Gülhane Týp Dergisi 2005; 47: 141-143 OLGU SUNUMU © Gülhane Askeri Týp Akademisi 2005 Accessory renal arteries and an anomalous testicular artery of high origin Necdet Kocabýyýk (*), Bülent Yalçýn (*), Cenk Kýlýç (*), Yalçýn Kýrýcý (*), Hasan Ozan (*) about accessory renal arteries, it can be Summary iki adet aksesuar renal arterle karþýlaþýldý. concluded that the average rate of occur- During the dissection in a 55-year-old Arterler, aorta abdominalis'in sol antero- male cadaver, two accessory renal arte- lateralinden orijin alýyor ve sol böbreðe rence is approximately 30% (8). ries were encountered in the abdominal giriyordu. Arteria testicularis sinistra, sol In this case, we emphasize that the region. The arteries were originating tarafta superior aksesuar renal arterden presence of two accessory renal arteries from left anterolateral aspect of the çýkýyordu. Arteria testicularis sinistra, supplying to the kidney is not only of aca- abdominal aorta and running into the inferior aksesuar renal arteri arkasýndan demic interest but may also be of practical left kidney. Left testicular artery was çaprazlýyordu. Superior aksesuar renal importance either for the correct inter- originating from the superior accessory arter, ana renal arter ve inferior aksesuar pretation of radiological examinations or renal artery. Left testicular artery renal arterin orijinleri, arteria mesenteri- for surgical interventions in this region. crossed behind the inferior accessory ca superior'un sýrasýyla 4.8 mm, 14.5 mm Testicular arterial anatomy has been well renal artery. Origins of the superior ve 46 mm altýndaydý. Sonuçta, aksesuar studied because of its importance in tes- accessory renal artery, main renal renal arterler, sol böbreðe üst ve alt ucun- ticular physiology and surgery (3). It is, artery and inferior accessory renal dan giriyorlardý. Bu anomali, renal trans- therefore, of considerable practical im- artery were 4.8 mm, 14.5 mm and 46 plantasyon, abdominal aortik anevrizma, portance for a surgeon to be as careful in mm below the superior mesenteric böbreðin vasküler pedikülleri ve anjiyo- dissecting peripheral fat over the renal artery, respectively. Subsequently, ac- grafik uygulamalar gibi abdomenle ilgili polus as in dissecting the hilar region (9). cessory renal arteries run into superior cerrahi giriþimlerde önemli olarak deðer- and inferior pole of the left kidney. lendirilmelidir. Case Report These kinds of anomalies are important Anahtar kelimeler: Aksesuar renal arter- During the dissection in a 55-year-old in surgical procedures related to the ler, vasküler varyasyonlar, renal cerrahi, male cadaver, two accessory renal arteries abdomen, such as renal transplantation, renal transplantasyon were encountered on the left side of the abdominal aortic aneurysm, ureter sur- abdominal aorta (Figure 1). gery, vascular pedicles of kidney and in Introduction angiographic interventions. The renal and gonadal arteries usually Key words: Accessory renal arteries, vascular variations, renal surgery, renal arise from the anterolateral or lateral transplantation aspect of the abdominal aorta (1-3). The testicular artery usually arises from the Özet abdominal aorta at the level of the second Aksesuar renal arterler ve yüksek lumbar vertebra, 2.5-5 cm below the renal çýkýmlý bir testiküler arter artery (4). In the abdomen, the testicular Ellibeþ yaþýnda bir erkek kadavranýn artery supplies the perirenal fat, ureter abdominal bölge diseksiyonu sýrasýnda, and iliac lymph; in the inguinal canal it supplies the cremaster muscle (2). *GATA Anatomi AD Variations relating to origin, course and number of these arteries have been Figure 1. *: The accessory renal artery (inferi- Ayrý basým isteði: Dr. Necdet Kocabýyýk, GATA or), LK: left kidney, RV: renal vein, RA: renal Anatomi AD, Etlik-06018, Ankara reported in a number of studies (2-7). artery, TV: testicular vein, SMA: superior E-mail: [email protected] The embryological bases for these varia- mesenteric artery, U: ureter, AA: abdominal tions have also been well established. aorta, CT: coeliac trunk, ipv: inferior phrenic Makalenin geliþ tarihi: 29.09.2004 vein, srv: suprarenal vein, SRG: suprarenal Kabul edilme tarihi: 21.02.2005 From the published studies and reports gland 141 Two accessory renal arteries originat- Discussion left inferior phrenic artery (6). In the ed from the left lateral part of the abdom- Certain knowledge of the embryology study of Notkovich including 405 testicu- inal aorta and run into left kidney. of the renal vasculature and structural lar or ovarian arteries, the gonadal arteries Superior accessory renal artery was aris- development of the kidney is essential to of renal origin were found in 14 percent, ing from 4.8 mm below the superior the understanding of the multitude of taking their origin from the principal mesenteric artery and running into the anomalies that may occur. With the com- renal artery from its branches or from an superior pole of the left kidney. Main plex development of the kidneys through accessory renal artery, as well (12). In our renal artery was arising from 14.5 mm the three stages of pronephros, meso- case, the left testicular artery was originat- below the superior mesenteric artery and nephros and metanephros, and the migra- ing from the superior accessory renal running into the middle pole of the left tion of the kidney from the pelvis to the artery. kidney. Inferior accessory renal artery was lumbal region, along with its longitudinal Accessory renal arteries usually arise arising from 46 mm below the superior location and simultaneous acquisition of a from the aorta above or below the main mesenteric artery and running into the vascular supply, there is reason to under- renal artery and follow it to the renal inferior pole of the left kidney (Figure 2). stand why the possibility for anomalous hilum. Higher or lower origins are not A schematic representation of the case development in the kidney may be greater uncommon, an accessory artery or leash is shown in Figure 3. Left testicular artery than for other organs within the body of arteries passing to the superior or infe- was originating from the superior acces- (10). rior renal pole are possible. They are sory renal artery. Main renal artery and Renal vasculature may be studied at regarded as persistent embryonic lateral inferior accessory renal artery crossed various levels, commencing with the splanchnic arteries. Accessory vessels to behind the left testicular artery. The main principal and accessory renal arteries. the inferior pole cross anterior to the renal artery and accessory renal artery on Their primary patterns of branching and ureter and may, by its obstruction, cause the right were already cut in the autopsy areas of distribution suggest the presence hydronephrosis. Rarely, accessory renal (Figures 2,3). of vascular segmentation. From the pri- arteries arise from the celiac or superior mary stems branch lobar, interlobar, mesenteric arteries near the aortic bifur- arcuate and interlobular arteries, afferent cation or from the common iliac arteries and efferent glomerular arterioles and (2). cortical intertubular capillary plexuses, Some authors (2,12,13) state that sim- cortical venous radicles drain them and ilar anomalies in their particular interest also the vasa recta and associated capillary may be important from the clinical point plexuses of the medulla to the renal vein of view in that they may cause; a) (2). Varicocele (ovarian varicocele in female) Variations in the origin, course and secondary to compression of the renal branches of the testicular arteries are vein by an arched gonadal artery, b) attributed to their embryologic origin. Hydronephrosis due to occlusion or During embryon development, the later- compression of the ureter by an inferior al splanchnic arteries on each side supply polar artery, c) Nephroptosis and malro- Figure 2. *: The accessory renal artery, RV: the mesonephros, metanephros, the testis tation of the kidney associated with an renal vein, RA: renal artery, TV: testicular vein, or ovary, and the suprarenal gland; all inferior polar artery, d) Arterial hyperten- TA: testicular artery, SMA: superior mesen- these structures develop, in whole or part, sion because of the constriction of renal teric artery, U: ureter, isra: inferior suprarenal from the intermediate mesenchyme of arteries and subsequent renal ischemia, e) artery, SRG: suprarenal gland the mesonephric ridge. One testicular or The risk of infarction in a kidney during ovarian artery and three suprarenal arter- urologic or oncologic surgical interven- ies persist on each side (2). tions and renal transplantations. As inferi- Machnicki and Grzybiak examined or polar artery is a segmental artery, the the variations of the testicular arteries in erroneous ligation or division of it is fetuses and adults. Four main types of tes- clearly hazardous to result in the necrosis ticular arteries were identified according of a segment of the kidney tissue to their site of origin from aorta or renal (2,12,13). arteries: 1- a single testicular artery arising The reported incidence of additional from the aorta (type A), 2- a single testic- renal arteries has a wide range between ular artery arising from the renal artery 8.7% and 75.7%, and they can cause (type B), 3- two testicular arteries arising hydronephrosis by compressing the from the aorta and penetrating the same ureter (2,14,15). This anomaly is impor- gonad (type C), and 4- two arteries pene- tant in surgical procedures