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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 3  |  Page : 375-379
Renal Artery Aneurysm: A Case Report and Review of Literature


Division of Nephrology and Hypertension, Department of Medicine, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

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   Abstract 

Renal artery aneurysm is an uncommon clinical occurrence. We report a 32­year-old lady with refractory hypertension who was found to have renal artery aneurysm. After a long clinical course, the aneurysm was successfully treated with coil embolization.

Keywords: Renal artery, Aneurysm, Hypertension, Coil embolization.

How to cite this article:
Raza H, Al Flaiw A, Quadri K, Al Ghamdi G, Qureshi J, Al Hejaili F, Huraib S. Renal Artery Aneurysm: A Case Report and Review of Literature. Saudi J Kidney Dis Transpl 2004;15:375-9

How to cite this URL:
Raza H, Al Flaiw A, Quadri K, Al Ghamdi G, Qureshi J, Al Hejaili F, Huraib S. Renal Artery Aneurysm: A Case Report and Review of Literature. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2019 Nov 12];15:375-9. Available from: http://www.sjkdt.org/text.asp?2004/15/3/375/32984

   Introduction Top


Renal artery aneurysm is a rare clinical entity, but when encountered is of great clinical significance because of propensity for rupture, etc. Autopsy studies have revealed an inci­dence of renal artey aneurysm of 0.01 to 0.09%. In two studies, renal artery aneurysms were documented in 0.73 to 0.97% of arterio­grams performed. [1],[2] We report on a case of renal artery aneurysm presenting with difficult to control hypertension and intracranial hemorrhage.


   Case Report Top


A 32-year-old lady known to have hyper­tension (HTN) since 1986 and with a history of uneventful pregnancy in 1989, was referred to the Nephrology out patient clinic in 1991, with complaints of dizziness, chest pain and uncontrolled blood pressure (BP). Clinical examination did not reveal any abnormality on chest, cardiovascular and abdominal exami­nation. Initial investigations showed normal hematological and biochemical indices. She was started on anti-hypertensive treatment (nifedipine and atenolol).

Three months later, she presented to the emergency department with accelerated HTN, headache and right hemiplegia. A compute­rized tomography (CT) scan revealed that she had subarachnoid hemmorhage. Cerebral angiogram showed left terminal internal carotid artery aneurysm (6 mm x 8 mm). She underwent clipping of the aneurysm and made a complete recovery from the hemiplegia. Subsequently she underwent investigations to exclude secondary causes of hypertension. 24-hour cathecholamine and renal vein renin levels were normal. Renal angiogram revealed an aneurysm in the right renal artery with no evidence of renal artery stenosis. Her antihy­pertensive treatment was modified (nifedipine, clonidine, captopril); however, no definitive treatment was used for the renal artery aneurysm possibly because of lack of con­trolled data. She was lost to follow-up for one year. She later returned to the HTN clinic, was found to have high BP and her anti-HTN treatment further modified. On subsequent visits, her BP control was variable. During this period, her renal functions remained normal. She had another uneventful pregnancy in 1993 during which period, her BP was adequately controlled. She was subsequently discharged from the HTN clinic to continue follow-up at family practice clinic.

After five years, she was referred to the HTN clinic with findings of high BP. She was on nifedipine and atenolol. A Doppler ultra­sound of her kidneys was repeated which was reported as normal. She was admitted for BP control. Examination revealed bruit over abdo­minal aorta and right renal artery. Systemic examination was normal. Her blood pressure normalized within 24 hours of hospital admi­ssion on her regular medications raising strong questions regarding patient-compliance with anti-hypertensive medications. Investigations revealed normal blood urea and serum crea­tinine levels. Renal renin vein sampling showed normal renin levels (right renal vein 40 mcU/ml, left renal vein 32 mcU/ml (normal 5-47 mcU/ ml). Renal artery angiogram showed a saccular right renal artery aneurysm (6 mm x 1.5 mm) arising from first bifurcation of the main right renal artery [Figure - 1].

The case was discussed with the vascular surgeons regarding further management. They were of the opinion that keeping in view the size of the aneurysm, there is a 15% chance of spontaneous rupture of this aneurysm so it must be treated aggressively.

Treatment options were discussed with the patient and subsequently coil embolization of the aneurysm was performed [Figure - 2],[Figure - 3].

All along, the patient's renal functions remained normal. Blood pressure was well controlled on medications. Patient was dis­charged home with a plan to follow-up in the HTN clinic and to have a repeat renal angiogram six months later in order to review the status of the renal artery aneurysm [Figure - 4].


   Discussion Top


As there is lack of controlled data, controversy persists regarding the management of asympto­matic renal artery aneurysms. Renal artery aneurysms may be true (saccular and fusiform), false (arising from penetrating or blunt trauma) or dissecting aneurysms. More than 90% of the renal artery aneurysms are extra­parenchymal. The peak incidence occurs between the ages of 40-60 years. If fibrodys­plastic cases are excluded, there is an equal incidence in males and females. [3],[4],[5],[6],[7] Renal artery aneurysms are bilateral in 10% of cases. [2],[4] Approximately 75% of the renal artery aneu­rysms are saccular and almost invariably occur at the main renal artery bifurcation. [3]

Stanley and colleagues have suggested that the aneurysms are probably due to either atherosclerosis or a congenital defect. [5],[8] Fusiform aneurysms are generally less than 2 cm in diameter and usually affect the main renal artery trunk. [6] Arterial fibrodysplasia is often a direct contributor to the development of aneurysm. [5],[8] Fewer than 10% of renal artery aneurysm are intra-parenchymal. 8 Intrarenal aneurysm can occur with polyarteritis nodosa and are usually in the renal cortex. [9]

The vast majority of renal artery aneurysms is asymptomatic and discovered during imaging studies. Renal artery aneurysms may cause renovascular hypertension by; a) distal emboli­zation with segmental hypoperfusion and renin-mediated vasoconstriction, b) fluid retention or c) compression of an adjacent renal artery branch or luminal stenosis due to extensive thrombus leading to renin-mediated hypertension. In a series of 39 patients with renal artery aneurysms, 33 had HTN of whom nine (23%) proved to have a reno­vascular origin. [4]

The most dreaded complication of renal artery aneurysm is rupture. Probably, fewer than 3% of renal artery aneurysms rupture. [5],[8] This complication is associated with a mortality rate of approximateli 10% in males and non­pregnant females. [1] Most authorities agree that pregnancy is associated with a significantly increased risk of rupture of renal artery aneurysm. [5],[8],[11] Pregnancy may increase the risk of rupture because of the prevailing hyper­dynamic state with increased blood volume and cardiac output, hormonal influences on the aneurysm and/or increased intra-abdominal pressure due to gravid uterus. [4],[8]

Cohen and Shamash reported 18 cases of rupture during pregnancy. [11] In a review of 43 ruptured renal artery aneurysms, 35 (81%) occurred in women of whom 18 were preg­nant. [12] Rupture of renal artery aneurysms in pregnancy has been associated with a maternal mortality rate of 55% and a fetal death rate of 85%. [5],[11]

Intrarenal aneurysm may rupture into calyces causing hematuria and sometimes severe flank pain. Rarely renal artery aneurysms may cause obstruction of the collecting systems; a 9 cm renal artery aneurysm has been docu­mented to cause hydronephrosis. [13]

Treatment options for renal artery aneuryem include operative or endovascular emboli­zation using detachable coil or balloons. Indications for treatment include:

a) rupture

b) renovascular HTN

c) embolization

d) dissection

e) aneurysm expansion

f) size >= 1.5 cm to >= 2.5 cm [7],[14],[15]

g) women who are pregnant or of child bearing age 15.

Dean [15] has suggested renal artery aneurysm repair with termination of pregnancy during the first trimester, but when aneurysm is discovered late in the gestation, watchful waiting is indicated.

Usual surgical procedures performed include aneurysmectomy and vein patch angioplasty or aorto-renal bypass. In endovascular treatment, aneurysms can be treated with transcatheter embolization using detachable platinum coils which occlude the aneurysm but maintain the renal blood flow. The largest series has been reported by Klein and co workers who treated 12 renal artery aneurysms with selective coil embolization. [16] Follow-up angiograms performed up to two years post­treatment on these patients, showed successful occlusion of all aneurysms except one, which was successfully treated by repeat coil emboli­zation. Two patients had complications. One had small asymptomatic renal infarction. In the other patient, the coil was misembolized with no adverse clinical outcome.

The patient in this report had a renal artery aneurysm sized 6 mm x 1.5 mm and had a relatively benign course despite loss to follow up, two pregnancies, and less than optimal blood pressure control. This contrasts with the reported high incidence of ruptured renal artery aneurysms during pregnancy with the associated significantly high maternal and fetal mortality. However, we agree that inter­vention should have been done when the aneurysm was found on the first angiogram, especially as the patient was hypertensive and of child bearing age. No clear association has been reported between aneurysms in the renal artery and intracranial arteries although it can be postulated that both may occur as a result of arteriosclerosis or secondary to the presence of congenital medial degenerative process with weakness of the elastic lamina of the blood vessels.

In conclusion, endovascular treatment is a safe and less invasive option for the treat­ment of renal artery aneurysms.

 
   References Top

1.Erdsman G. Angionephrography and suprarenal angiography. Acta Radiol 1957;155 (Suppl): 104.  Back to cited text no. 1    
2.Tham G, Ekelund L, Herrlin K, et al. Renal artery aneurysm: natural history and prognosis. Ann Surg 1983;197:348-52.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Cinat M, Yoon P, Wilson SE. Management of renal artery aneurysm. Semin Vasc Surg 1996;9:236-44.  Back to cited text no. 3  [PUBMED]  
4.Martin RS 3 rd , Meacham PW, Ditesheim JA, et al. Renal artery aneurysm: selective treatment for hypertension and prevention of rupture. J Vasc Surg 1989;9:26-34.  Back to cited text no. 4    
5.Stanley JC. Natural history of renal artery stenosis and aneurysm. In calligaro KD, Dougherty MJ, Dean RH (eds). Modern management of renovascular HTN and renal salvage, Baltimore, William and Wilkins, 1996.  Back to cited text no. 5    
6.Fry WF: renal artery aneurysm. In Ernst CB, Stanley JC (eds): current therapy in vascular surgery. Philadelphia, BC Decker, 1987; p 363.  Back to cited text no. 6    
7.Lumsden AB, Salam TA, Walton KG. Renal artery aneurysm: a report of 28 cases. Cardiovascular Surg 1996;4:185-9.  Back to cited text no. 7    
8.Stanley JC, Rhodes EL, Gewertz BL, Chag CY, Walter JF, Fry WJ. Renal artery aneurysms: significance of macroaneurysms exclusive of dissections and fibrodysplastic mural dilatations. Arch Surg 1975;110: 1327-33.  Back to cited text no. 8    
9.Hekali P, Kivisaari L, Standerskjold­Nordenstam GG, Pajari R, Turto H. Renal complications of polyarteritis nodosa: CT findings. J Comput Assist Tomogr 1985;9:333-8.  Back to cited text no. 9    
10.Hageman JH, Smith RF, Szilagyi E, Elliott JP. Aneurysms of the renal artery: problems of prognosis and surgical management. Surgery 1978;84:563-72.  Back to cited text no. 10  [PUBMED]  
11.Cohen JR, Shamash FS. Ruptured renal artery aneurysms during pregnancy. J Vasc Surg 1987;6:51-9.  Back to cited text no. 11  [PUBMED]  
12.Hidai H, Kinoshita Y, Murayama T, et al. Rupture of renal artery aneurysm. Eur Urol 1985;1:249-53.  Back to cited text no. 12    
13.Bernhardt J, Zwicker C, Hering M, et al. A major renal artery aneurysm as the cause of a hydronephrosis with renovascular hypertension. Urol Int 1996;57:237-9.  Back to cited text no. 13    
14.Dzsinich C, Gloviczki P, Mckusick MA, et al. Surgical management of renal artery aneurysm. Cardiovascular Surg 1993;1:243-7.  Back to cited text no. 14    
15.Dean RH. Renal artery aneurysm. In Yao JST, Pearce WH, eds: Aneurysm: new findings and treatment. Norwalk, Conn, 1994 Appleton and Lange, pp 439-449.  Back to cited text no. 15    
16.Klein GE, Szolar DH, Breinl E, et al. Endovascular treatment of renal artery aneurysms with conventional non­detachable microcoils and guglielmi detachable coils. Br J Urol 1997;79:852-60.  Back to cited text no. 16  [PUBMED]  

Top
Correspondence Address:
Hammad Raza
Nephrology, Hypertension and Renal Transplant Division-1531, Department of Medicine, King Fahad National Guard Hospital, P.O. Box 22490, Riyadh 11426
Saudi Arabia
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PMID: 18202486

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

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