1979, British Journal of Radiology, 52, 752-754 Case reports
Renal artery originating from the inferior mesenteric artery By J. Tisnado, M.D., M. A. Amendola, M.D. and M. C. Beachley, M.D. Department of Radiology, Virginia Commonwealth University/Medical College of Virginia, Richmond, Virginia23298, USA (Received December 1978)
The arterial supply to the kidneys is variable. Many papers have been written dealing with the blood supply to normal and congenitally abnormal kidneys (Anson et al., 1936; Graves, 1956; Merklin and Michels, 1958; Olsson and Wholey, 1964). Variations in the number of renal arteries are very frequent and, indeed, a single renal artery may be present in only 33% of normal subjects (Anson et al., 1936; Gillaspie et al., 1916). The origin of accessory renal arteries may be from the aorta or from other vessels. The latter variation has been infrequently mentioned in the anatomic or radiologic literature (Anson et al., 1936; Gillaspie et al., 1916; Merklin and Michels, 1958). In this paper, we report an extremely rare anomaly in which a renal artery originated from the inferior mesenteric artery in a normally-positioned kidney. We believe that this is the first time such an anomaly has been demonstrated by selective arteriography.
very few occasions, mostly in the anatomic literature. Anson et al. (1936) in an anatomic study of the blood supply to about 400 kidneys mentions that arteries to ectopic kidneys "may originate from the inferior mesenteric artery", but he does not provide illustrations for such findings. Also he does not state if the arteries originating from the inferior mesenteric artery are to the upper, middle, or lower portions of the kidneys. Gillaspie et al., (1916) describe a case of an upper pole artery originating from the coeliac axis which was seen during anatomic
CASE REPORT
A 22-year-old white male was admitted for evaluation of hypertension discovered during a routine physical examination. Except for the elevated blood pressure of 160/130 mm Hg, the physical examination was entirely within normal limits. Workup at our institution included routine laboratory investigations which showed no abnormalities. An intravenous pyelogram was obtained which revealed smooth enlargement and rounding of the lower pole of the left kidney (Fig. 1). Abdominal aortography and selective renal arteriography, as well as sampling of renal veins for renin assay, were then performed to rule out the possibility of renovascular hypertension. The aortogram revealed that the right kidney was supplied by two arteries originating from the aorta at the level of T12-L1. The left kidney was also supplied by two arteries. The main one originated opposite to the right renal arteries and the "plump" lower pole was supplied by a rather large branch originating from the inferior mesenteric artery (Fig. 2). This was confirmed by selective inferior mesenteric arteriography (Fig. 3). No renovascular cause for his hypertension was found and the patient was discharged. DISCUSSION
Aortic origin of renal arteries from as high as the level of T11 has been reported (Doppman, 1967). Renal arteries originating from the distal aorta, or the common iliac or hypogastric arteries, are frequent in malrotated, ectopic and congenitally abnormal kidneys. Renal arteries originating from visceral branches of the aorta have been described on only a
FIG. 1. Excretory urogram reveals slight enlargement of the lower pole of the left kidney (arrows).
752
SEPTEMBER
1979
Case reports
FIG. 2. Midstream aortogram. There are two arteries to each kidney. On the right, they are of similar calibre and arise close to each other at the level of T12-L1. On the left, the main artery (arrow) originates from the aorta opposite to the upper right artery. The accessory lower pole artery (curved arrow) originates from the inferior mesenteric artery (open arrow). Incidentally, the right hepatic artery arises from the superior mesenteric artery.
dissection, but again there are no illustrations. One case of an upper pole artery arising from the superior mesenteric artery was described by Merklin and Michels (1958) in their excellent review of the variants of the renal arteries, based upon the dissection of 185 kidneys and from a review of the literature including reports on the blood supply to about 11,000 kidneys. Blood supply to the lower poles of both kidneys from a common trunk originating from the aorta and bifurcating to supply both kidneys was reported by Levine (1970). Two single cases of renal arteries supplying normally located kidneys, originating from the contralateral renal artery, have been reported (Jeffery, 1972; Libshitz et ah, 1972). Contralateral supply in cases of horseshoe, "dumbbell", or crossed ectopic kidneys have been reported with relative frequency (Olsson and Wholey, 1964). In the case reported herein, the supply to the lower pole of the left kidney originated from the inferior mesenteric artery. This is an extremely rare anomaly. No similar case has ever been reported in the angiographic literature. In the reports of Gillaspie et al (1916) and Merklin and Michels (1958), the anomalous arteries originated from the superior rather than the inferior mesenteric artery and supplied the upper pole of the kidney rather than the lower pole. The kidneys develop through three stages: pronephros, mesonephros and metanephros. They originate in the pelvis and ascend upward and
FIG. 3. Inferior mesenteric arteriogram (arrowhead) demonstrates a large branch supplying the lower pole of the left kidney and the left colic artery (arrow)
rotate to occupy the lumbar region. At the mesonephric stage, the kidneys acquire their blood supply from branches of the aorta originating from the level of the second cervical to the second lumbar segments. There are from 20-30 segmental mesonephric arteries on each side constituting the rete arteriosum urogenitale (Gillaspie et al., 1916; Graves, 1956). As the mesonephros degenerate and the metanephros develops, only the more caudal mesonephric vessels remain. Early in embryological development, the inferior mesenteric artery originates from the aorta by several roots, many of which are anastomosed with or constitute part of the rete arteriosum urogenitale (Bremer, 1915). Multiple renal arteries thus represent persistence of mesonephric vessels. Renal branches originating from the iliac, inferior mesenteric or middle sacral arteries, or distal aorta, represent persistence of the more caudal branches of the vascular network supplying the kidneys (Anson et al, 1936; Bremer, 1915; Graves, 1956). This network is so complex that it is not surprising that
753
1979, British Journal of Radiology, 52, 754-755 Case reports accessory renal arteries are, in general, fairly common. It is difficult to explain, however, why the anomaly being reported is so rare. Recognition of this anomaly is of obvious clinical importance to the surgeon. ACKNOWLEDGMENT
The authors would like to express their gratitude to Mr. Everett Tompkins for his expert secretarial assistance in the preparation of this manuscript.
GILLASPIE,
MILLER, L.
I. and
BASKIN, M.,
LIBSHITZ, H., BEN-MENACHEM, Y. and KURODA, K.,
ANSON, B. J., RICHARDSON, G. A. and MINEAR, W. L., 1936.
renal and suprarenal blood supply with data on the inferior phrenic, ureteral and gonadal arteries. Journal of the International College of Surgeons, 29, 41-76. OLSSON, O. and WHOLEY, M., 1964. Vascular abnormalities
in gross anomalies of kidneys. Acta Radiologica (Diagnosis), 2, 420-432.
By E. A. Schneider, M.D., M. Eisner, M.D. and R. Fridrich, M.D. Department of Nuclear Medicine, Kantonsspital Basel, Switzerland. (Received December 1978)
••: '•;
CASE REPORT
A 77-year-old white female with known chronic active hepatitis was referred for liver studies. A sulphur colloid scintigram showed a shift in spleen/liver ratio and slight ': enlargement of the left lobe of liver. There was a focus of decreased uptake of colloid in the right lobe compatible with a hepatoma (Fig. 1). Hepatobiliary scintigraphy with 9 9Tc m HIDA, however, showed a region of increased uptake corresponding with the area of decreased uptake of colloid suggesting that the focus was filled with bile (Fig. 2). An intravenous cholecystogram (Fig. 3) confirmed the intrahepatic location of the gall-bladder.
FIG. 1. Colloid scintigraphy of the liver 1 5 minutes after intravenous m injection of 1 mCi "Tc -S-colloid. Focal decreased uptake in the right lobe.
754
1972.
MERKLIN, R. J. and MICHELS, N. A., 1958. The variant
Scintlgraphic demonstration of an intrahepatic gall-bladder presenting as a focal liver lesion
When a conventional liver scintigram shows a localized intrahepatic defect, additional scintigraphy with "Tc m -diethyl-acetanilid-iminodiacetate (HID A) can help to distinguish lesions caused by dilated bile ducts and gall-bladder impressions from parenchymal lesions. The present case is an example of an intrahepatic gall-bladder (Swart, 1976) presenting as a defect of colloid uptake in the right lobe of liver (Chang, 1976; Blanton et al, 1974).
1916.
Unusual renal vascular supply. British Journal of Radiology, 45, 536-538.
REFERENCES Variations in the number and arrangement of the renal vessels. Journal of Urology, 36, 211-219. BREMER, J. L., 1915. The origin of the renal artery in mammals and its anomalies. American Journal of Anatomy, 75,179-200. DOPPMAN, J., 1967. An ectopic renal artery. British Journal of Radiology, 40, 312-313.
C,
Anomalous renal vessels and their surgical significance. Anatomical Record, 11, 77-86. GRAVES, F. T., 1956. The aberrant renal artery. Journal of Anatomy, 90, 553-558. JEFFERY, R. E., 1972. Unusual origins of renal arteries. Radiology, 102, 309-310. LEVINE, N. D., 1970 An unusual renal artery anomaly: common origins of arteries to lower poles. British Journal of Radiology, 43, 66-67.
Renal artery originating from the inferior mesenteric artery By J. Tisnado, M.D., M. A. Amendola, M.D. and M. C. Beachley, M.D. Department of Radiology, Virginia Commonwealth University/Medical College of Virginia, Richmond, Virginia23298, USA (Received December 1978)
The arterial supply to the kidneys is variable. Many papers have been written dealing with the blood supply to normal and congenitally abnormal kidneys (Anson et al., 1936; Graves, 1956; Merklin and Michels, 1958; Olsson and Wholey, 1964). Variations in the number of renal arteries are very frequent and, indeed, a single renal artery may be present in only 33% of normal subjects (Anson et al., 1936; Gillaspie et al., 1916). The origin of accessory renal arteries may be from the aorta or from other vessels. The latter variation has been infrequently mentioned in the anatomic or radiologic literature (Anson et al., 1936; Gillaspie et al., 1916; Merklin and Michels, 1958). In this paper, we report an extremely rare anomaly in which a renal artery originated from the inferior mesenteric artery in a normally-positioned kidney. We believe that this is the first time such an anomaly has been demonstrated by selective arteriography.
very few occasions, mostly in the anatomic literature. Anson et al. (1936) in an anatomic study of the blood supply to about 400 kidneys mentions that arteries to ectopic kidneys "may originate from the inferior mesenteric artery", but he does not provide illustrations for such findings. Also he does not state if the arteries originating from the inferior mesenteric artery are to the upper, middle, or lower portions of the kidneys. Gillaspie et al., (1916) describe a case of an upper pole artery originating from the coeliac axis which was seen during anatomic
CASE REPORT
A 22-year-old white male was admitted for evaluation of hypertension discovered during a routine physical examination. Except for the elevated blood pressure of 160/130 mm Hg, the physical examination was entirely within normal limits. Workup at our institution included routine laboratory investigations which showed no abnormalities. An intravenous pyelogram was obtained which revealed smooth enlargement and rounding of the lower pole of the left kidney (Fig. 1). Abdominal aortography and selective renal arteriography, as well as sampling of renal veins for renin assay, were then performed to rule out the possibility of renovascular hypertension. The aortogram revealed that the right kidney was supplied by two arteries originating from the aorta at the level of T12-L1. The left kidney was also supplied by two arteries. The main one originated opposite to the right renal arteries and the "plump" lower pole was supplied by a rather large branch originating from the inferior mesenteric artery (Fig. 2). This was confirmed by selective inferior mesenteric arteriography (Fig. 3). No renovascular cause for his hypertension was found and the patient was discharged. DISCUSSION
Aortic origin of renal arteries from as high as the level of T11 has been reported (Doppman, 1967). Renal arteries originating from the distal aorta, or the common iliac or hypogastric arteries, are frequent in malrotated, ectopic and congenitally abnormal kidneys. Renal arteries originating from visceral branches of the aorta have been described on only a
FIG. 1. Excretory urogram reveals slight enlargement of the lower pole of the left kidney (arrows).
752
SEPTEMBER
1979
Case reports
FIG. 2. Midstream aortogram. There are two arteries to each kidney. On the right, they are of similar calibre and arise close to each other at the level of T12-L1. On the left, the main artery (arrow) originates from the aorta opposite to the upper right artery. The accessory lower pole artery (curved arrow) originates from the inferior mesenteric artery (open arrow). Incidentally, the right hepatic artery arises from the superior mesenteric artery.
dissection, but again there are no illustrations. One case of an upper pole artery arising from the superior mesenteric artery was described by Merklin and Michels (1958) in their excellent review of the variants of the renal arteries, based upon the dissection of 185 kidneys and from a review of the literature including reports on the blood supply to about 11,000 kidneys. Blood supply to the lower poles of both kidneys from a common trunk originating from the aorta and bifurcating to supply both kidneys was reported by Levine (1970). Two single cases of renal arteries supplying normally located kidneys, originating from the contralateral renal artery, have been reported (Jeffery, 1972; Libshitz et ah, 1972). Contralateral supply in cases of horseshoe, "dumbbell", or crossed ectopic kidneys have been reported with relative frequency (Olsson and Wholey, 1964). In the case reported herein, the supply to the lower pole of the left kidney originated from the inferior mesenteric artery. This is an extremely rare anomaly. No similar case has ever been reported in the angiographic literature. In the reports of Gillaspie et al (1916) and Merklin and Michels (1958), the anomalous arteries originated from the superior rather than the inferior mesenteric artery and supplied the upper pole of the kidney rather than the lower pole. The kidneys develop through three stages: pronephros, mesonephros and metanephros. They originate in the pelvis and ascend upward and
FIG. 3. Inferior mesenteric arteriogram (arrowhead) demonstrates a large branch supplying the lower pole of the left kidney and the left colic artery (arrow)
rotate to occupy the lumbar region. At the mesonephric stage, the kidneys acquire their blood supply from branches of the aorta originating from the level of the second cervical to the second lumbar segments. There are from 20-30 segmental mesonephric arteries on each side constituting the rete arteriosum urogenitale (Gillaspie et al., 1916; Graves, 1956). As the mesonephros degenerate and the metanephros develops, only the more caudal mesonephric vessels remain. Early in embryological development, the inferior mesenteric artery originates from the aorta by several roots, many of which are anastomosed with or constitute part of the rete arteriosum urogenitale (Bremer, 1915). Multiple renal arteries thus represent persistence of mesonephric vessels. Renal branches originating from the iliac, inferior mesenteric or middle sacral arteries, or distal aorta, represent persistence of the more caudal branches of the vascular network supplying the kidneys (Anson et al, 1936; Bremer, 1915; Graves, 1956). This network is so complex that it is not surprising that
753
1979, British Journal of Radiology, 52, 754-755 Case reports accessory renal arteries are, in general, fairly common. It is difficult to explain, however, why the anomaly being reported is so rare. Recognition of this anomaly is of obvious clinical importance to the surgeon. ACKNOWLEDGMENT
The authors would like to express their gratitude to Mr. Everett Tompkins for his expert secretarial assistance in the preparation of this manuscript.
GILLASPIE,
MILLER, L.
I. and
BASKIN, M.,
LIBSHITZ, H., BEN-MENACHEM, Y. and KURODA, K.,
ANSON, B. J., RICHARDSON, G. A. and MINEAR, W. L., 1936.
renal and suprarenal blood supply with data on the inferior phrenic, ureteral and gonadal arteries. Journal of the International College of Surgeons, 29, 41-76. OLSSON, O. and WHOLEY, M., 1964. Vascular abnormalities
in gross anomalies of kidneys. Acta Radiologica (Diagnosis), 2, 420-432.
By E. A. Schneider, M.D., M. Eisner, M.D. and R. Fridrich, M.D. Department of Nuclear Medicine, Kantonsspital Basel, Switzerland. (Received December 1978)
••: '•;
CASE REPORT
A 77-year-old white female with known chronic active hepatitis was referred for liver studies. A sulphur colloid scintigram showed a shift in spleen/liver ratio and slight ': enlargement of the left lobe of liver. There was a focus of decreased uptake of colloid in the right lobe compatible with a hepatoma (Fig. 1). Hepatobiliary scintigraphy with 9 9Tc m HIDA, however, showed a region of increased uptake corresponding with the area of decreased uptake of colloid suggesting that the focus was filled with bile (Fig. 2). An intravenous cholecystogram (Fig. 3) confirmed the intrahepatic location of the gall-bladder.
FIG. 1. Colloid scintigraphy of the liver 1 5 minutes after intravenous m injection of 1 mCi "Tc -S-colloid. Focal decreased uptake in the right lobe.
754
1972.
MERKLIN, R. J. and MICHELS, N. A., 1958. The variant
Scintlgraphic demonstration of an intrahepatic gall-bladder presenting as a focal liver lesion
When a conventional liver scintigram shows a localized intrahepatic defect, additional scintigraphy with "Tc m -diethyl-acetanilid-iminodiacetate (HID A) can help to distinguish lesions caused by dilated bile ducts and gall-bladder impressions from parenchymal lesions. The present case is an example of an intrahepatic gall-bladder (Swart, 1976) presenting as a defect of colloid uptake in the right lobe of liver (Chang, 1976; Blanton et al, 1974).
1916.
Unusual renal vascular supply. British Journal of Radiology, 45, 536-538.
REFERENCES Variations in the number and arrangement of the renal vessels. Journal of Urology, 36, 211-219. BREMER, J. L., 1915. The origin of the renal artery in mammals and its anomalies. American Journal of Anatomy, 75,179-200. DOPPMAN, J., 1967. An ectopic renal artery. British Journal of Radiology, 40, 312-313.
C,
Anomalous renal vessels and their surgical significance. Anatomical Record, 11, 77-86. GRAVES, F. T., 1956. The aberrant renal artery. Journal of Anatomy, 90, 553-558. JEFFERY, R. E., 1972. Unusual origins of renal arteries. Radiology, 102, 309-310. LEVINE, N. D., 1970 An unusual renal artery anomaly: common origins of arteries to lower poles. British Journal of Radiology, 43, 66-67.
