sign in sign up
<<
Home , Aneurysm

DUE TO RENAL ANEURYSM

Fuat Sar1, Cigdem Kutlu1, Yesim Kara1, Mehnur Turan1, Faik Cetin1, Omer Sarılar2, Rumeyza Kazancioglu3

Haseki Training and Research Hospital, Departments of Internal Medicine1, Urology2 and Nephrology3, Istanbul, Turkiye The most common pathogenetic lesion associated with renovascular hypertension is . Next in etiologic incidence is arterial fibromuscular hyperplasia. The only other lesion common enough to warrant percentage classification is renal artery aneurysm. Here, we present a case with an aneurysm of the left renal artery following a gunshot wound and its resultant malign hypertension.

Key words: Hypertension, renal artery aneurysm, renovascular.

Eur J Gen Med 2008; 5(4):251-253

INTRODUCTION CASE The most common pathogenetic lesion A 16-year old female patient presented associated with renovascular hypertension to our clinic with severe and is atherosclerosis. Next in etiologic fits. She had sustained hypertension incidence is arterial fibromuscular for the last six months. In 2003, she hyperplasia. The only other lesion underwent an intra-abdominal operation common enough to warrant percentage due to a self-inflicted gunshot to the classification is renal artery aneurysm abdomen. She did not smoke or use any (RAA) (1). Renal artery aneurysms are illicit drug. Physical examination revealed uncommon in vascular pathology with an an abdominal significant bruit below the incidence of 0.01-1%, though the first median incision scar. case was described by Rouppe in 1770 was 210/120 mm Hg. The examination (2). Anatomically it has been recognized of the ocular fundus showed grade that an increase in blood pressure is IV hypertensive retinopathy. Electro- based upon the formation of cardiography had sinus rhythm and limited within the RAA and that the degree of signs of left ventricular hypertrophy. hypertension is related to the degree Laboratory data were as follows: creatinine of occlusion and the diameter of the 106.4 mmol/L, sodium 136 mmol/L, aneurysm (3). Traumatic aneurysm of the potassium 4.3 mmol/L, calcium 2.6 mmol/ abdominal secondary to penetrating L, renin 68.06 ng/(L.s). Computerized are rare (4, 5, 6). A few decades tomography showed a distinct ago, the frequency of aneurysms was aneurismal dilatation in the proximal determined from post-mortem analysis left renal artery (approximately 20 mm and arteriographies performed for the diameter) and accessory artery aneurysm assessment systemic hypertension. (Figure1). Scintigraphy revealed normal Accordingly Tcherdakoff found that 1.3% function of the right while non of patients undergoing arteriography had functional kidney was detected on the RAA (2). left. Renovascular hypertension due to Here, we present a case with an RAA was diagnosed. All other causes of aneurysm of the left renal artery following RAA was discarded. Therefore; abdominal a gunshot wound and its resultant trauma was detected as the possible cause. malignant hypertension resolving after She was referred to the unit and nephrectomy. total left nephrectomy was performed. The Correspondence: Rumeyza Kazancioglu, MD Nefroloji Klinigi Haseki Egitim ve Arastirma Hastanesi Haseki cad. No 29 34304, Haseki Fatih Istanbul Türkiye Phone: 902123430997, Fax: 902123431000 E-mail: [email protected] Hypertension due to renal artery aneurysm 252

Figure 1. Computerized tomography Figure 2. The view of the excised angiography kidney

postoperative course was uneventful and purpose. Some patients have abdominal her blood pressure decreased to 120/80 pain, palpable abdominal mass, subcostal mm Hg. Since then the patient remained or flank pain and hematuria. Almost 90% normotensive without any medication. of symptomatic patients have systemic hypertension (2, 4). Our patient had also DISCUSSION hypertension and abdominal bruit. Clinical Renovascular hypertension is the most characteristics such as age, sex and history common cause of surgically correctable play a little role in traumatic renovascular hypertension (1). Its cause in most hypertension, but the sudden onset and younger individuals is fibromuscular rapid progression of hypertension in a dysplasia (about 40%), and the remainder young previously healthy individual who of renal is due to has suffered an abdominal trauma should atherosclerotic stenoses of the proximal provide an appropriate index of suspicion renal (about 25%). Medial (1). Our patient had an operation due to degeneration, trauma, injury are other gun shot wound of the abdomen. potential causes (4). Arterial aneurysms Direct arterial trauma is usually have been described in the aorta and manifested by either laceration, transaction, several major arteries including the contusion, or spasm. Laceration includes renal arteries. They were associated with incomplete disruption of one or more connective tissue diseases, Kawasaki layers of the wall (5). Evans and Moggs disease, Takayasu disease, cystinosis, suggested that deceleration injury to the sepsis and as left renal artery is more common due to well as neurofibromatosis and tuberous the comparative hypermobility of the left sclerosis (7). In our patient, all of these kidney as compared with the right (6, rare diseases were excluded based on 8). In our patient, renal artery aneurysm clinical, laboratory and imaging findings. was at the left kidney. The phenomenon The incidence of RAA has increased of cured or improved hypertension in in recent years, with the rising number of patients with RAA but without renal artery arteriographic explorations carried out for is hard to explain because the the study of systemic hypertension (2, 3). mechanism that might cause hypertension Many patients with renal artery aneurysm is difficult to show. Macroembolism or are and diagnosed as microembolism from the RAA into the renal an incidental finding on CT scan or parenchyma has been described, which angiography performed for another can cause hypertension even without 253 Sar et al.

additional stenotic lesions of the renal REFERENCES artery. It is also possible that the RAA 1. Ingram JC, Marks C, Gray LW. Surgically induces hemodynamic changes in terms corrected renovascular hypertension of resistance, impedance, or shear stress secondary to traumatic : at the vessel wall caused by turbulence, A human experimental model. Am Surg which may play a still unknown role (9). 1973;39:642-4 Aneurysms may rapidly develop to a 2. Bielsa AA, Rodriguez JP, Castromil RG. large size and may potentially rupture; Extraparenchymal renal artery aneurysms : hence it represents a serious threat Is hypertension an indication for (2). Furthermore, although an effective revascularization surgery? Ann Vasc Surg antihypertensive drug treatment has 2002;16:339-44 been introduced in the recent years, 3. Grossman RE, Babbitt D. Renal artery hypertension still means an indication aneurysms; their diagnosis and endocrine for the operative treatment of RAA (9). In implications: A case report in a child. J Urol the literature, the indication of RAA repair 1967;97:172-5 with regard to the prevention of aneurysm 4. Messina LM, Pak LK, Tierney LM. Blood rupture is almost exclusively discussed in Vessels and Lymphatics. In: Tierney LM, relation to aneurysm size. Although there McPhee SJ, Papadakis MA, ed. Current is no clear correlation between maximal Medical Diagnosis and Treatment. McGraw- aneurysm diameter and the risk of rupture, Hill, USA:2004;432-3 on the basis of clinical experience, the 5. David D, Blumenberg R. Subintimal aortic treatment of RAAs with a diameter of 1.5 with occlusion after blunt - 2 cm is generally recommended (9). abdominal trauma. Arch Surg 1970;100:302-4 The size of our patient’s aneurysm was 6. Payne SR, Snell ME. Traumatic renal artery 2 cm and the patient was transferred to dissection. Urology 1988;31:335-7 the surgery unit. The standard surgical 7. Robitaille P, Lord H, Dubois J, Rypens F, approach for renal artery aneurysms is Oligny LL. A large unilateral renal artery excision with interposition grafting; if aneurysm in a young child. Pediatr Radiol applicable. Infrequently, the aneurysm 2004;34:253-5 extends into the branch vessels and ex 8. Evans A, Mogg RA. Renal artery thrombosis vivo reconstruction may be required. Our due to closed trauma. J Urol 1971;105:330 patient had total nephrectomy since there 9. Pfeiffer T, Reiher T, Grabitz K, et al. was no kidney function. The pathological Reconstruction for renal artery aneurysm: examination of the excised kidney revealed Operative techniques and long-term results. subcapsular and intraparenchymal J Vasc Surg 2003;37:293-300 , double ureters and increased wall thickness (Figure 2). Renal artery aneurysm associated with renovascular hypertension due to abdominal trauma is rare. We emphasize the importance of thorough exploration of retroperitoneum following penetrating trauma in order to prevent future, sustained renal artery damage.