Surgical treatment of renal artery compression by diaphragmatic crus

Symptomatic compression of the renal artery by the diaphragmatic crus is a rare disorder. To our knowledge, renal artery compression by the diaphragmatic crus complicated with poststenosis aneurysm has not been reported. We present the case of a 28-year-old man with refractory hypertension. Extrinsic compression of the bilateral renal arteries and celiac artery and the aneurysm were proven by surgical exploration. We successfully performed left renal artery revascularization and renal autotransplantation in situ. Normal perfusion of the two bypass graft vessels was proven by computed tomography angiography.     

Renovascular hypertension from renal artery compression by congenital bands.

Renal artery compression by fibromuscular bands containing sympathetic nerves and ganglia was encountered in 3 of 75 patients with renovascular hypertension. The hypertension was successfully managed by resection of the bands. The absence of mortality and morbidity dictates that the "stenotic" area of the renal artery be explored, especially in children and adults with minimal angiographic evidence of visceral atherosclerosis, before proceeding with a bypass graft to the renal artery.     

Unusual problems in renal hypertension.

Ten cases of renal hypertension with uncommon causes were presented and unusual problems in their diagnosis and surgical management were discussed. These causes included segmental stenosis involving aberrant renal artery, renal artery stenosis in association with renal arteriovenous fistula, postoperative renal hypertension and hypertension secondary to renal tuberculosis. A high index of clinical suspicion and increasing awareness will help in diagnosing such rare and unusual cases of renal hypertension.     

Left testicular artery arching over the ipsilateral renal vein

Aim:To report two cases of the left testicular artery arching over the left renal vein(LRV)before running downwardto the testis.Methods:The subjects were obtained from two Japanese cadavers.During the student course ofgross-anatomical dissection,the anatomical relationship between the testicular vessels and the renal vein was specifi-cally observed.Results:The arching left testicular artery arose from the aorta below the LRV and made a looparound the LRV,which appeared to be mildly compressed between the arching artery and the psoas major muscle.Conclusion:Clinically,compression of the LRV between the abdominal aorta and the superior mesenteric arteryoccasionally induces LRV hypertension,resulting in varicocele,orthostatic protenuria and hematuria.Consideringthat the incidence of a left arching testicular artery is higher than that of a right one,an arching left artery could be anadditional cause of LRV hypertension.(Asian J Androl 2006 Jan;8:107-110)     

Non-invasive imaging diagnosis of left renal vein compression causing hematuria. Part 2. CT

Left renal veins of 77 patients were examined by computed tomography (CT) to evaluate its usefulness in determining the left renal vein compression which is causing renal bleeding. From CT image, left renal vein compression was observed in 6 (86%) of the 7 cases which had been classified as idiopathic renal bleeding, in 9 (21%) of the 42 cases which had urinary tract diseases causing hematuria, and in 3 (11%) of the 28 cases which did not have hematuria. In 15 of the 18 cases of left renal vein compression, left renal vein was compressed between the superior mesenteric artery and the abdominal aorta, showing so-called nutcracker phenomenon. In the remaining 3 cases, however, the superior mesenteric artery provided sharp delineation from the abdominal aorta. The superior mesenteric artery and the abdominal aorta made the mean angle of 35.5 degree in patients with normal left renal vein, the mean angle of 45.4 degrees in those with left renal vein compression without nutcracker phenomenon, and the mean angle of 11.9 degrees in those with nutcracker phenomenon. CT was superior to ultrasonography, in revealing left renal vein compression.     

Left renal venous hypertension “nutcracker” syndrome: Managed by Direct Renocaval Reimplantation

Since 1978 a diagnosis of left renal venous hypertension has been established in 3 patients. All 3 had otherwise unexplained left flank and abdominal pain, 2 had left renal gross hematuria, and 2 were found to have ureteral and peripelvic varices demonstrated by selective renal venography. All were found to have mild to moderate pressure gradients between the left renal vein and vena cava, presumably due to compression of the left renal vein between the aorta and overlying superior mesenteric artery. Direct left renocaval reimplantation was performed in all cases, with resection of the collateral varices that were present in 2 cases. Severe unrelenting pain was the primary indication for surgery in all cases, rather than hematuria. All remain asymptomatic one to four years after surgery.     

Plasma renin activity revealed renal artery stenosis concealed by aneurysms

We describe a case of renovascular hypertension with renal artery stenosis concealed by aneurysms. Arteriography demonstrated no apparent renal artery stenosis, but did reveal aneurysms on the left renal artery. Captopril-loaded renoscintigraphy could not detect disturbed renal perfusion. High basal and exaggerated plasma renin activity after captopril administration were the only clues indicating renovascular hypertension. A reduction of the systemic blood pressure and normalized plasma renin activity after resection of the aneurysms confirmed preoperative renovascular hypertension. Fibromuscular dysplasia was an underlying cause of the arterial deformity. In cases of hypertension accompanied by renal artery aneurysms, the captopril-challenge test can be a useful tool to detect renal artery stenosis concealed by the aneurysms.     

Arterial hypertension and neurovascular compression at the ventrolateral medulla. A comparative microanatomical and pathological study.

Intraoperative observations and animal experiments suggest that neurovascular compression at the left ventrolateral medulla is a possible etiological factor in essential hypertension. In pursuing this hypothesis, the authors examined the neurovascular relations in the posterior cranial fossa of 24 patients with essential hypertension, of 10 with renal hypertension, and of 21 normotensive control patients. Artificial perfusion of the vessels and microsurgical investigations during autopsy identified the vascular relations at the brain stem and at the root entry zone of the caudal cranial nerves. There was no evidence of neurovascular compression at the ventrolateral medulla on the left side in any patient from the control group or among those with renal hypertension. Two normotensive patients had neurovascular compression at the right ventrolateral medulla by the posterior inferior cerebellar artery. In contrast, all patients with essential hypertension had definite neurovascular compression at the left ventrolateral medulla. Additional compression of the right side was seen in three of these patients. Based on the anatomical appearance, it was possible to define three distinct types of neurovascular compression at the ventrolateral medulla. Common to all three types is the compression of the medulla oblongata at its rostral part just caudal to the pontomedullary junction and lateral to the olive in the retro-olivary sulcus. Comparative histopathological study of the microsurgically examined brain-stem specimens revealed no differences between patients with essential hypertension, those with renal hypertension, and normal controls. There was a structural integrity at the site of neurovascular compression at the ventrolateral medulla. The microanatomical findings of this study show that neurovascular relations at the ventrolateral medulla in essential hypertension give rise to pulsatile compression on the left. This supports Jannetta's hypothesis of neurovascular compression at the left ventrolateral medulla as an etiology of essential hypertension.     

Non-invasive imaging diagnosis of left renal vein compression causing hematuria. Part 1. Ultrasonography

Left renal veins of 100 out-patients were examined by transabdominal ultrasonography to evaluate its usefulness in determining left renal vein compression which is causing renal bleeding. Ultrasonography revealed the left renal vein in 86 patients. In 61 of the 86 cases, the internal cavity of left renal vein was opened at least in diastolic phase, but in 23 cases, the internal cavity was closed between the abdominal aorta and the superior mesenteric artery in both systolic and diastolic phases. In the remaining 2 cases, left renal vein was compressed at a point where it intersected the right renal artery. Left renal vein compression was observed in 18 (69%) of the 26 cases which had been classified as idiopathic renal bleeding and in 7 (26%) of the 27 cases which had urinary tract diseases causing hematuria. In 33 cases which did not have hematuria, left renal vein compression was not observed. These results suggest that diagnosis of left renal vein compression causing renal bleeding is possible by transabdominal ultrasonography.     

Renal autotransplantation in dissecting aortic aneurysm with renal artery involvement.

A dissecting aortic aneurysm in a 60-year-old woman resulted in renal artery insufficiency and medically uncontrollable hypertension. Following a nephrectomy and renal autotransplantation, the patient's renal insufficiency improved dramatically and her hypertension became easily manageable with antihypertensives. Nephrectomy with renal autotransplantation is discussed as an alternative to conventional renal artery reconstruction in cases where reconstruction is either too hazardous or impossible to perform.     

Post-transplant renal artery stenosis: a cause of anuria. Report of 2 cases corrected by revascularization

We report 2 cases of severe hypertension and acute onset of anuria after renal transplantation in which angiography revealed renal artery stenosis. After renal artery reconstructive surgery renal function returned to normal and the hypertension improved. A high index of suspicion is needed to make the diagnosis. Only by heightened awareness of this important entity will patients with post-transplantation anuria secondary to renal artery stenosis be identified. Such patients may benefit from renal artery revascularization to reverse this type of renal failure.     

Renal artery occlusion in autosomal dominant polycystic kidney disease

Several vascular abnormalities have been reported in autosomal dominant polycystic kidney disease (ADPKD). Occlusion of the renal artery is uncommon in ADPKD and can be associated with hypertension. We report a 38-year-old woman with ADPKD and severe hypertension, abdominal magnetic resonance angiogram and arteriography revealed left renal artery total occlusion. A revascularization approach was not considered feasible and she was given conservative treatment. We review the literature and make some comments about renal artery occlusion in ADPKD. This association should be kept in mind in cases of ADPKD with severe or resistant hypertension.     

Hypernephroma as a cause of high blood pressure (author's transl)

In the group of 111 patients treated for hypernephroma, 24 have shown in addition to their usual symptoms a more systolic an elevated blood pressure up to 22 mm Hg and higher. In two cases was hypertension the only symptom. In the hypertensive group, 20 patients underwent nephrectomy and blood pressure returned to normal in all but one. Four pathophysiologic mechanisms of blood pressure elevation in hypernephroma are discussed: (1) AV shunts; (2) Compression of the renal artery or its branches due to tumor expansion; (3) Polycythemia; (4) Hypernephroma with hormonal activity. The hypertension of 6 of our patients was due to AV shunts, of 7, to renal vessels compression, and of 6 others, to a polycythemia.     

Extraparenchymal Renal Artery Aneurysms: Is Hypertension an Indication for Revascularization Surgery?

We report here the surgical management of extraparenchymal renal artery aneurysms associated with hypertension and the results of this treatment. From January 1978 through December 1999, 19 consecutive patients with 23 extraparenchymal renal artery aneurysms underwent surgery with renal revascularization techniques. Of these 19 patients, 89.5% had systemic hypertension, and 12 of 16 patients had associated renovascular hypertension. Twenty of the aneurysms were patent, one was chronically thrombosed, and one patient presented with acute thrombosis of abdominal aortic and bilateral renal aneurysms; 11 of the 20 patent cases had significant stenosis in the preoperative arteriography. Seventeen aneurysms (74%) were located on the main trunk of the renal artery. Response of hypertension and renal function were examined. Surgical technique patency was evaluated by life-table methods. Our basic surgical indication for extraparenchymal renal artery aneurysms in this series was renovascular hypertension. Nonrenal hypertension alone does not indicate surgery. We consider the saphenous vein to be the graft of choice for renal revascularization.     

Washout urography in the diagnosis of renal hypertension

Washout urography was used as a screening test for 100 hypertensive patients. Eleven patients had renal hypertension. These were 4 cases of unilateral renal artery stenosis, 6 cases of unilateral pyelonephritis and one case of bilateral pyelonephritis with atherosclerosis of the right renal artery. The increase in size of the affected kidneys after Lasix injection was much restricted relative to the normal contralateral kidneys. The test proved valuable for screening cases of renovascular hypertension and unilateral pyelonephritis.     

腹腔镜手术治疗小儿副肾动脉压迫引起肾积水的临床体会

目的探讨小儿副肾动脉压迫引起肾积水的临床特点及腹腔镜手术治疗的安全性和应用价值。 方法2017年１月至2019年12月我院收治副肾动脉压迫引起肾积水的患儿13例，男9例，女4例，左侧11例，右侧2例。回顾性分析了副肾动脉压迫引起肾积水患儿的临床资料。 结果本组13例均证实副肾动脉压迫肾盂输尿管交界处引起肾积水，副肾动脉起源于腹主动脉11例，起源于肾动脉2例。均在腹腔镜下完成离断式肾盂成形术，置入双J管，吻合口周围放置引流管，术后3~ 6 d拔除。手术时间（120±25）min；出血量（6.0±2.5）ml，患儿手术当天全流食。1例术后第2天出现漏尿，经治疗3 d后愈合。住院时间（8.5±0.5）d。术后随访3~15个月，1例肾萎缩者肾功能继续下降，出现完全无功能，反复出现发热、腰痛等泌尿道感染症状，二期行肾切除术，其余患儿无出现肾功能继续下降。 结论腹腔镜手术治疗小儿副肾动脉压迫引起的肾积水安全，创伤小，术后康复快，具有微创优势。     

Coarctation of the abdominal aorta: current options in surgical management.

Coarctation or hypoplasia of the abdominal aorta is a rare cause of life-threatening hypertension. In most cases the mechanism of hypertension is elevated blood renin levels secondary to associated renal artery stenosis. Medical control of the hypertension is often difficult, and thus patients usually require renal artery revascularization combined with aortic bypass or replacement early in life. Current surgical management should optimize the use of autogenous methods of renal artery reconstruction including saphenous vein aortorenal bypass, splenorenal arterial anastomosis, hepatorenal saphenous vein bypass, and renal autotransplantation. In selected patients the reconstruction can be staged by correction of the renal artery stenosis and postponement of definitive repair of the aortic coarctation until it becomes hemodynamically significant.     

The nutcracker syndrome

Left renal vein (LRV) compression, commonly referred to as the nutcracker syndrome or renal vein entrapment syndrome, is a rare and often overlooked condition. Anatomically, the LRV traverses the space between the superior mesenteric artery and the aorta in close proximity to the origin of the artery. In affected individuals, the LRV is subjected to compression between these two structures, resulting in renal venous hypertension. A review of published data on this condition reveals either case reports or small case series. The classic symptoms of nutcracker syndrome include left flank pain with gross or microscopic hematuria. Patients are often children or young adults, with a slight predisposition for women who may also present with pelvic congestion symptoms such as pelvic pain and dyspareunia. Most patients have disease symptoms for many years and nondiagnostic investigations before proper diagnosis can be made. Appropriate diagnostic work-up and treatment may help alleviate patient morbidity from this chronic condition. Although surgical repair has been the standard of care, more recently endovascular intervention has become the first line of therapy. This tabular review compiles published cases in the adult population during the period between 1980 and 2009.     

Revascularization of totally occluded renal arteries.

Two cases of total renal artery occlusion are presented. The clinical durations of occlusion were 10 days and 6 months. Revascularization procedures were successful in both patients, resulting in return of renal function and alleviation of hypertension. Our 2 cases and a review of 30 other cases demonstrate that the maximum duration of main renal artery occlusion with subsequent return of renal function is unknown.     

Results of the treatment of renal artery stenosis in transplanted kidneys

Fifty-six renal artery stenoses involving transplanted kidneys among a series of 819 renal transplants performed from 1978 to 1986 were treated. Forty-two patients underwent surgery. Surgery was the initial treatment in 38 cases and followed failed or complicated dilatation in four cases. Surgical treatment ensured successful control of hypertension in 85% of cases with a mean time lag of 26 months. Recurrence rate was 12%. Two patients died in the perioperative period. Percutaneous dilatation was performed in 18 renal artery stenoses and ensured control of hypertension in 61% of cases with a mean time lag of 19.6 months and a 33% recurrence rate.