Aberrant Inferior Suprarenal Vessels Crossing Posterior Pararenal Space: a Case Report

Maryna Kornieieva et al., IJCR, 2019 4:86

Case Report IJCR (2019) 4:86

International Journal of Case Reports (ISSN:2572-8776)

Aberrant inferior suprarenal vessels crossing posterior pararenal space: a case report

Maryna Kornieieva, Andrew Vierra, Abdul Razzaq

American University of Caribbean School of Medicine, Lowlands, Sint Maarten

ABSTRACT

During routine educational dissection of a cadaver (63-year-old, *Correspondence to Author: male, USA), an atypical course of the left inferior suprarenal ves- Maryna Kornieieva sels via the posterior pararenal space was discovered. American University of Caribbean Detailed analysis of the abdominal vascular pattern showed that School of Medicine, Lowlands, Sint the atypical inferior suprarenal artery represented a terminal Maarten branch of the left inferior phrenic artery. The last one branched off from the very beginning of the left renal artery, ascended between the fibers of the left crus of the diaphragm, then ran How to cite this article: laterally giving off muscular branches and, finally, descended Maryna Kornieieva, Andrew Vierra, along the costal part of the diaphragm to the left posterior para- Abdul Razzaq. Aberrant inferior renal space. The terminal branch of the inferior phrenic artery suprarenal vessels crossing poste- pierced the retrorenal fascia and entered the perirenal space rior pararenal space: a case report. as an atypical left inferior suprarenal artery. It ran upward and International Journal of Case Re- medially crossing the anterior surface of the kidney to reach and ports, 2019 4:86 supply the lower pole of the left suprarenal gland. The left inferior phrenic vein accompanied the artery taking a similar course. It received numerous tributaries passing via the posterior pararenal space, drained the inferior suprarenal vein, and opened into the left renal vein. Such anomalous pararenal vascular pattern is a challenge for eSciPub LLC, Houston, TX USA. surgeons performing open procedures on retroperitoneal organs, Website: https://escipub.com/ not to mention specialists employing minimally invasive laparoscopic techniques. The anatomical variation reported in this paper requires urgent attention of the related specialists. Keywords: inferior phrenic artery, inferior suprarenal artery, accessory renal vessels, pararenal space.

IJCR: https://escipub.com/international-journal-of-case-reports/ 1 Maryna Kornieieva et al., IJCR, 2019 4:86 Introduction the anterior surface of the kidney is a potentially The abdominal aorta gives off visceral, risky anomaly for the open surgical procedures posterior, and lateral branches to supply the on the adrenal gland, kidney, and ureter via the viscera of the abdominal cavity, posterior wall posterior and posterolateral approaches due to of the abdomen, and the structures of the compromised visualization. Broad retroperitoneal space, respectively. The lateral implementation of the minimally invasive abdominal aortic branches nourishing the surgical technics in this region such as diaphragm and retroperitoneal organs are retroperitoneoscopic adrenalectomy and represented by paired inferior phrenic, middle nephrectomy [2,9] requires a thorough suprarenal, renal, and gonadal arteries. Each of understanding of the range of vascular these arteries may contribute to perfusion of the variability in this region and detailed analysis of adrenal glands giving off superior, middle, and rare anatomical cases like ours. inferior suprarenal branches, thus supporting a Case Report wide range of anatomic variability in this region. During the routine educational dissection of a The previous anatomical studies on the cadaver (63-year-old, male, USA), an atypical variability of the adrenal gland vasculature have course of the left inferior suprarenal vessels via revealed that the superior suprarenal artery the posterior pararenal space associated with branches off from the inferior phrenic artery in the presence of accessory renal vessels was 83.3% of cases; however, it also may be a discovered. direct branch of the aorta [7]. The middle The left inferior phrenic artery, 2.4 mm in suprarenal artery typically originates from the diameter, branched out from the very beginning inferior phrenic artery (77.4%), though, it may of the left renal artery and ascended between also be a branch of the renal artery (12.9), or the fibers of the left crus of the diaphragm, may even take off from the celiac trunk (9.6%) giving off no branches to the suprarenal gland [1]. The inferior suprarenal artery is considered (Figure 1). Initially, it ran laterally supplying the the most important one, as it supplies a large muscle, then descended to the posterior part of the gland. In 70% of cases, it arises from pararenal space along the costal part of the the renal artery, but also may take origin diaphragm, and, finally, pierced the retrorenal directly from the abdominal aorta [1, 6]. The fascia and turned upward and medial, passing origin of the inferior suprarenal artery from the in front of the left kidney toward the lower pole inferior phrenic artery has never been reported of the adrenal gland as an aberrant inferior before. suprarenal artery (Figure 2, 3). The left middle In all cases described in the literature, the and superior suprarenal arteries branched off suprarenal arteries took the shortest course directly from the abdominal aorta via a short from the point of origin to the parenchyma of common suprarenal trunk (Figure 1). The left the gland. In this paper, we report a unique inferior phrenic vein, 7.3 mm in width, aberrant inferior suprarenal artery, which accompanied the aberrant artery through the crossed the posterior pararenal space, pierced posterior pararenal space receiving numerous the retrorenal fascia and reached the inferior tributaries along its course (Figure 2). Entering pole of the adrenal gland passing obliquely the perirenal space, it crossed the anterior upward and medially in front of the left kidney. surface of the kidney passing bellow the The accompanying inferior phrenic vein atypical inferior suprarenal artery, drained the received the inferior suprarenal vein and inferior suprarenal vein, and joined the left renal contributed to the renal vein on the same side vein. The superior and middle parts of the of the body. adrenal gland were drained by a separate The presence of the aberrant vessels crossing vessel, 6.8 mm in diameter, which also IJCR: https://escipub.com/international-journal-of-case-reports/ 2 Maryna Kornieieva et al., IJCR, 2019 4:86 contributed to the left renal vein (Figure 1). which entered the hilum of the kidney, but one Additionally, the content of the hilum of the ended up as an aberrant renal artery and kidney was altered by the presence of an entered the upper pole of the kidney by piercing accessory renal artery arising from the aorta, its substance. The accessory renal artery 1.8 mm below the origin of the proper renal bifurcated into pre-segmental branches, artery on both sides. The proper renal artery entering the lower part of the kidney’s hilum gave off three pre-segmental branches, two of independently.

Diagram 1. Schematically represented early development of the lateral splanchnic arteries (lsa) into the superior suprarenal (ssr), middle suprarenal (msr) and inferior suprarenal (isr) arteries; A - regular branching pattern of the inferior phrenic (IPA) and renal (RA) arteries; B – alternated branching pattern with migration of the isr and ssr sprouts; C – proliferation of the aberrant inferior suprarenal artery (aISR) via the posterior pararenal space (presented case). Other abbreviations: MD – mesonephric duct; UB – ureteric bud; AA – dorsal aorta; AG – adrenal gland; K – kidney. IJCR: https://escipub.com/international-journal-of-case-reports/ 3 Maryna Kornieieva et al., IJCR, 2019 4:86

Figure 1. Cadaver dissection view showing an aberrant inferior suprarenal artery (aISR) crossing the left kidney anteriorly. The atypical inferior phrenic vein (aIPV) follows the artery, receives the tributary from the lower pole of the adrenal gland (black arrow), and contributes to the renal vein (RV) along with the regular suprarenal vein (white arrow). The superior and middle suprarenal arteries (SSR and MSR, respectively) branch off from the abdominal aorta via a common suprarenal trunk (CSRT), while the inferior phrenic artery (IPA) does not give any suprarenal branches at its origin. An accessory renal artery (aRA) appears bellow the renal artery proper (RA); both give off pre-segmental branches approaching the hilum of the kidney (asterisks).

Figure 2. Cadaver dissection view showing the contents of the left posterior pararenal space. The atypical inferior phrenic artery and vein (aIPA, aIPV) descend from the costal part of the diaphragm (CD) and pierce the retrorenal fascia (RRF). Several venous tributaries (arrows) enter the atypical venous vessel in the posterior pararenal space; TF – transversalis fascia.

IJCR: https://escipub.com/international-journal-of-case-reports/ 4 Maryna Kornieieva et al., IJCR, 2019 4:86 aISR

Figure 3. Cadaver dissection exposing the perirenal space, anterior view. The retrorenal fascia (RRF) is pierced by the atypical inferior phrenic vein (aIPV) and aberrant inferior suprarenal artery (aISR); RRF – retrorenal fascia.

On the right side of the body, the arrangement suprarenal artery, the middle one continues to of suprarenal vessels did not show any supply the adrenal gland becoming the middle peculiarities. The inferior phrenic artery gave off suprarenal artery, while the renal artery arises the superior suprarenal artery, the middle from the most caudal one (Diagram 1, A). suprarenal artery branched off from the The formation of the vascular pattern reported abdominal aorta, and the inferior suprarenal in our case implies multiple re-arrangements of one ascended from the right renal artery. the lateral splanchnic arteries, with significant Discussion alteration of their branching pattern. We can The renal vessels start to develop in the assume that the cranial splanchnic artery mesenchyme of the aorta-gonad-mesonephros developed into the inferior phrenic artery, the region in an embryo 2.0 mm length [3]. The rete caudal lateral splanchnic artery became the peri-intestinale surrounding the hindgut renal artery proper, and only the middle one establishes paired connections with the caudal reached the adrenal gland as the typical middle part of the dorsal aorta via the numerous suprarenal artery (Diagram 1, B). The sprouting sproutings, referred to as rami intestinale. of the inferior suprarenal artery from the inferior These rami develop into somatic, ventral phrenic artery, as well as the growing of the splanchnic, and lateral splanchnic arteries superior suprarenal artery from the vascular nourishing the body wall, digestive tube, and wall of the middle one, may be explained, in mesonephric ridge, respectively. One gonadal part, from a position of molecular regulation of and three suprarenal arteries, derivatives of the embryonic angiogenesis. lateral splanchnic arteries, persist on each side The proliferation and free migration of the of the developing mesonephros, metanephros, endothelial cells require an interplay between gonad, and the adrenal gland [3]. The inferior the various forms of vascular endothelial growth phrenic artery branches from the most cranial factors (VEGF), angiopoietins (Ang), fibroblast IJCR: https://escipub.com/international-journal-of-case-reports/ 5 Maryna Kornieieva et al., IJCR, 2019 4:86 growth factors (FGFs) and their receptors [4]. variability of the vascular pattern is essential in Modern genetics provides clear evidence that such cases. the receptor for VEGF-C is highly expressed References: during embryonic vascular remodeling [10]. A 1. 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