Surg Radiol Anat DOI 10.1007/s00276-015-1446-3
ANATOMIC VARIATIONS
Multiple anatomical variations of the renal vessels associated with malrotated and unrotated kidneys: a case report Barbara Buffoli • Lorenzo Franceschetti • Francesco Belotti Marco Ferrari • Lena Hirtler • Manfred Tschabitscher • Luigi F. Rodella
•
Received: 23 October 2014 / Accepted: 16 February 2015 Ó Springer-Verlag France 2015
Abstract Variations in the number of renal vessels represent the most common anatomical variations in renal vasculature. Here, a rare case of multiple anatomical variations of renal vessels was found in a 70-year-old female cadaveric dissection. Three renal arteries and two renal veins were observed to supply the right kidney, which was malrotated and ectopic; on the left side, the kidney was unrotated and presented two renal arteries and normal renal vein. In particular, we paid attention to the pattern of the three renal arteries that originated from the lateral side of the aorta and passed anteriorly to the inferior vena cava. A rare case of ovarian vein that drained into the right renal vein was also reported. The descriptions of these multiple anatomical variations should be considered by clinicians for performing correct surgical and radiological procedures. Keywords Anatomical variations Renal vessels Dissection Unrotated kidney Malrotated kidney
B. Buffoli and L. Franceschetti equally share the first authorship. B. Buffoli L. Franceschetti F. Belotti M. Ferrari M. Tschabitscher L. F. Rodella (&) Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, V.le Europa 11, 25123 Brescia, Italy e-mail: [email protected] L. Hirtler Department for Systematic Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
Introduction Congenital anomalies of the kidney and urinary tract (CAKUT) are relatively common and constitute approximately about 30 % of all congenital anomalies. These congenital defects can be hereditary but in most cases are due to an acquired developmental defect that starts during gestation; defects can be bilateral or unilateral, and multiple defects may often coexist in a single individual. In particular, anomalies in renal structure and position are the most frequent but variations in renal vasculature are also common and strictly related with kidneys development [1–3, 14]. The different patterns of renal arteries (accessory, additional, aberrant, supplementary), their position, method of entry to the kidney and segmentation were studied extensively by several authors [4, 5, 11, 13, 15]. According to Graves [4], any artery arising from the aorta in addition to the main renal artery should be named ‘‘accessory’’ and the renal arteries arising from sources other than aorta should be called ‘‘aberrant’’. Differently, according to Sampaio and Passos [13] these arteries should be called multiple, since they are segmental vessels for the kidney, without anastomoses between themselves and they should be named according to the territory supplied by them, as hilar, superior polar and inferior polar. We followed Sampaio and Passos [13] nomenclature for our study, using the term ‘‘multiple’’. In this case report, we report a multiple pattern of congenital renal variations with surgical and radiological importance.
Case report During dissection of a 70-year-old female cadaver in the Department for Systematic Anatomy of the Medical
123
Surg Radiol Anat
University of Vienna, multiple anatomical variations of the renal vasculature associated with malrotated and unrotated kidneys were observed. On the right side The right kidney was ectopic and was located lower than its physiological position, with the inferior polar margin at about 1.5 cm from the right iliac common artery. It had an abnormal shape with a flat superior pole. The kidney was malrotated and its hilum was located ventro-laterally towards the posterior parietal peritoneum. The right ureter originated from the renal hilum and ran laterally lying to the renal capsule. Three right renal arteries arose from the anterior side of the aorta. The right superior renal artery (SRA) arose 52.1 mm below the superior mesenteric artery (SMA), passed anteriorly to the inferior vena cava (IVC) and reached the superior renal pole. The right middle renal artery (MRA) originated distally (66.2 mm below SRA) before the aortic bifurcation, passed anteriorly to the IVC and reached the renal hilum. The right inferior renal artery (IRA) originated between the aortic bifurcation (27.8 mm below MRA), passed anteriorly to the right common iliac artery and then to the IVC, and reached the inferior renal pole. Moreover, two right renal veins emerged from the hilum to enter the IVC separately. The right ovarian vein (OV) drained into the superior renal vein, just before the renal vein reached the inferior vena cava (Figs. 1, 2). The caliber of the arteries was: SRA 6.7 mm, MRA 4.8 mm and IRA 5.7 mm.
Fig. 1 Photograph showing anterior view of dissected right ectopic and malrotated kidney, left unrotated kidney and multiple renal vessels. Ao aorta, IVC inferior vena cava, SMA superior mesenteric artery (cut), SRA superior renal artery, MRA middle renal artery, IRA inferior renal artery, SRV superior renal vein, IRV inferior renal vein, RP renal pelvis, OV ovarian vein, U ureter, rCIA right common iliac artery
On the left side The left kidney was unrotated and the hilum was located towards the posterior parietal peritoneum. The left kidney had no variations in the position and had a normal shape. Two left renal arteries arose from the lateral side of the aorta. The left SRA arose 16.6 mm below SMA and reached the renal hilum. The left IRA originated distally, just before the aortic bifurcation, and about 10.3 mm below the origin of the right MRA and 104.4 mm below the origin of left SRA, and reached the inferior renal pole. Normal left renal vein was observed (Fig. 1). The caliber of the arteries was: SRA 5.5 mm and IRA 5.0 mm.
Discussion Morphological variations of the kidneys such as in size, shape, location or position, are numerous and well-known and the embryological bases for these variations have been well-established. In the embryo, the kidneys begin their
123
development in the pelvic cavity and ascend to their final position in the lumbar region at the end of 5th–8th week of intrauterine life. In their ascent towards the lumbar region, kidneys rotate medially so that the renal hilum, which is initially directed ventrally towards the posterior parietal peritoneum, is normally directed in a medial direction, facing the abdominal aorta. Nevertheless, the rotation cannot be occurred (unrotated kidney) or can be incomplete or abnormal (malrotated kidney) and this situation is often caused by or related to aberrant renal vessels [1, 12]. During the ascent of the kidney from the pelvis, in fact, the organs derive their blood supply sequentially from the vessels that are closest to them: initially median sacral, then common iliac and inferior mesenteric, and finally aorta with degeneration of primitive lower vessels. Failure of degeneration of the primitive vessels results in the origin of multiple renal arteries. The persistence of one of the fetal arteries is common and multiple renal arteries are present in 30 % of individuals and their pattern presents a wide variability [7–9, 14].
Surg Radiol Anat
alterations in anastomotic channels of post-cardinal, supracarinal and subcardinal veins [10].
Conclusion In recent years, interest in multiple renal vasculature has been high. In fact, it is important for surgical and medical practice to have extensive knowledge of the renal anatomy mainly for surgical planning during nephrectomy or renal transplantation procedures, and for other kinds of renal surgery, i.e. ureter surgery, gonadal surgery, uroradiology, angiographic interventions and surgery of abdominal aorta aneurysms. In this case report, we described multiple variations of renal structure and vasculature that should be known and considered together by radiologists and surgeons. Acknowledgments We thank Professor Rita Rezzani (Chief of the Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia) for the critical reading of the manuscript. Conflict of interest of interest. Fig. 2 Photograph showing anterior view after removing the right kidney. Ao aorta, IVC inferior vena cava, SRA superior renal artery, MRA middle renal artery, IRA inferior renal artery, SRV superior renal vein, IRV inferior renal vein, OV ovarian vein
In this case report, malrotated right kidney and unrotated left kidney were associated with additional renal vessels (three renal arteries and two renal veins on the right side; two renal arteries and one renal vein on the left side). Among the different anatomical variations of the renal vessels, we paid attention of the anomalous course of the three right renal arteries. The three renal arteries, in fact, arose from the anterior aspect of aorta and passed anteriorly to the inferior vena cava (precaval artery). The anterior origin of the renal artery has been already reported in literature, with a low incidence [17]. In the same way, literature data about anomalies in the relationship between renal artery(ies) and inferior vena cava (precaval renal arteries) are also reported in a very few cases, but with different patterns [3, 6, 17]. Literature data reported a less incidence of renal vein respect to renal artery variations; however, variations occurring in both arteries and veins are not so rare [3, 16]. Here, we observed two renal veins (superior and inferior renal veins) on the right side and the right ovarian vein drained into the superior renal vein, a rare case due to errors of embryological development in venous shift and
The authors declare that they have no conflict
References 1. Atasever A, Hamdi Celik H, Durgun B, Yilmaz E (1992) Unrotated left kidney associated with an accessory renal artery. J Anat 181:507–508 2. Bordei P, Sapte E, Iliescu D (2004) Double renal arteries originating from the aorta. Surg Radiol Anat 26:474–479 3. Bouali O, Labarre D, Molinier F, Lopez R, Benouaich V, Lauwers F, Moscovici J (2012) Anatomic variations of the renal vessels: focus on the precaval right renal artery. Surg Radiol Anat 34:441–446 4. Graves FT (1956) The aberrant renal artery. J Anat 90:553–558 5. Lipper H, Pabst R (1985) Arterial variations in man: classification and frequency. JF Bergman Verlag, Munchen, pp 25–29 6. Meng MV, Yeh BM, Breiman RS, Schwartz BF, Coakley FV, Stoller ML (2002) Precaval right renal artery: description and embryologic origin. Urology 60:402–405 7. Miclaus GD, Matusz P (2012) Bilateral quadruple renal arteries. Clin Anat 25:973–976 8. Natsis K, Paraskevas G, Panagouli E, Tsaraklis A, Lolis E, Piagkou M, Veneiratos D (2014) A morphometric study of multiple renal arteries in Greek population and a systematic review. Rom J Morphol Embryol 55:1111–1122 9. Pestemalci T, Mavi A, Yildiz YZ, Yildirim M, Gumusburun E (2009) Bilateral triple renal arteries. Saudi J Kidney Dis Transpl 20:468–470 10. Phalgunan V, Mugunthan N, Rani DJ, Anabalagan J (2012) A study of renal and gonadal vein variations. Nat J Clin Anat 1:125–128 11. Poisel S, Spangler HP (1970) The ramifications of the renal artery in relationship to the arterial blood supply of the renal parenchyma. Problem of the so-colled renal segments. Acta Anat 76:516–529
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Surg Radiol Anat 12. Ramteerthakar RN, Joshi DS, Joshi RA, Pote AJ (2011) Bilateral unrotation of kidneys. Saudi J Kidney Dis Transpl 22:1033–1034 13. Sampaio FJ, Passos MA (1992) Renal arteries: anatomical study for surgical and radiological practice. Surg Radiol Anat 14:113–117 14. Satyapal KS, Haffejee AA, Singh B, Ramsaroop L, Robbs JV, Kaliden JM (2001) Additional renal arteries: incidence and morphometry. Surg Radiol Anat 23:33–38 15. Sikes D (1963) The arterial supply of the human kidney with special reference to accessory arteries. Br J Surg 50:368–374
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16. Uzmansel D, Ozturk NC, Kara A, Ozturk H (2014) A rare combination of vascular variations of both kidneys. Surg Radiol Anat 36:195–198 17. Yeh BM, Coakley FV, Meng MV, Breiman RS, Stoller ML (2004) Precaval right renal arteries: prevalence and morphologic associations at spiral CT. Radiology 230:429–433
ANATOMIC VARIATIONS
Multiple anatomical variations of the renal vessels associated with malrotated and unrotated kidneys: a case report Barbara Buffoli • Lorenzo Franceschetti • Francesco Belotti Marco Ferrari • Lena Hirtler • Manfred Tschabitscher • Luigi F. Rodella
•
Received: 23 October 2014 / Accepted: 16 February 2015 Ó Springer-Verlag France 2015
Abstract Variations in the number of renal vessels represent the most common anatomical variations in renal vasculature. Here, a rare case of multiple anatomical variations of renal vessels was found in a 70-year-old female cadaveric dissection. Three renal arteries and two renal veins were observed to supply the right kidney, which was malrotated and ectopic; on the left side, the kidney was unrotated and presented two renal arteries and normal renal vein. In particular, we paid attention to the pattern of the three renal arteries that originated from the lateral side of the aorta and passed anteriorly to the inferior vena cava. A rare case of ovarian vein that drained into the right renal vein was also reported. The descriptions of these multiple anatomical variations should be considered by clinicians for performing correct surgical and radiological procedures. Keywords Anatomical variations Renal vessels Dissection Unrotated kidney Malrotated kidney
B. Buffoli and L. Franceschetti equally share the first authorship. B. Buffoli L. Franceschetti F. Belotti M. Ferrari M. Tschabitscher L. F. Rodella (&) Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, V.le Europa 11, 25123 Brescia, Italy e-mail: [email protected] L. Hirtler Department for Systematic Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
Introduction Congenital anomalies of the kidney and urinary tract (CAKUT) are relatively common and constitute approximately about 30 % of all congenital anomalies. These congenital defects can be hereditary but in most cases are due to an acquired developmental defect that starts during gestation; defects can be bilateral or unilateral, and multiple defects may often coexist in a single individual. In particular, anomalies in renal structure and position are the most frequent but variations in renal vasculature are also common and strictly related with kidneys development [1–3, 14]. The different patterns of renal arteries (accessory, additional, aberrant, supplementary), their position, method of entry to the kidney and segmentation were studied extensively by several authors [4, 5, 11, 13, 15]. According to Graves [4], any artery arising from the aorta in addition to the main renal artery should be named ‘‘accessory’’ and the renal arteries arising from sources other than aorta should be called ‘‘aberrant’’. Differently, according to Sampaio and Passos [13] these arteries should be called multiple, since they are segmental vessels for the kidney, without anastomoses between themselves and they should be named according to the territory supplied by them, as hilar, superior polar and inferior polar. We followed Sampaio and Passos [13] nomenclature for our study, using the term ‘‘multiple’’. In this case report, we report a multiple pattern of congenital renal variations with surgical and radiological importance.
Case report During dissection of a 70-year-old female cadaver in the Department for Systematic Anatomy of the Medical
123
Surg Radiol Anat
University of Vienna, multiple anatomical variations of the renal vasculature associated with malrotated and unrotated kidneys were observed. On the right side The right kidney was ectopic and was located lower than its physiological position, with the inferior polar margin at about 1.5 cm from the right iliac common artery. It had an abnormal shape with a flat superior pole. The kidney was malrotated and its hilum was located ventro-laterally towards the posterior parietal peritoneum. The right ureter originated from the renal hilum and ran laterally lying to the renal capsule. Three right renal arteries arose from the anterior side of the aorta. The right superior renal artery (SRA) arose 52.1 mm below the superior mesenteric artery (SMA), passed anteriorly to the inferior vena cava (IVC) and reached the superior renal pole. The right middle renal artery (MRA) originated distally (66.2 mm below SRA) before the aortic bifurcation, passed anteriorly to the IVC and reached the renal hilum. The right inferior renal artery (IRA) originated between the aortic bifurcation (27.8 mm below MRA), passed anteriorly to the right common iliac artery and then to the IVC, and reached the inferior renal pole. Moreover, two right renal veins emerged from the hilum to enter the IVC separately. The right ovarian vein (OV) drained into the superior renal vein, just before the renal vein reached the inferior vena cava (Figs. 1, 2). The caliber of the arteries was: SRA 6.7 mm, MRA 4.8 mm and IRA 5.7 mm.
Fig. 1 Photograph showing anterior view of dissected right ectopic and malrotated kidney, left unrotated kidney and multiple renal vessels. Ao aorta, IVC inferior vena cava, SMA superior mesenteric artery (cut), SRA superior renal artery, MRA middle renal artery, IRA inferior renal artery, SRV superior renal vein, IRV inferior renal vein, RP renal pelvis, OV ovarian vein, U ureter, rCIA right common iliac artery
On the left side The left kidney was unrotated and the hilum was located towards the posterior parietal peritoneum. The left kidney had no variations in the position and had a normal shape. Two left renal arteries arose from the lateral side of the aorta. The left SRA arose 16.6 mm below SMA and reached the renal hilum. The left IRA originated distally, just before the aortic bifurcation, and about 10.3 mm below the origin of the right MRA and 104.4 mm below the origin of left SRA, and reached the inferior renal pole. Normal left renal vein was observed (Fig. 1). The caliber of the arteries was: SRA 5.5 mm and IRA 5.0 mm.
Discussion Morphological variations of the kidneys such as in size, shape, location or position, are numerous and well-known and the embryological bases for these variations have been well-established. In the embryo, the kidneys begin their
123
development in the pelvic cavity and ascend to their final position in the lumbar region at the end of 5th–8th week of intrauterine life. In their ascent towards the lumbar region, kidneys rotate medially so that the renal hilum, which is initially directed ventrally towards the posterior parietal peritoneum, is normally directed in a medial direction, facing the abdominal aorta. Nevertheless, the rotation cannot be occurred (unrotated kidney) or can be incomplete or abnormal (malrotated kidney) and this situation is often caused by or related to aberrant renal vessels [1, 12]. During the ascent of the kidney from the pelvis, in fact, the organs derive their blood supply sequentially from the vessels that are closest to them: initially median sacral, then common iliac and inferior mesenteric, and finally aorta with degeneration of primitive lower vessels. Failure of degeneration of the primitive vessels results in the origin of multiple renal arteries. The persistence of one of the fetal arteries is common and multiple renal arteries are present in 30 % of individuals and their pattern presents a wide variability [7–9, 14].
Surg Radiol Anat
alterations in anastomotic channels of post-cardinal, supracarinal and subcardinal veins [10].
Conclusion In recent years, interest in multiple renal vasculature has been high. In fact, it is important for surgical and medical practice to have extensive knowledge of the renal anatomy mainly for surgical planning during nephrectomy or renal transplantation procedures, and for other kinds of renal surgery, i.e. ureter surgery, gonadal surgery, uroradiology, angiographic interventions and surgery of abdominal aorta aneurysms. In this case report, we described multiple variations of renal structure and vasculature that should be known and considered together by radiologists and surgeons. Acknowledgments We thank Professor Rita Rezzani (Chief of the Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia) for the critical reading of the manuscript. Conflict of interest of interest. Fig. 2 Photograph showing anterior view after removing the right kidney. Ao aorta, IVC inferior vena cava, SRA superior renal artery, MRA middle renal artery, IRA inferior renal artery, SRV superior renal vein, IRV inferior renal vein, OV ovarian vein
In this case report, malrotated right kidney and unrotated left kidney were associated with additional renal vessels (three renal arteries and two renal veins on the right side; two renal arteries and one renal vein on the left side). Among the different anatomical variations of the renal vessels, we paid attention of the anomalous course of the three right renal arteries. The three renal arteries, in fact, arose from the anterior aspect of aorta and passed anteriorly to the inferior vena cava (precaval artery). The anterior origin of the renal artery has been already reported in literature, with a low incidence [17]. In the same way, literature data about anomalies in the relationship between renal artery(ies) and inferior vena cava (precaval renal arteries) are also reported in a very few cases, but with different patterns [3, 6, 17]. Literature data reported a less incidence of renal vein respect to renal artery variations; however, variations occurring in both arteries and veins are not so rare [3, 16]. Here, we observed two renal veins (superior and inferior renal veins) on the right side and the right ovarian vein drained into the superior renal vein, a rare case due to errors of embryological development in venous shift and
The authors declare that they have no conflict
References 1. Atasever A, Hamdi Celik H, Durgun B, Yilmaz E (1992) Unrotated left kidney associated with an accessory renal artery. J Anat 181:507–508 2. Bordei P, Sapte E, Iliescu D (2004) Double renal arteries originating from the aorta. Surg Radiol Anat 26:474–479 3. Bouali O, Labarre D, Molinier F, Lopez R, Benouaich V, Lauwers F, Moscovici J (2012) Anatomic variations of the renal vessels: focus on the precaval right renal artery. Surg Radiol Anat 34:441–446 4. Graves FT (1956) The aberrant renal artery. J Anat 90:553–558 5. Lipper H, Pabst R (1985) Arterial variations in man: classification and frequency. JF Bergman Verlag, Munchen, pp 25–29 6. Meng MV, Yeh BM, Breiman RS, Schwartz BF, Coakley FV, Stoller ML (2002) Precaval right renal artery: description and embryologic origin. Urology 60:402–405 7. Miclaus GD, Matusz P (2012) Bilateral quadruple renal arteries. Clin Anat 25:973–976 8. Natsis K, Paraskevas G, Panagouli E, Tsaraklis A, Lolis E, Piagkou M, Veneiratos D (2014) A morphometric study of multiple renal arteries in Greek population and a systematic review. Rom J Morphol Embryol 55:1111–1122 9. Pestemalci T, Mavi A, Yildiz YZ, Yildirim M, Gumusburun E (2009) Bilateral triple renal arteries. Saudi J Kidney Dis Transpl 20:468–470 10. Phalgunan V, Mugunthan N, Rani DJ, Anabalagan J (2012) A study of renal and gonadal vein variations. Nat J Clin Anat 1:125–128 11. Poisel S, Spangler HP (1970) The ramifications of the renal artery in relationship to the arterial blood supply of the renal parenchyma. Problem of the so-colled renal segments. Acta Anat 76:516–529
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Surg Radiol Anat 12. Ramteerthakar RN, Joshi DS, Joshi RA, Pote AJ (2011) Bilateral unrotation of kidneys. Saudi J Kidney Dis Transpl 22:1033–1034 13. Sampaio FJ, Passos MA (1992) Renal arteries: anatomical study for surgical and radiological practice. Surg Radiol Anat 14:113–117 14. Satyapal KS, Haffejee AA, Singh B, Ramsaroop L, Robbs JV, Kaliden JM (2001) Additional renal arteries: incidence and morphometry. Surg Radiol Anat 23:33–38 15. Sikes D (1963) The arterial supply of the human kidney with special reference to accessory arteries. Br J Surg 50:368–374
123
16. Uzmansel D, Ozturk NC, Kara A, Ozturk H (2014) A rare combination of vascular variations of both kidneys. Surg Radiol Anat 36:195–198 17. Yeh BM, Coakley FV, Meng MV, Breiman RS, Stoller ML (2004) Precaval right renal arteries: prevalence and morphologic associations at spiral CT. Radiology 230:429–433
