Dissecting aneurysm of renal artery. Reversible cause of high-renin hypertension

Spontaneous renal artery dissection: three cases and clinical algorithms

Spontaneous renal artery dissection (SRAD) is rare. Clinical manifestations vary from minimal symptoms to life-threatening hypertension. We analysed three cases from our institution and conducted a literature review in order to design diagnostic and treatment algorithms for SRAD.

Spontaneous dissection of renal artery: long-term results of extracorporeal reconstruction and autotransplantation1

PURPOSE

We undertook this study to assess the outcome of spontaneous dissection of the renal artery and its branches surgically treated with extracorporeal reconstruction and autotransplantation.

SUBJECTS

Between 1975 and 1996, 15 consecutive patients (19 kidneys) with spontaneous renal artery dissection underwent renal artery reconstruction. Fourteen patients had accelerated hypertension. Five patients had impaired renal function. In 14 patients the dissection was associated with fibrodysplasia, and in 1 patient it was related to arteriosclerosis.

INTERVENTION

In 17 kidneys extracorporeal reconstruction and autotransplantation was used. The renal artery of 1 kidney was reconstructed in situ. One primary nephrectomy was performed.

RESULTS

There were no operative deaths or major morbidity. All but 1 reconstruction was successful (94.4%). Results at follow-up (range, 1-8 years) were favorable in 14 patients; 79% had satisfactory blood pressure control, and all patients had normal renal function, including those with impaired renal function preoperatively.

CONCLUSIONS

Extracorporeal reconstruction and autotransplantation can be effectively used in patients with spontaneous renal artery dissection located in or extending into the distal branches. Early recognition and appreciation of the clinical presentation of spontaneous renal artery dissection are important.

Unusual manifestations of renal artery aneurysms

Two unusual cases of renal artery aneurysm are presented. The first, a 10.4-cm aneurysm, the largest yet reported, manifested as an abdominal mass in an otherwise asymptomatic patient. The second was associated with renovascular hypertension in a 6-month-old infant, the youngest patient yet reported.

Surgical treatment for isolated dissection of the renal artery

From 1974 to 1989, 18 patients underwent surgical treatment for isolated dissection of the renal artery causing high grade stenosis, including 2 patients with bilateral renal involvement. The causes of renal artery dissection were blunt trauma (1 patient), unsuccessful percutaneous transluminal angioplasty (5) and atherosclerosis (5) or intimal fibroplasia (7) of the renal artery. The most common presenting signs or symptoms of a dissection were hypertension (94%), an abdominal bruit (44%), headache (44%), minimal proteinuria (44%), microscopic hematuria (38%) and flank pain (38%). Renal artery dissection led to segmental or total renal infarction in 8 of 20 involved kidneys (40%). Seventeen patients underwent unilateral surgical revascularization with amelioration of hypertension and preservation of renal function. Three kidneys were lost due to irreversible ischemic damage from an occlusive dissection. Isolated renal artery dissection is an uncommon lesion that can cause hypertension and threaten renal function.

Isolated renal artery dissection secondary to medial degeneration

Renal artery aneurysms can have variable presentations, often resulting in a therapeutic dilemma to the clinician. We review the causes, clinical features, pathological conditions and treatment options for this problem. We report a case of a thrombus in 1 of 2 left renal arteries, which resulted in uncontrollable hypertension. At nephrectomy the angiographically normal vessel had medial degeneration, demonstrating the diffuse nature of this disease. Conservative renal-sparing management should be considered whenever possible.