. J. U rol., 77: 697, 1957. 6 Siderys, H. and Shumacker, H.B., Jr.: Aneurysm of the renal artery: successful resection with reconstruction of the bifurcation. Amer. J. Surg., 105: 269, 1963. 7 Harrow, B. R. and Sloane, J. A.: Aneurysm of renal artery: report of five cases. J. Urol., 81: 35, 1959.
RENAL ARTERY ANEURYSM
non-calcified aneurysms should be treated surgically even if the patient is asymptomatic. 1- 3 , s- 10 Indications for operation on calcified aneurysms are less clear. Partially calcified aneurysms have ruptured and probably should be surgically excised. 2· 8 However, there are no reports of rupture of a completely calcified aneurysm. 11 Most observers believe that asymptomatic, Burkett, J. A.: Sacciform aneurysm of renal artery. Amer. Surg., 18: 457, 1952. 9 Nesbit, R. M. and Crenshaw, W. B.: Aneurysm of the renal artery. J. Urol., 75: 380, 1956. 1 ° Kaufman, J. J.: Surgery of the renal vessels. In: Urologic Surgery. Edited by J. F. Glenn and W. H. Boyce. New York: Harper and Row, Publishers, p. 661, 1969. 11 McKiel, C. F., Jr., Graf, E. C. and Callahan, D. H.: Renal artery aneurysms: a report of 16 cases. J. Urol., 96: 593, 1966. 8
157
round, neatly calcified aneurysms less than 2 cm. in diameter do not require removal but can be treated expectantly with periodic plain roentgenograms to be sure the calcified wall remains intact.2, 7, 10, 12 SUMMARY AND CO="CLUSION
A patient with successful local excision of a non-calcified aneurysm of the renal artery is presented. Review of previous experience indicates that non-calcified or partially calcified aneurysms of the renal artery should be excised whereas completely calcified renal aneurysms, especially if small, may be treated conservatively. 12 Ippolito, J. J. and LeYeen, H. H.: Treatment of renal artery aneurysms. J. Urol., 83: 10, 1960.