A Renal Perforating Artery Mistaken for Arterial Bleeding after Percutaneous Renal Biopsy: A Case Report

김예림,이창희,김경아,박철민 대한초음파의학회 2009 ULTRASONOGRAPHY Vol.28 No.4

Perirenal hematoma after a renal biopsy is a common complication that usually resolves spontaneously, but this rarely requires transfusions or surgical/radiological intervention. We report here on a case of a renal perforating artery that was mistaken for renal arterial bleeding in a 53-year-old woman who was complicated with perirenal hematoma after undergoing a percutaneous renal biopsy. On the color and pulsed wave Doppler ultrasonography, linear blood flow was seen in the perirenal hematoma, which extended perpendicularly from the renal parenchyma into the perirenal space, and this linear blood flow exhibited an arterial pulse wave. On CT angiography, the renal perforating artery was demonstrated as a curvilinear vessel coursing tangentially to the renal margin and we decided that it was a pseudolesion caused by the renal perforating artery. A renal perforating artery may be mistaken for renal arterial bleeding after a percutaneous renal biopsy. A renal perforating artery and arterial bleeding can be differentiated by the location and shape seen on a color Doppler examination and the pulse waves characteristics. Perirenal hematoma after a renal biopsy is a common complication that usually resolves spontaneously, but this rarely requires transfusions or surgical/radiological intervention. We report here on a case of a renal perforating artery that was mistaken for renal arterial bleeding in a 53-year-old woman who was complicated with perirenal hematoma after undergoing a percutaneous renal biopsy. On the color and pulsed wave Doppler ultrasonography, linear blood flow was seen in the perirenal hematoma, which extended perpendicularly from the renal parenchyma into the perirenal space, and this linear blood flow exhibited an arterial pulse wave. On CT angiography, the renal perforating artery was demonstrated as a curvilinear vessel coursing tangentially to the renal margin and we decided that it was a pseudolesion caused by the renal perforating artery. A renal perforating artery may be mistaken for renal arterial bleeding after a percutaneous renal biopsy. A renal perforating artery and arterial bleeding can be differentiated by the location and shape seen on a color Doppler examination and the pulse waves characteristics.

Renal artery stenosis presenting as preeclampsia

Omar Michael Brandon,Kogler William,Maharaj Satish,Aung Win 대한고혈압학회 2020 Clinical Hypertension Vol.26 No.3

Background: Renal artery stenosis is a notorious cause of secondary hypertension which classically presents as chronic refractory hypertension, recurrent flash pulmonary edema or renal insufficiency after initiation of an angiotensin converting enzyme inhibitor. Rarely, there have been reported cases of pregnant patients presenting with new onset or superimposed preeclampsia secondary to renovascular hypertension. In this subset of patients, renovascular hypertension carries significantly higher risks including obstetric, fetal and medical emergencies and death. Prompt treatment is required. However, the teratogenic risks of radiological investigations and antihypertensive medications limit diagnostic and management options thus posing quite a dilemma. Case presentation: A 38-year-old female, at 33 weeks of gestation, was hospitalized for preeclampsia with severe features. A viable neonate had been expeditiously delivered yet the patient’s post-partum blood pressures remained severely elevated despite multi-class anti-hypertensive therapy. Renal artery dopplers revealed greater than 60% stenosis of the proximal left renal artery and at least 60% stenosis of the right renal artery. Renal angiography showed 50% stenosis of the left proximal renal artery for which balloon angioplasty and stenting was performed. The right renal artery demonstrated less than 50% stenosis with an insignificant hemodynamic gradient, thus was not stented. Following revascularization, the patient’s blood pressure improved within 48 h, on dual oral antihypertensive therapy. Conclusions: Preeclampsia that is refractory to multi-drug antihypertensive therapy should raise suspicion for renal artery stenosis. Suspected patients can be screened safely with Doppler ultrasonography which can be then followed by angiography. Even if renal artery stenosis does not seem severe, early renal revascularization may be considered in patients with severe preeclampsia who do not respond to antihypertensive management. Background: Renal artery stenosis is a notorious cause of secondary hypertension resulting from the activation of the renin-angiotensin system in response to reduced renal blood flow. Classic presentations include chronic refractory hypertension, recurrent flash pulmonary edema and renal insufficiency after initiation of an angiotensin converting enzyme inhibitor. Although rare, there have also been reported cases of pregnant patients presenting with new onset or superimposed preeclampsia secondary to renovascular hypertension [1, 2]. In this subset of patients, renovascuar hypertension carries significantly higher risks including obstetric, fetal and medical emergencies and death. Prompt treatment is required. However, the teratogenic risks of radiological investigations and antihypertensive medications such as angiotensin converting enzyme inhibitors or aldosterone antagonists limit management options and poses quite the dilemma. When possible, expedited delivery is beneficial; notwithstanding the fact that there has been success with interventional treatment prior to successful delivery. Furthermore, even after delivery, the mortality risk of pre-eclampsia continues into the post-partum period thus urgent and aggressive treatment strategies should continue to be pursued for these patients including consideration of early revascularization.

Establishment of normal reference of radiological morphology of renal artery in mini-pigs by renal angiography

Lee, Won Jae,Kim, Ji Yeon,Park, Jae Hyung,Park, Lisa Soyeon The Korean Society of Veterinary Science 2016 大韓獸醫學會誌 Vol.56 No.3

Mini-pigs have been widely employed in preclinical studies to explore new therapeutic strategies for diseases of the human urinary system; however, the normal reference of the renal artery has not been clearly investigated in the mini-pig model. Therefore, we aimed to establish a normal reference of the radiological morphology of the renal artery in mini-pigs by renal angiography via catheterization of the carotid artery. The renal angiographies obtained from 15 mini-pigs were evaluated to determine the orifice from the aorta, facing direction, size and the number of branches of renal arteries. Cranio-laterally facing renal arteries with 2 distal branches were mainly observed in the renal artery of mini-pigs. Both sides of the renal artery presented symmetrical sizes; however, the right renal artery orifice from the aorta was located more cranially than the left counterpart. The results of this study will contribute to radiological diagnosis of the renal artery as well as preclinical studies of mini-pigs.

Regions of the human renal artery: histomorphometric analysis

Blanca Mompeó-Corredera,Pablo Hernández-Morera,Irene Castaño-González,María del Pino Quintana-Montesdeoca,Natalia Mederos-Real 대한해부학회 2022 Anatomy & Cell Biology Vol.55 No.3

The renal artery is frequently involved in the pathogenesis of vasculorenal diseases, and it is a target in kidney surgery and therapeutic techniques for refractory hypertension. However, few detailed structural studies on the human renal artery have been conducted. Using histocytochemistry, immunohistochemistry, and quantitative image analysis, the wall thickness, structure, smooth muscle cells, extracellular matrix, and proportion of elastic tissue in the tunica media of main human renal arteries were used estimated. Ninety-six tissue samples were collected from sections of the right and left main renal arteries. The results showed that the renal artery changed from an elastic vessel in its proximal segment to a muscular artery in its distal part. A critical characteristic of the renal artery was the presence of longitudinal smooth muscle cell formations in the tunica adventitia of middle and distal segments but not in the proximal part of the artery. In addition, the tunica adventitia of the renal artery showed a rich vascularization and the presence of numerous nerves profiles. The artery's regional structural and morphometric features explain that a particular arterial pathology is more frequent in a specific vessel sector than in others. In addition, those characteristics could determine a different therapeutic response attending to the arterial sector.

증례 : 신동맥협착증 환자에서 신동맥 우회재건술 후에 재발한 급성 폐부종 1예

오숙의 ( Sook Eui Oh ),이영기 ( Young Ki Lee ),이해리 ( Hae Ri Lee ),노정우 ( Jeong Woo Noh ),신상준 ( Sang Joon Shin ) 대한내과학회 2006 대한내과학회지 Vol.71 No.3

저자들은 호흡 곤란으로 내원한 환자에서 우측 신동맥의 완전 폐쇄로 신동맥 우회재건술을 시행하였던 환자에서 재발한 flash pulmonary edema 1예를 경험하였기에 문헌 고찰과 함께 보고하는 바이다. 또한 신동맥 협착에 대해 수술적 처치를 한 후에도 드물게 재협착이 올 수 있으므로 지속적인 경과 관찰이 필요할 것으로 생각된다. Renal artery stenosis is a rare cause of acute pulmonary edema. So-called flash pulmonary edema is associated with bilateral renal artery stenosis or stenosis in a single functioning kidney. Flash pulmonary edema has been recognized as an absolute indication for vascular intervention. A 33-year old man was admitted with acute shortness of breath. Renal angiography showed occlusion of the right renal artery. He underwent a right renal artery bypass graft. However, after the renal artery bypass graft, episodes of pulmonary edema recurred. A renal angiography showed complete obstruction of the right renal artery and bypass graft. The left renal angiography showed an intact renal artery and decreased kidney size.(Korean J Med 71:322-327, 2006)

단일 제대 동맥을 가진 건강한 신생아에서 신장 초음파 검사의 유용성

강주미,송은송,국진화,이형신,김소영,최영륜,Kang, Ju-Mi,Song, Eun-Song,Kuk, Jin-Hwa,Lee, Hyung-Sin,Kim, So-Young,Choi, Young-Youn 대한소아청소년과학회 2003 Clinical and Experimental Pediatrics (CEP) Vol.46 No.9

목 적 : 단일 제대 동맥을 가진 건강한 신생아의 약 1/3에서 위장관 폐색 및 요로 기형을 동반할 수 있으므로 요로 기형을 발견하기 위해 초음파 검사를 관습적으로 시행하고 있지만 실제초음파 검사상 이상이 발견되는 경우는 드물다. 이에 저자는 단일 제대 동맥을 가진 건강한 신생아에서 신장 초음파 검사의 유용성을 알아보고자 본 연구를 실시하였다. 방 법 : 1995년 1월부터 2002년 7월까지 출생 후 이학적 검사상 단일 제대 동맥이 있는 신생아에서 단일 제대 동맥이면서 증후군의 일부이거나 수술적 치료가 필요한 심각한 질환이 동반된 경우는 제외하고 건강한 신생아 총 30명을 대상으로 하였다. 임상적 배경과 출생 72시간 이후 신장 초음파를 실시하였고, 신장초음파상 이상이 있는 경우 지속적 추적관찰과 더불어 배뇨성 방광요도 조영술 및 technetium-99m-mercaptoacetyl-triglycerine(MAG3) 신스캔 검사를 실시하여 수신증의 크기, 폐쇄의 정도 및 신기능 변화를 분석하였다. 결 과 : 총 30명의 남녀비는 1 : 1이었으며 평균 재태 연령은 $38.0{\pm}2.56$주, 평균 출생 체중은 $2,780{\pm}690g$이었다. 단일 제대동맥을 가진 건강한 신생아 30명 중 신장 초음파상 이상이 발견 된 례는 5명으로 16.7%이었고, 의미 있는 요로 기형은 1명으로 3.3%이었다. 이상이 발견된 5명 중 4명은 경도의 수신증으로 추적 검사상 자연 소실되었고, 1명은 심한 수신증으로 배뇨성 방광 요도 조영술상 역류는 없었고 MAG3 검사상 좌측 신장 기능 저하가 보여 외래 추적 관찰 중이다. 결 론 : 단일 제대 동맥을 가진 건강한 신생아에서 신장 초음파 검사상 발견된 신장 이상은 16.7%로 일반인에서 보이는 신장 이상의 빈도와 큰 차이는 없었고 1명을 제외한 4명(80.0%)에서 자연 소실되었으므로, 비용-이익 면에서 볼 때 단일 제대 동맥을 가진 건강한 신생아에서 관습적으로 신장 초음파 검사를 실시하는 것에 대해 고려해 볼 필요가 있다고 사료된다. Purpose : It is known that single umbilical artery is frequently associated with gastrointestinal or urogenital anomaly, however, routine renal sonography has been debated in healthy neonate with isolated single umbilical artery. This study is designed to determine the usefulness of routine renal sonography in apparently healthy infants with an isolated single umbilical artery. Methods : Thirty healthy neonates with a single umbilical artery without a major anomaly from January 1995 to July 2002 were enrolled. The authors investigated the clinical background of babies and their mothers after renal sonography after 72 hours of age. When the abnormalities were found at the first renal sonography, the severity of hydronephrosis and degree of obstruction and renal function were analyzed by follow up renal sonography, voiding cystourethrography(VCUG) and technetium-99m-dimercaptosuccinic acid(DMSA) scan or technetium-99m-mercaptoacetyl-triglycerine (MAG3) scan. Results : Among the 30 healthy patients with isolated single umbilical artery, five patients(16.7%) showed abnormalities on first renal sonography with one major(3.3%) and four(13.4%) minor renal anomaly(minimal or mild hydroneohrosis). One major renal anomaly(severe hydronephrosis) showed severe decreased renal function on MAG3 scan without reflux, and the other four minor regressed spontaneously on follow up study. Conclusion : The value of routine early renal sonograpy for detecting renal anomaly in healthy infants with an isolated single umbilical artery remained unclear because most of the anomalies would regress spontaneously in the follow up study.

Fenestrated Stent Graft Repair of Abdominal Aortic Aneurysm: Hemodynamic Analysis of the Effect of Fenestrated Stents on the Renal Arteries

Zhonghua Sun,Thanapong Chaichana 대한영상의학회 2010 Korean Journal of Radiology Vol.11 No.1

Objective: We wanted to investigate the hemodynamic effect of fenestrated stents on the renal arteries with using a fluid structure interaction method. Materials and Methods: Two representative patients who each had abdominal aortic aneurysm that was treated with fenestrated stent grafts were selected for the study. 3D realistic aorta models for the main artery branches and aneurysm were generated based on the multislice CT scans from two patients with different aortic geometries. The simulated fenestrated stents were designed and modelled based on the 3D intraluminal appearance, and these were placed inside the renal artery with an intra-aortic protrusion of 5.0-7.0 mm to reflect the actual patients’treatment. The stent wire thickness was simulated with a diameter of 0.4 mm and hemodynamic analysis was performed at different cardiac cycles. Results: Our results showed that the effect of the fenestrated stent wires on the renal blood flow was minimal because the flow velocity was not significantly affected when compared to that calculated at pre-stent graft implantation, and this was despite the presence of recirculation patterns at the proximal part of the renal arteries. The wall pressure was found to be significantly decreased after fenestration, yet no significant change of the wall shear stress was noticed at post-fenestration, although the wall shear stress was shown to decrease slightly at the proximal aneurysm necks. Conclusion: Our analysis demonstrates that the hemodynamic effect of fenestrated renal stents on the renal arteries is insignificant. Further studies are needed to investigate the effect of different lengths of stent protrusion with variable stent thicknesses on the renal blood flow, and this is valuable for understanding the long-term outcomes of fenestrated repair. Objective: We wanted to investigate the hemodynamic effect of fenestrated stents on the renal arteries with using a fluid structure interaction method. Materials and Methods: Two representative patients who each had abdominal aortic aneurysm that was treated with fenestrated stent grafts were selected for the study. 3D realistic aorta models for the main artery branches and aneurysm were generated based on the multislice CT scans from two patients with different aortic geometries. The simulated fenestrated stents were designed and modelled based on the 3D intraluminal appearance, and these were placed inside the renal artery with an intra-aortic protrusion of 5.0-7.0 mm to reflect the actual patients’treatment. The stent wire thickness was simulated with a diameter of 0.4 mm and hemodynamic analysis was performed at different cardiac cycles. Results: Our results showed that the effect of the fenestrated stent wires on the renal blood flow was minimal because the flow velocity was not significantly affected when compared to that calculated at pre-stent graft implantation, and this was despite the presence of recirculation patterns at the proximal part of the renal arteries. The wall pressure was found to be significantly decreased after fenestration, yet no significant change of the wall shear stress was noticed at post-fenestration, although the wall shear stress was shown to decrease slightly at the proximal aneurysm necks. Conclusion: Our analysis demonstrates that the hemodynamic effect of fenestrated renal stents on the renal arteries is insignificant. Further studies are needed to investigate the effect of different lengths of stent protrusion with variable stent thicknesses on the renal blood flow, and this is valuable for understanding the long-term outcomes of fenestrated repair.

다발 신동맥 공여자에서 손을 이용한 복강경하 공여신 적출술의 안정성

최항원,정진우,정조운,조혁진,홍성후,김준철,박용현,황태곤 대한비뇨의학회 2008 Investigative and Clinical Urology Vol.49 No.5

Purpose: We wanted to present the feasibility and safety of hand-assisted laparoscopic donor nephrectomy(HALDN) for treating patients with multiple renal arteries. Materials and Methods: Between February 2000 and July 2006, 252 patients underwent HALDN. The results for the patients with a single renal artery (n=187)(Group I) and those patients with multiple renal arteries(n=65) (Group II) were compared in terms of the donor and recipient outcomes. A retrospective chart review was performed and statistical analysis included Student's t-test, the chi square test and Kaplan-Meier survival probability analysis. Results: HALDN was technically successful in 251 patients(1 patient had to be converted to open donor nephrectomy). The operative times were increased in group II, but the differences between the groups were not statistically significant. The warm ischemic times were significantly longer in group II. The intraoperative blood loss, postoperative hospital stay and complication rate in the donor group were not associated with the number of renal arteries. The recipients' renal function and overall graft survival were similar between groups I and II. Conclusions: In our single-center study, the presence of renal artery multiplicity when performing HALDN does not have a significant impact on the outcomes of the renal donors or recipients. (Korean J Urol 2008;49:443-448) Purpose: We wanted to present the feasibility and safety of hand-assisted laparoscopic donor nephrectomy(HALDN) for treating patients with multiple renal arteries. Materials and Methods: Between February 2000 and July 2006, 252 patients underwent HALDN. The results for the patients with a single renal artery (n=187)(Group I) and those patients with multiple renal arteries(n=65) (Group II) were compared in terms of the donor and recipient outcomes. A retrospective chart review was performed and statistical analysis included Student's t-test, the chi square test and Kaplan-Meier survival probability analysis. Results: HALDN was technically successful in 251 patients(1 patient had to be converted to open donor nephrectomy). The operative times were increased in group II, but the differences between the groups were not statistically significant. The warm ischemic times were significantly longer in group II. The intraoperative blood loss, postoperative hospital stay and complication rate in the donor group were not associated with the number of renal arteries. The recipients' renal function and overall graft survival were similar between groups I and II. Conclusions: In our single-center study, the presence of renal artery multiplicity when performing HALDN does not have a significant impact on the outcomes of the renal donors or recipients. (Korean J Urol 2008;49:443-448)

혈전성 양측 신동맥 폐쇄로 인한 급성 신부전증 환자에서의 성공적인 스텐트 삽입술

최정욱 ( Choe Jeong Ug ),김장영 ( Kim Jang Yeong ),이승환 ( Lee Seung Hwan ),유종명 ( Yu Jong Myeong ),한병근 ( Han Byeong Geun ),최승옥 ( Choe Seung Og ) 대한신장학회 2004 Kidney Research and Clinical Practice Vol.23 No.3

Renal artery disease is one of the significant factors that lead to compromise renal function and/or aggravate hypertension in the elderly population. Since the non-surgical treatment of renal artery stenosis,percutaneous transluminal renal angioplasty, is available, it is possible to cure the decreased renal function and exacerbated hypertension. However, bilateral renal artery occlusion (BRAO) that brings about anuria and azotemia is rare. In this communication, we`d like to describe a patient who developed acute renal failure due to BRAO. His renal function was completely recovered after successful implantation of stents into both renal arteries. We are unaware of prior reports documenting the beneficial effect of a distal embolic protection device, the Percu-Surge GuardWire system (Medtronic, Minneapolis, MN, USA), in a clinical setting as described here. The GuardWire arm, a device for transient distal balloon occlusion during angioplasty or stent placement, allows recovery of any liberated plaque by aspiration before restoration of antegrade flow, and thereby performs a double service. We`d like to strongly recommend that stent implantation with adjunctive distal protection is essential to obtain a complete restoration of distal blood flow although there is sufficient collateral blood flow in elderly patients with BRAO and azotemia.

신동맥의 자기공명 혈관조영술

배상훈 대한영상의학회 1993 대한영상의학회지 Vol.29 No.1

We reviewed MR angiograms to evaluate its efficacy for visualizing the renal arteries and detecting renovascular disease. 41 renal arteries in 19 patients were examined by MR angiography. 3-D time-of-flight technique was used as routine examination method for MR angiography and 2-D time-of-flight technique was added in some particular cases to visualize venous flow. Within two weeks after MR angiography was performed, 23 renal arteries in 10 patients were additionally examined by conventional angiography or intraarterial DSA. The success rates of vessel visualization on MR angiography in normal renal arteries were 100% in main 67.7% in segmental, and 11.8% in intrarenal arteries. As a result of comparative study in normal main renal arteries with MR angiograms and conventional angiograms, overall correspondence in the number and the shape was noted and the caliber discrepancy between two examination did not exceed 3.0 mm. one arteriovenous fistula with aneurysm, one stenotic artery and two occluded arteries were well evaluated One arteriovenous fistula with aneurysm, and two occluded arteries were well evaluated by MR angiography. However three stenotic lesions were misdiagnosed as occlusions on MR angiography. and the overall accuracy was 87% We conclude that MR angiography has the potential to be a noninvasive and useful screening method for determining the number of renal arteries and for detection of abnormalities of main renal arteries.