• Users Online: 109
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2020  |  Volume : 69  |  Issue : 3  |  Page : 178-181

Multiple renal vasculature


1 Department of Rachana Shareera (Anatomy), Government Ayurveda Medical College, Tripunithura, India
2 Department of Rachana Shareera (Anatomy), Government Ayurveda Medical College, Kannur, Kerala, India
3 Department of Anatomy, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, India

Date of Submission25-Dec-2019
Date of Acceptance22-May-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. V Vijaynath
Department of Rachana Shareera (Anatomy), Government Ayurveda Medical College, Tripunithura, Kochi, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JASI.JASI_232_19

Rights and Permissions
  Abstract 


Variations in the renal vasculature are often encountered in routine cadaveric dissection. In this case, variations were found in the right renal vein (RRV), right renal artery (RRA) and left renal artery (LRA) of a formalin-fixed cadaver. The RRV had two tributaries and the RRA had three branches. The LRA had two branches and was anterior to the left renal vein. Such vascular anomalies are significant clinically.

Keywords: Left renal artery, left renal vein, right renal artery, right renal vein


How to cite this article:
Vijaynath V, Ravi V, Mukundan M, Tintu T S. Multiple renal vasculature. J Anat Soc India 2020;69:178-81

How to cite this URL:
Vijaynath V, Ravi V, Mukundan M, Tintu T S. Multiple renal vasculature. J Anat Soc India [serial online] 2020 [cited 2020 Oct 19];69:178-81. Available from: https://www.jasi.org.in/text.asp?2020/69/3/178/296911




  Introduction Top


The large renal veins lie anterior to the renal arteries and open into the inferior venacava almost at the right angles. The left renal vein (LRV) three times longer than the right (7.5 cm and 2.5 cm, respectively). For this reason, the left kidney is the preferred side for live donor nephrectomy. The right renal vein (RRV) can be extremely short (<1 cm) such that safe nephrectomy may require excision of a cuff of the inferior venacava. The RRV has no significant collateral drainage like that of the left and cannot be ligated with impunity.

Renal arteries branch laterally from the abdominal aorta just below the origin of the superior mesenteric artery. Both the arteries cross the corresponding crus of the diaphragm at right angles to the aorta. The right renal artery (RRA) is longer and often higher, passing posterior to the inferior venacava, RRV, head of the pancreas and splenic vein.

A single renal artery to each kidney is present in approximately 70% of individuals. The arteries vary in their level of origin and in their caliber, obliquity, and precise relations. In its extra renal course, each renal artery gives off one or more inferior suprarenal arteries, a branch to the ureter, and branches which supply perinephric tissue, the renal capsule and the pelvis. Near the renal hilum each artery divides into an anterior and a posterior division, and these divide into segmental arteries supplying the renal vascular segments. Accessory renal arteries are common (30% of the individuals) and usually arise from the aorta above or below (most commonly below) the main renal artery and follow it to the renal hilum. They are regarded as persistent embryonic lateral splanchnic arteries. Accessory vessels to the inferior pole cross anterior to the ureter and may, by obstructing the ureter, cause hydronephrosis. Rarely, accessory renal arteries arise from the coeliac or from the superior mesenteric arteries near the aortic bifurcation or from the common iliac arteries.[1]

Supernumerary renal arteries are relatively common. They represent persistent fetal renal arteries which grow in sequence from the aorta to supply the kidney as it ascends from the pelvis. Their occurrence is clinically important because a supernumerary artery may cross the pelviureteral junction and obstruct the outflow of urine, producing dilatation of the calyces and pelvis, a condition known as hydronephrosis.[2]

Aberrant real vessels from the development of kidney it is clear that there may be an aberrant renal artery supplying the kidney. Such artery is usually small and insignificant, but occasionally it may be large and become significant due to the fact that it supplies a segment of the kidney. Such artery is more often seen supplying the lower pole of the kidney. This artery may be associated with hydronephrosis by compressing the pelvi-ureteric junction or it simply accompanies it, is a point of debate. One must be careful in dividing such aberrant artery as it may cause infarction of the corresponding segment of the renal tissue if it be the only arterial supply to that region.

Aberrant renal artery is more often seen on the left side, and it is more common in females. There may be aberrant renal vein but its significance is much less than aberrant renal artery and it is also less common. Moreover, due to venous collateral circulation, its importance is insignificant.[3]


  Case Report Top


During routine dissection of a 55-year old male cadaver in the department of anatomy, variations were found in the RRV, RRA, and left renal artery (LRA) simultaneously. There were two tributaries for the RRV, the upper tributary emerged slightly below the middle of the hilum, ran upwards and to the left with an inclination of 45° with the horizontal plane. The upper tributary was about 1.5 cm long and joined the lower tributary at an acute angle. The lower tributary was slender than the upper one and emerged from lower part of the hilum, 1 cm below the exit of the upper tributary. It also ran upwards and to the left, parallel to the upper tributary and joined the upper one at an acute angle after a course of 1.5 cm. The combined wider single RRV, about 1.5 cm wide, continued upward and left for a length of 3 cm and joined the inferior vena cava on its right margin. The tributaries and the single RRV were anterior to the RRA and its branches [Figure 1].
Figure 1: Single right renal vein and its tributaries located in the front of the right renal artery and its branches. (IVC: Inferior vena cava, RRV: Right renal vein with its upper and lower tributaries, PM: Psoas major muscle, U: Ureter)

Click here to view


The single RRA emerged from the abdominal aorta under cover of the inferior vena cava and after a course of 1 cm toward the right and in upward direction, divided into three before entering the hilum. The upper branch, 2 cm long, continued upward and to the right, above the upper margin of RRV and entered the hilum at its upper angle. The middle branch ran almost horizontal above the RRV for a distance of 3 cm and entered the hilum just above its center. The lower branch curved downward and entered the hilum near the lower pole. The division of the artery into upper and middle branches was visible just above the middle of the upper border of the RRV [Figure 2].
Figure 2: Divisions of the right renal artery into upper and middle branches visible just above the middle of the upper border of the right renal vein. Inferior vena cava reflected downward. (RRA: Right renal artery with upper, middle and lower branches, RRV: Right renal vein, AA: Abdominal aorta, IVC: Inferior vena cava)

Click here to view


The LRV was single throughout its length. The vein 1.5 cm wide and 7 cm long, emerged from the middle of the hilum posterior to the entrance of the branches of LRA, ran almost horizontal, dorsal to the branches of LRA. The origin of the superior mesenteric artery lies immediately above the terminal part of the LRV. The terminal part of the LRV curved upward and to the right and entered the inferior vena cava at its left margin, opposite to the entrance of the RRV.

The LRA originated as two branches, upper and lower, from the abdominal aorta, immediately below and slightly to the left of the origin of superior mesenteric artery. The upper branch originated from the left margin and after a very short course of 2 cm divided into two twigs, dorsal and ventral. The origin of branches lay posterior to the LRV. The two branches after a course to the left appeared on the left side of the opening of the lumbar vein to the LRV. The upper branch of LRA then subdivided into ventral and dorsal twigs. The dorsal twig of upper branch ran horizontally to the left and entered the upper angle of the hilum. The ventral twig separated from the common trunk ran slightly downward to the right above the upper margin of the LRV and divided into two. The upper subdivision of the ventral twig of LRA ran horizontally to enter the upper part of the hilum just below the entrance of the upper branch. The lower subdivision of the ventral twig ran almost vertically downward and to the left, crossed the LRV and entered the lower part of the hilum, below the exit of the LRV.

The separate lower branch emerged from the aorta slightly anterior to and below the origin of the common trunk of upper and lower branches and ran upward and anteriorly, wound around the upper margin of LRV and continued downward and to the left crossing anterior to the LRV. The branch opened into the lower pole of the kidney anterior to the renal pelvis [Figure 3].
Figure 3: Left renal artery with its upper and lower branches and their distribution. (ULRA: Upper branch of the left renal artery with its dorsal and ventral twigs, LLRA: Lower branch of the left renal artery, U: Ureter, PM: Psoas major muscle, LRV: Left renal vein)

Click here to view



  Discussion Top


The large renal veins lie anterior to the renal arteries and open into the inferior vena cava almost at right angles. The LRVs are three times longer than the right (7.5 cm and 2.5 cm, respectively). For this reason, the left kidney is the preferred side for live donor nephrectomy. The RRV can be extremely short (<1 cm) such that safe nephrectomy may require excision of a cuff of the inferior vena cava. The RRV has no significant collateral drainage like that of the left and cannot be ligated with impunity.

Renal arteries branch laterally from the abdominal aorta just below the origin of the superior mesenteric artery. Both the arteries cross the corresponding crus of the diaphragm at right angles to the aorta. The RRA is longer and often higher, passing posterior to the inferior vena cava, RRV, head of the pancreas and splenic vein.

A single renal artery to each kidney is present in approximately 70% of individuals. The arteries vary in their level of origin and in their caliber, obliquity, and precise relations. In its extra renal course, each renal artery gives off one or more inferior suprarenal arteries, a branch to the ureter, and branches which supply perinephric tissue, the renal capsule and the pelvis. Near the renal hilum each artery divides into an anterior and a posterior division, and these divide into segmental arteries supplying the renal vascular segments. Accessory renal arteries are common (30% of the individuals) and usually arise from the aorta above or below (most commonly below) the main renal artery and follow it to the renal hilum. They are regarded as persistent embryonic lateral splanchnic arteries. Accessory vessels to the inferior pole cross anterior to the ureter and may, by obstructing the ureter, cause hydronephrosis. Rarely, accessory renal arteries arise from the coeliac or superior mesenteric arteries near the aortic bifurcation or from the common iliac arteries.[1]

Supernumerary renal arteries are relatively common. They represent persistent fetal renal arteries which grow in sequence from the aorta to supply the kidney as it ascends from the pelvis. Their occurrence is clinically important because a supernumerary artery may cross the pelvi-ureteral junction and obstruct the outflow of urine, producing dilatation of the calyces and pelvis, a condition known as hydronephrosis.[2]

Aberrant real vessels from the development of the kidney it is clear that there may be an aberrant renal artery supplying the kidney. Such artery is usually small and insignificant, but occasionally, it may be large and become significant due to the fact that it supplies a segment of the kidney. Such artery is more often seen supplying the lower pole of the kidney. This artery may be associated with hydronephrosis by compressing the pelviureteric junction or it simply accompanies it, is a point of debate. One must be careful in dividing such aberrant artery as it may cause infarction of the corresponding segment of the renal tissue if it be the only arterial supply to that region.

Aberrant renal artery is more often seen on the left side, and it is more common in females. There may be aberrant renal vein, but its significance is much less than aberrant renal artery and it is also less common. Moreover, due to venous collateral circulation, its importance is insignificant.[3]

The variations in renal vasculature, though very usual in occurrence, are very significant from the surgical point of view. Renal artery variations are of two types: early division and extra renal artery. Branching of the main renal arteries into segmental branches more proximally than the renal hilum level is called early division. Extra renal arteries are of two types: hilum (accessory) and polar (aberrant) arteries. Hilum arteries enter the kidneys from the hilum with the main artery, whereas polar arteries enter the kidney directly from the capsule outside the hilus.[4]

The LRA in the current case thus showed both the two varieties of the variations. The upper branch showed early division and the lower branch can be considered as an extra renal artery and comes under the polar variety of the extra renal artery. The lower branch can be considered as the aberrant renal artery, and its presence is important from the clinical point of view as this artery may be associated with hydronephrosis by compressing the pelviureteric junction or infarction of the corresponding segment of the renal tissue if it be the only arterial supply to that region.[3] The RRA showed early division variety of renal artery variation.

In the study conducted by Ozkan et al., including 855 patients, one renal artery was observed feeding both the kidneys in 76% of the patients. More than one renal artery was observed in 24% patients, of which 16% were on the right side and 13% on the left side. In 5% patients, more than one renal artery was present on both sides.[4] In this case, the extra real artery and early divisions of the renal artery were present in the left side and early division alone in the right side.

Gulas et al. has reported that with regard to ethnicity, the incidence of accessory renal arteries fluctuates from 4% in a Malaysian population to 61.5% in a Brazilian population. The frequency is the lowest in the Eastern and Southern Asia (from 4% to 18.4%). In some, not ethnically homogenous populations, wide span of occurrence of accessory renal arteries is described (e.g., American – averaging from 18% to 28.8%). A higher frequency of accessory renal arteries was observed in fetuses compared to adults.[5]

Dhar and Lal has reported in a study of 40 cadavers that revealed a single main renal artery on either side in 80% of the specimens. Multiple (accessory) renal arteries were observed in 20% of the specimens with unilateral anomaly (15%) being more commonly encountered than bilateral anomaly (5%).[6]

The right kidney in the present case showed the presence of supernumerary renal vein which is an additional renal vein arising from the renal hilum and draining into the inferior vena cava.

Glodny et al., in a study on hypertension associated with multiple renal arteries on 62 individuals, has concluded that patients with multiple renal arteries constitute a group who have high plasma renin activity and may therefore be prone to develop arterial hypertension.[7]

Kumar et al. has reported a case of an accessory RRV draining into the posterior aspect of the inferior vena cava.[8] Kumar et al. has reported a case of bilateral variations at the hilum involving both renal veins and arteries.[9] Mukundan et al. has reported a case of bilateral double renal vein.[10]

Satyapal, states that statistically significant changes have been noted in the drainage pattern of right and LRVs. Three hundred and six kidneys were studied and three major types (I, II, and III) of kidney drainage were observed. Type IA consisted of 2 primary tributaries only-an upper and a lower which occurred in 118 (38.6%). It was commonly present on the left side. In addition to upper and lower primary tributaries, a posterior primary tributary was also present in Type IB. This type was observed in 77 (25.2%) cases. In Type IIA, the existence of more than two tributaries, i.e., upper, middle, and lower, were observed. A maximum of five primary tributaries was identified and was noted in 36 (11.8%) cases. In Type IIB, in addition to the primary tributaries present in Type IIA, a posterior primary tributary was also present. Type II B was present in 31 (10.1%) out of the 306 kidneys. Type III consisted of either Types IA, IB, IIA, or IIB along with an additional renal vein or veins. Such variety occurred in 44 (14.4%) cases.[11]


  Conclusion Top


Variations in the renal vasculature are important from an urologist's perspective. A correct knowledge of this vasculature will help a surgeon while performing renal transplantation and other vascular surgeries. The clinicians dealing with the renal vessels ought to know these variations to keep away from the harm's way.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Standring S, editor. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. London: Elsevier, Churchill Livingstone; 2005. p. 1231-3.  Back to cited text no. 1
    
2.
Snell RS. Clinical Anatomy by Regions. 9th ed. New Delhi: Wolters Kluwer (India) Pvt Ltd; 2012. p. 213.  Back to cited text no. 2
    
3.
Das S. A Concise Textbook of Surgery. 4th ed. Kolkata: Old Mayors' Court (India); 2006. p. 1150-1.  Back to cited text no. 3
    
4.
Ozkan U, Oǧuzkurt L, Tercan F, Kizilkiliç O, Koç Z, Koca N. Renal artery origins and variations: Angiographic evaluation of 855 consecutive patients. Diagn Interv Radiol 2006;12:183-6.  Back to cited text no. 4
    
5.
Gulas E, Wysiadecki G, Cecot T, Majos A, Stefanczyk L, Topol M, et al. Accessory (multiple) renal arteries – Difference in frequency according to population, visualizing techniques and stage of morphological development. Vascular 2016;24:531-7.  Back to cited text no. 5
    
6.
Dhar P, Lal K. Main and accessory renal arteries – A morphological study. Ital J Anat Embryol 2005;110:101-10.  Back to cited text no. 6
    
7.
Glodny B, Cromme S, Reimer P, Lennarz M, Winde G, Vetter H. Hypertension associated with multiple renal arteries may be rennin – Dependent. J Hypertens 2000;18:1437-44.  Back to cited text no. 7
    
8.
Kumar N, Swamy RS, Patil J, Nayak SB, Shetty SD, Aithal A. Accessory right renal vein draining into inferior vena cava. OA Case Rep 2014;3:48.  Back to cited text no. 8
    
9.
Kumar N, Aithal AP, Guru A, Nayak SB. Bilateral vascular variations at the renal hilum: A case report. Case Rep Vasc Med 2012;2012:968506.  Back to cited text no. 9
    
10.
Mukundan M, Vijaynath V, Ravi V. Bilateral variation of renal vein: A case report. Int J Anat Res 2016;4:3153-5.  Back to cited text no. 10
    
11.
Satyapal KS. Classification of the drainage patterns of the renal veins. J Anat 1995;186 (Pt 2):329-33.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed43    
    Printed0    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal