RENALARTERYANEURYSMS MUHAMMAD A. BULBUL, M.D. GRANT A. FARROW, M.D.
From the Division of Urology, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada ABSTRACT-Renal artery aneurysms, previously considered to be rare, have been diagnosed more frequently in recent years mainly due to the extensive use of angiography. Fifty-six patients with 67 aneurysms were evaluated, 5 of these were dissecting aneurysms. Most cases were manifestations of medial hyperplasia or atherosclerosis of the renal arteries. Symptomatology is not pathognomanic. Expanding aneuysm, intractable hypertension, hematuria, and renal infarction represent the most common indications for surgical repair. Reconstruction and repair of these aneurysms, with preservation of the kidney, is the preferred treatment. Surgery was performed on 17 patients (30 %): 14 patients had primay repail; while 3 patients underwent nephrectomy for associated carcinoma and end-stage kidney disease. Temporay occlusion of the renal artery with hypothermic perfusion allows surgical repair safely to both patient and kidney. Autotransplantation into the ipsilateral iliac fossa was employed for dissecting aneuysms after resection and repair of the diseased segment. Nine of 12 hypertensive patients required no treatment for hypertension following aneuysmal repaiq while 3 patients had improved control.
Increased interest in aneurysms involving the renal artery and its branches has occurred during the past two decades. Several reports were published and more patients added to the 304 patients reported by 1966.1-3 The incidence of renal artery aneurysms varies between 0.01 and 1 percent. In some series 1 of 112 patients with hypertension had renal artery aneurysms4y5
A total of 56 patients documented to have 67 aneurysms were reviewed: 34 males (60 % ), and 22 females (40 % ). Ages ranged between twenty and seventy-five years, with a mean of sixtythree years. Clinical presentation included hypertension in 31 patients (55%), hematuria in 18 (30 %), and flank pain in 12 (21%); 6 patients (11% ) complained of headache and all were hypertensive. One patient presented with gastrointestinal bleeding, 1 with polyarteritis, and 1 with renal failure. The only rupture seen was in a pregnant woman. There were 62 ex-
trarenal aneurysms (92.5%) and 5 intrarenal aneurysms. Forty-seven aneurysms were saccular (70%), 15 (22.5%) were fusiform, and 5 (7.5%) were dissecting, 3 of which were iatrogenie secondary to catheterization. Thirty-eight aneurysms were less than 1 cm in diameter, 17 were 1-2 cm in diameter, and 7 were greater than 2 cm in diameter. Fifty-nine aneurysms were noncalcified (88%) while 8 (12%) were calcified, underlying the importance of angiography in diagnosis rather than relying on calcifications seen on xray film. Twelve patients (20 % ) had medial hyperplasia of the renal arteries, 2 of which were bilateral. Three patients had cystic disease while 2 had associated carcinoma. Seven patients had associated abdominal aneurysms: 4 aortic, 2 splenic, and 1 gastroduodenal. Seventeen patients (30 % ) were treated surgically with indications being: hypertension, hematuria, associated lesions, size, pain, and rupture in a pregnant woman. Ten patients had excision of the aneurysm and primary repair of
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UROLOGY
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the artery, 5 of these had noncalcified aneurysms greater than 2 cm in diameter. One patient had a large bilobar aneurysm consisting of a false aneurysm secondary to rupture of a calcified aneurysm. Hypothermic in situ perfusion was employed in all cases. Nephrectomy had to be done in 3 patients because of associated disease: 2 with carcinoma and 1 with end-stage kidney disease. Four dissecting aneurysms were resected and the kidney autotransplanted into the ipsilateral iliac fossa. Results No renal units were lost following repair as confirmed by intravenous pyelograms (IVP) and renal scans. Eighteen hypertensive patients with aneurysms less than 1 cm in diameter treated with antihypertensive medications did not show any serious complications over a period of ten years. Nine hypertensive patients required no pharmacologic treatment postoperatively. Three hypertensive patients with severe associated vascular disease had improved control requiring lower doses of antihypertensive medications after surgery. One patient with a dissecting aneurysm, following transluminal angioplasty, treated by autotransplantation continued to be hypertensive despite excellent blood flow to the kidney on renal scan. The ruptured aneurysm in the pregnant woman was repaired primarily with preservation of normal kidney, mother, and fetus. Hematuria ceased in both medically and surgically treated patients. One patient with polyarteritis nodosa and another with necrotizing angiitis died despite aggressive medical treatment. Patients with aneurysms less than 1 cm in diameter were treated conservatively. Comment Renal artery aneurysms are more frequently diagnosed with improved imaging techniques. Poutasse’ classified aneurysms involving the renal artery into four types: saccular, fusiform, dissecting, and mixed, including microaneurysms. In our series, 70 percent were saccular, 22.5 percent fusiform, and 7.5 percent dissecting; 12 percent were calcified while other series reported calcifications up to 40 percent.2z3s5,6 Abnormal findings on IVP are seen in up to 60 percent of the cases and can suggest the possibility of a vascular lesion, but angiography confirms the diagnosis .‘s8No pathognomonic signs and symptoms accompany renal artery aneu-
UROLOGY
/ AUGUST1992
I VOLUME40,NUMBER2
rysms.‘J Hypertension continues to be the most common presentation (55 % ) in our series and in up to 75 percent in others, presumably secondary to renal ischemia. 5~10-12 Hematuria, either gross or microscopic, occurred in 30 percent of our cases and is attributed to be secondary to hypertension, thrombosis of small vessels, and microinfarcts Hypertension, hematuria, pain, size, and pregnancy are indications for surgery. l”~13~14 Although some investigators have reported a 25 percent incidence of rupture, review of thousands of angiograms and autopsy series confirms the rarity of spontaneous rupture for small aneurysms (less than 1 cm).13-19In our series only one rupture was seen in a pregnant woman. The size of the aneurysm seems to be an important factor, and most reports agree that aneurysms greater than 1 cm in diameter whether calcified or not should be treated surgically. ‘s8 We had 1 case of double aneurysm in which the noncalcified component represented a false aneurysm secondary to concealed rupture of the calcified component. Most series (9 of 14 in our series) report successful control of The high incihypertension with surgery. l 1~12-20 dence of rupture (80 % ) makes surgery an absolute indication in pregnant patients or those wishing child bearing.5t8B21-24 Extrarenal saccular or fusiform aneurysms are best treated by primary repair. Many modalities have been suggested for repair: resection of aneurysm and primary repair, end-toend anastomosis, vein graft, reimplantation of artery into aorta, use of prosthetic grafts, and splenorenal anastomosis.25~2s All of our patients were treated by excision of aneurysm and repair of the artery without resection or grafting. Repair was done following clamping of the renal artery and hypothermic perfusion of the kidney. Dissecting aneurysms of the renal artery can be classified etiologically as traumatic, spontaneous, and secondary to catheterization.27 There is a tear in the intima with subsequent dissection resulting in fibrosis and varying degrees of occlusion. 28 Patients usually present with sudden flank pain and hypertension.29 Spontaneous dissection is usually associated with pre-existing arterial disease, namely medial hyperplasia, aneurysms, and atherosclerosis.27 Dissection secondary to catheterization is increasing with the widespread application of angiography and transluminal angioplasty for treatment of renal artery stenosis. In our series three were secondary to catheterization; one of
125
1. Poutasse EF: Renal artery aneurysms: their natural history and surgery, J Urol 95: 297 (1966). 2. Mercier C, Piquet R Piligian F, and Ferdani M: Aneurysms of the renal artery and its branches, Ann Vast Surg 1: 321 (1986). 3. Ruberti U, et al: Aneurysms of the renal artery, Int Angiol6: 407 (1987). 4. Charron J: Renal artery aneurysm: polyaneurysmal lesion of kidney, Urology 5: 1 (1975). 5. Cerny JC: Renal artery aneurysms, Arch Surg 96: 653 (1968). 6. Barry WS: Renal artery aneurysms, Am J Roentgen01 Radium Ther Nucl Med 98: 132 (1966). 7. Glass PM: Aneurysms of the renal artery: a study of 20 cases, J Urol 98: 285 (1967). 8. Ortenberg J, Novick AC, Straffon RA, and Stewart BH: Surgical treatment of renal artery aneurysms, Br J Urol 55: 341 (1983).
9. Rhodes JF: Renal artery aneurysm, J Urol 105: 155 (1971). 10. Nordus 0: Surgical treatment of renal artery aneurysms, Stand J Thorac Cardiovasc Surg 11: 243 (1977). 11. Martin RS III, et al: Renal artery aneurysm: selective treatment for hypertension and prevention of rupture, J Vast Surg 9: 26 (1989). 12. ‘Youkey JR, et al: Saccular renal artery aneurysm as a cause of hypertension, Surgery 97: 498 (1985). 13. Hidai H, et al: Rupture of renal artery aneurysm, Eur Urol 11: 249 (1985). 14. Henriksson C, Bjorkerud S, Nilson AE, and Pettersson S: Natural history of renal artery aneurysm elucidated by repeated angiography and pathoanatomical studies, Eur Urol 11: 244 (1985). 15. Seppala FE, and Levy J: Renal artery aneurysm: case report of a ruptured calcified renal artery aneurysm, Am Surgeon 48: 42 (1982). 16. Tham G, et al: Renal artery aneurysms, natural history and prognosis, Ann Surg 197: 348 (1983). 17. McCarron JR Marshall VF, and Whitsell JC: Indications for surgery on renal artery aneurysms, J Urol 114: 177 (1975). 18. Hubert JP Pairolero PC, and Kazmier FJ: Solitary renal artery aneurysm, Surgery 84: 391 (1980). 19. Cummings KB, Lecky JW, and Kaufman JJ: Renal artery aneurysms and hypertension, J Urol 109: 144 (1973). 20. Vaughn TJ: Renal artery aneurysms and hypertension, Radiology 99: 287 (1971). 21. Love WK, Robinette MA, and Vernon CP: Renal artery aneurysm rupture in pregnancy, J Urol 126: 809 (1981). 22. Barrett JM, Dean RH, and Boehm FH: Rupture of renal artery aneurysm during pregnancy, South Med J 74: 1549 (1981). 23. Schoiin IM, et al; Rupture of renal arterial aneurysm in pregnancy. Case report, Acta Chir Stand 154: 593 (1988). 24. Cohen JR, and Shamash FS: Ruptured renal artery aneurysms during pregnancy, J Vast Surg 6: 51 (1987). 25. Kyle VN: Renal artery aneurysms, Can Med Assoc J 98: 815 (1968). 26. Dubernard JM, Martin X, Celet A, and Mongin D: Aneurysms of the renal artery: surgical management with special reference to extracorporeal surgery and autotransplantation, Eur Urol 11: 26 (1985). 27. Gewertx BL: Renal artery dissections, Arch Surg 112: 409 (1977). 28. Kaufman JJ, Coulson WF, Lecky J, and Popjik G: Primary dissecting aneurysms of renal artery, Ann Surg 177: 259 (1973). 29. Hare WSC: Dissecting aneurysms of the renal artery, Radiology 97: 255 (1970). 30. Novick AC, Stewart BH, and Straffon RA: Extracorporeal renal surgery and autotransplantation: indications, techniques and results, J Urol 123: 806 (1980). 31. Smith JN: Intrarenal arterial aneurysms, J Urol 97: 990 (1967). 32. Poutasse EF: Renal artery aneurysms, J Urol 113: 443 (1975).
126
UROLOGY
these occurred during transluminal angioplasty. Treatment should be directed to preserve renal tissue. Nephrectomy is acceptable only in cases with atrophic kidney or severe infarcts. Conservative management with antihypertensive drugs and rest was reported to have good results in 3 patients. 2e Extension of dissection with significant occlusion and worsening of hypertension, are indications for surgical correction. Autotransplantation was employed in treating dissecting aneurysms. The aneurysm was resected; the kidney was perfused and cooled, and then transplanted into the ipsilateral iliac fossa. Intrarenal aneurysms represent an interesting entity. In our series, 8 percent were intrarenal mostly microaneurysms. Etiologically they can be congenital, atherosclerotic, traumatic, or secondary to polyarteritis nodosa, syphilis, and tuberculosis.22 Treatment is conservative. Partial or total nephrectomy may be performed if surgery is indicated.5*31,32 200 Elizabeth Street Toronto, Ontario, Canada M5G 2C4 (DR.
BULBUL)
References
/ AUGUST 1992 /
VOLUME 40, NUMBER 2
From the Division of Urology, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada ABSTRACT-Renal artery aneurysms, previously considered to be rare, have been diagnosed more frequently in recent years mainly due to the extensive use of angiography. Fifty-six patients with 67 aneurysms were evaluated, 5 of these were dissecting aneurysms. Most cases were manifestations of medial hyperplasia or atherosclerosis of the renal arteries. Symptomatology is not pathognomanic. Expanding aneuysm, intractable hypertension, hematuria, and renal infarction represent the most common indications for surgical repair. Reconstruction and repair of these aneurysms, with preservation of the kidney, is the preferred treatment. Surgery was performed on 17 patients (30 %): 14 patients had primay repail; while 3 patients underwent nephrectomy for associated carcinoma and end-stage kidney disease. Temporay occlusion of the renal artery with hypothermic perfusion allows surgical repair safely to both patient and kidney. Autotransplantation into the ipsilateral iliac fossa was employed for dissecting aneuysms after resection and repair of the diseased segment. Nine of 12 hypertensive patients required no treatment for hypertension following aneuysmal repaiq while 3 patients had improved control.
Increased interest in aneurysms involving the renal artery and its branches has occurred during the past two decades. Several reports were published and more patients added to the 304 patients reported by 1966.1-3 The incidence of renal artery aneurysms varies between 0.01 and 1 percent. In some series 1 of 112 patients with hypertension had renal artery aneurysms4y5
A total of 56 patients documented to have 67 aneurysms were reviewed: 34 males (60 % ), and 22 females (40 % ). Ages ranged between twenty and seventy-five years, with a mean of sixtythree years. Clinical presentation included hypertension in 31 patients (55%), hematuria in 18 (30 %), and flank pain in 12 (21%); 6 patients (11% ) complained of headache and all were hypertensive. One patient presented with gastrointestinal bleeding, 1 with polyarteritis, and 1 with renal failure. The only rupture seen was in a pregnant woman. There were 62 ex-
trarenal aneurysms (92.5%) and 5 intrarenal aneurysms. Forty-seven aneurysms were saccular (70%), 15 (22.5%) were fusiform, and 5 (7.5%) were dissecting, 3 of which were iatrogenie secondary to catheterization. Thirty-eight aneurysms were less than 1 cm in diameter, 17 were 1-2 cm in diameter, and 7 were greater than 2 cm in diameter. Fifty-nine aneurysms were noncalcified (88%) while 8 (12%) were calcified, underlying the importance of angiography in diagnosis rather than relying on calcifications seen on xray film. Twelve patients (20 % ) had medial hyperplasia of the renal arteries, 2 of which were bilateral. Three patients had cystic disease while 2 had associated carcinoma. Seven patients had associated abdominal aneurysms: 4 aortic, 2 splenic, and 1 gastroduodenal. Seventeen patients (30 % ) were treated surgically with indications being: hypertension, hematuria, associated lesions, size, pain, and rupture in a pregnant woman. Ten patients had excision of the aneurysm and primary repair of
124
UROLOGY
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/
AUGUST 1992
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VOLUME 40, NUMBER 2
the artery, 5 of these had noncalcified aneurysms greater than 2 cm in diameter. One patient had a large bilobar aneurysm consisting of a false aneurysm secondary to rupture of a calcified aneurysm. Hypothermic in situ perfusion was employed in all cases. Nephrectomy had to be done in 3 patients because of associated disease: 2 with carcinoma and 1 with end-stage kidney disease. Four dissecting aneurysms were resected and the kidney autotransplanted into the ipsilateral iliac fossa. Results No renal units were lost following repair as confirmed by intravenous pyelograms (IVP) and renal scans. Eighteen hypertensive patients with aneurysms less than 1 cm in diameter treated with antihypertensive medications did not show any serious complications over a period of ten years. Nine hypertensive patients required no pharmacologic treatment postoperatively. Three hypertensive patients with severe associated vascular disease had improved control requiring lower doses of antihypertensive medications after surgery. One patient with a dissecting aneurysm, following transluminal angioplasty, treated by autotransplantation continued to be hypertensive despite excellent blood flow to the kidney on renal scan. The ruptured aneurysm in the pregnant woman was repaired primarily with preservation of normal kidney, mother, and fetus. Hematuria ceased in both medically and surgically treated patients. One patient with polyarteritis nodosa and another with necrotizing angiitis died despite aggressive medical treatment. Patients with aneurysms less than 1 cm in diameter were treated conservatively. Comment Renal artery aneurysms are more frequently diagnosed with improved imaging techniques. Poutasse’ classified aneurysms involving the renal artery into four types: saccular, fusiform, dissecting, and mixed, including microaneurysms. In our series, 70 percent were saccular, 22.5 percent fusiform, and 7.5 percent dissecting; 12 percent were calcified while other series reported calcifications up to 40 percent.2z3s5,6 Abnormal findings on IVP are seen in up to 60 percent of the cases and can suggest the possibility of a vascular lesion, but angiography confirms the diagnosis .‘s8No pathognomonic signs and symptoms accompany renal artery aneu-
UROLOGY
/ AUGUST1992
I VOLUME40,NUMBER2
rysms.‘J Hypertension continues to be the most common presentation (55 % ) in our series and in up to 75 percent in others, presumably secondary to renal ischemia. 5~10-12 Hematuria, either gross or microscopic, occurred in 30 percent of our cases and is attributed to be secondary to hypertension, thrombosis of small vessels, and microinfarcts Hypertension, hematuria, pain, size, and pregnancy are indications for surgery. l”~13~14 Although some investigators have reported a 25 percent incidence of rupture, review of thousands of angiograms and autopsy series confirms the rarity of spontaneous rupture for small aneurysms (less than 1 cm).13-19In our series only one rupture was seen in a pregnant woman. The size of the aneurysm seems to be an important factor, and most reports agree that aneurysms greater than 1 cm in diameter whether calcified or not should be treated surgically. ‘s8 We had 1 case of double aneurysm in which the noncalcified component represented a false aneurysm secondary to concealed rupture of the calcified component. Most series (9 of 14 in our series) report successful control of The high incihypertension with surgery. l 1~12-20 dence of rupture (80 % ) makes surgery an absolute indication in pregnant patients or those wishing child bearing.5t8B21-24 Extrarenal saccular or fusiform aneurysms are best treated by primary repair. Many modalities have been suggested for repair: resection of aneurysm and primary repair, end-toend anastomosis, vein graft, reimplantation of artery into aorta, use of prosthetic grafts, and splenorenal anastomosis.25~2s All of our patients were treated by excision of aneurysm and repair of the artery without resection or grafting. Repair was done following clamping of the renal artery and hypothermic perfusion of the kidney. Dissecting aneurysms of the renal artery can be classified etiologically as traumatic, spontaneous, and secondary to catheterization.27 There is a tear in the intima with subsequent dissection resulting in fibrosis and varying degrees of occlusion. 28 Patients usually present with sudden flank pain and hypertension.29 Spontaneous dissection is usually associated with pre-existing arterial disease, namely medial hyperplasia, aneurysms, and atherosclerosis.27 Dissection secondary to catheterization is increasing with the widespread application of angiography and transluminal angioplasty for treatment of renal artery stenosis. In our series three were secondary to catheterization; one of
125
1. Poutasse EF: Renal artery aneurysms: their natural history and surgery, J Urol 95: 297 (1966). 2. Mercier C, Piquet R Piligian F, and Ferdani M: Aneurysms of the renal artery and its branches, Ann Vast Surg 1: 321 (1986). 3. Ruberti U, et al: Aneurysms of the renal artery, Int Angiol6: 407 (1987). 4. Charron J: Renal artery aneurysm: polyaneurysmal lesion of kidney, Urology 5: 1 (1975). 5. Cerny JC: Renal artery aneurysms, Arch Surg 96: 653 (1968). 6. Barry WS: Renal artery aneurysms, Am J Roentgen01 Radium Ther Nucl Med 98: 132 (1966). 7. Glass PM: Aneurysms of the renal artery: a study of 20 cases, J Urol 98: 285 (1967). 8. Ortenberg J, Novick AC, Straffon RA, and Stewart BH: Surgical treatment of renal artery aneurysms, Br J Urol 55: 341 (1983).
9. Rhodes JF: Renal artery aneurysm, J Urol 105: 155 (1971). 10. Nordus 0: Surgical treatment of renal artery aneurysms, Stand J Thorac Cardiovasc Surg 11: 243 (1977). 11. Martin RS III, et al: Renal artery aneurysm: selective treatment for hypertension and prevention of rupture, J Vast Surg 9: 26 (1989). 12. ‘Youkey JR, et al: Saccular renal artery aneurysm as a cause of hypertension, Surgery 97: 498 (1985). 13. Hidai H, et al: Rupture of renal artery aneurysm, Eur Urol 11: 249 (1985). 14. Henriksson C, Bjorkerud S, Nilson AE, and Pettersson S: Natural history of renal artery aneurysm elucidated by repeated angiography and pathoanatomical studies, Eur Urol 11: 244 (1985). 15. Seppala FE, and Levy J: Renal artery aneurysm: case report of a ruptured calcified renal artery aneurysm, Am Surgeon 48: 42 (1982). 16. Tham G, et al: Renal artery aneurysms, natural history and prognosis, Ann Surg 197: 348 (1983). 17. McCarron JR Marshall VF, and Whitsell JC: Indications for surgery on renal artery aneurysms, J Urol 114: 177 (1975). 18. Hubert JP Pairolero PC, and Kazmier FJ: Solitary renal artery aneurysm, Surgery 84: 391 (1980). 19. Cummings KB, Lecky JW, and Kaufman JJ: Renal artery aneurysms and hypertension, J Urol 109: 144 (1973). 20. Vaughn TJ: Renal artery aneurysms and hypertension, Radiology 99: 287 (1971). 21. Love WK, Robinette MA, and Vernon CP: Renal artery aneurysm rupture in pregnancy, J Urol 126: 809 (1981). 22. Barrett JM, Dean RH, and Boehm FH: Rupture of renal artery aneurysm during pregnancy, South Med J 74: 1549 (1981). 23. Schoiin IM, et al; Rupture of renal arterial aneurysm in pregnancy. Case report, Acta Chir Stand 154: 593 (1988). 24. Cohen JR, and Shamash FS: Ruptured renal artery aneurysms during pregnancy, J Vast Surg 6: 51 (1987). 25. Kyle VN: Renal artery aneurysms, Can Med Assoc J 98: 815 (1968). 26. Dubernard JM, Martin X, Celet A, and Mongin D: Aneurysms of the renal artery: surgical management with special reference to extracorporeal surgery and autotransplantation, Eur Urol 11: 26 (1985). 27. Gewertx BL: Renal artery dissections, Arch Surg 112: 409 (1977). 28. Kaufman JJ, Coulson WF, Lecky J, and Popjik G: Primary dissecting aneurysms of renal artery, Ann Surg 177: 259 (1973). 29. Hare WSC: Dissecting aneurysms of the renal artery, Radiology 97: 255 (1970). 30. Novick AC, Stewart BH, and Straffon RA: Extracorporeal renal surgery and autotransplantation: indications, techniques and results, J Urol 123: 806 (1980). 31. Smith JN: Intrarenal arterial aneurysms, J Urol 97: 990 (1967). 32. Poutasse EF: Renal artery aneurysms, J Urol 113: 443 (1975).
126
UROLOGY
these occurred during transluminal angioplasty. Treatment should be directed to preserve renal tissue. Nephrectomy is acceptable only in cases with atrophic kidney or severe infarcts. Conservative management with antihypertensive drugs and rest was reported to have good results in 3 patients. 2e Extension of dissection with significant occlusion and worsening of hypertension, are indications for surgical correction. Autotransplantation was employed in treating dissecting aneurysms. The aneurysm was resected; the kidney was perfused and cooled, and then transplanted into the ipsilateral iliac fossa. Intrarenal aneurysms represent an interesting entity. In our series, 8 percent were intrarenal mostly microaneurysms. Etiologically they can be congenital, atherosclerotic, traumatic, or secondary to polyarteritis nodosa, syphilis, and tuberculosis.22 Treatment is conservative. Partial or total nephrectomy may be performed if surgery is indicated.5*31,32 200 Elizabeth Street Toronto, Ontario, Canada M5G 2C4 (DR.
BULBUL)
References
/ AUGUST 1992 /
VOLUME 40, NUMBER 2
