Renal artery aneurysm is a relatively uncommon form of renovascular disease. Early diagnosis by appropriate imaging is essential in order to avoid emergency nephrectomy for rupture. We report a 78 year old man who presented with gross hematuria. Doppler ultrasound and CT showed aneurysm of the right renal artery. Because of hemodynamic instability, right nephrectomy was performed with a good outcome.Key Words: Renal artery, aneurysm, treatmen

Abbar, M

Ameur, A

Elharrech, Y

Ghadouane, M

Qarro, A

Zaini, R

English

AJOL - African Journals Online

African Journal of Urology1110-5704Vol. 16, No. 1, 201020            20-23Case Report Renal Artery Aneurysm Presenting with HematuriaA. Qarro, M. Ghadouane, Y. Elharrech, R. Zaini, A. Ameur and M. AbbarUrological Clinic, Military Hospital Mohamed the Fifth, Rabat, MoroccoABSTRACTRenal artery aneurysm is a relatively uncommon form of renovascular disease. Early diagnosis by appropriate imaging is essential in order to avoid emergency nephrectomy for rupture. We report a 78 year old man who presented with gross hematuria. Doppler ultrasound and CT showed aneurysm of the right renal artery. Because of hemodynamic instability, right nephrectomy was performed with a good outcome. Key Words: Renal artery, aneurysm, treatment                                                                                             Corresponding Author: Dr. Abdelmounaim Qarro, n°: 154, Bloc: D, OLD OJH, Kenitra, Morocco, Email: abdelmounaimqarro@yahoo.fr          Article Info :     Date received: 14/2/2009                  Date accepted (after revision): 18/1/2010 INTRODUCTION                                                    Renal artery aneurysm (RAA) is a localized dilatation of the artery secondary to weakness of the arterial intima and media. Most RAAs are small (1–2 cm) and unilateral. The etiology of RAA is either congenital or acquired. The malformation is usually diagnosed by Doppler ultrasound, computerized tomography or renal angiography1. We report a patient who presented with macroscopic hematuria secondary to RAA.CASE REPORT                                      The patient, a 78-year old man, presented with total, macroscopic hematuria for 10 days. Physical examination revealed right lumbar fossa tenderness. Abdominal ultrasound revealed right hydronephrosis with a lesion in the hilum of the kidney measuring 52mm in diameter and communicating with the renal pedicle. Doppler ultrasound showed enlargement of the right renal artery (52-44 mm) with atheroma and calcification, compatible with a saccular aneurysm of the right renal artery. There was no arterialisation of venous flow in the kidney. Contrast-enhanced computerized tomo-graphy revealed a large right kidney with sub-capsular hematoma. There were two lesions showing enhancement after IV contrast injec-tion, compatible with intra-renal aneurysm of the right renal artery (Fig. 1). The nephrogram phase of the right kidney was hypodense. During follow-up there was aggravation of the hematuria with hemodynamic instability which required urgent nephrectomy. Patholo-gic study of the operative specimen showed aneurysmal dilatation of the renal artery com-municating with the excretory system, with necrosis and pyelonephritis. Postoperative recovery was good.DISCUSSION                                                             RAA is uncommon. Rouppe (1770) des-cribed the first case in a sailor who died after a fall on his right flank. Autopsy revealed a large false aneurysm with rupture. Rouppe stated that RAA accounts for nearly 20% of all visceral aneurysms1,2. The incidence of RAA varies according to the way of dia-gnosis, from 0,009 % in an autopsy study to 21RENAL ARTERY ANEURYSM PRESENTING WITH HEMATURIAsease, polyarteritis nodosa, tuberculosis, neu-rofibromatosis, or Ehlers-Danlos syndrome7. RAA may appear as a vascular complication after kidney transplantation. It occurs in less than 1% of recipients, but can cause hyperten-sion, renal dysfunction and even graft loss8. Mycotic RAA may be secondary to immuno-suppression after renal transplantation9. The diagnosis may be confirmed with Dop-pler ultrasound, arteriography or spiral CT imaging. CT angiography and 3-dimensional reconstruction allow accurate pre-interven-tional planning by defining the precise size and location of the aneurysm, the presence of calcification, thrombosis or dissection. Ma-gnetic resonance angiography (MRA) with gadolinium enhancement and 3-dimensional reconstruction can produce images similar in quality to those obtained with arteriogra-phy. Imaging studies can also differentiate between fibro-muscular dysplasia and pseu-do-aneurysm, which may occur after kidney biopsy, penetrating (stab or gunshot) renal trauma, percutaneous nephrostomy or neph-rolithotomy, endopyelotomy, ureteroscopy or endoscopic fulguration of upper urinary tract transitional cell carcinoma10-14. Renal artery pseudo-aneurysm may present many years after the injury. In cases of hematuria, flank pain and CT showing a tumour in the renal hilum, the patient should be questioned about previous abdominal trauma, as pseudo-aneu-rysms can rupture many years after the cau-sative injury14. Endovascular treatment of RAA invol-ves a stent graft placed under angiographic control across the neck of the aneurysm to exclude it from the circulation and preserve distal flow15,16. The stent is placed via a per-cutaneous femoral approach17. Angiography, which confirms the diagnosis, allows se-lective embolization of pseudo-aneurysms arising from interlobular arteries inside the parenchyma of the kidney18-20. It is mini-mally invasive, safe, effective for control of haemorrhage from a pseudo-aneurysm, and specifically indicated in patients with haemo-dynamic instability19,22,23. Surgery to prevent rupture is indicated for aneurysms >1.5cm in diameter, those asso-0.1-1.5 % in patients with hypertension who underwent arteriography1. The incidence was 0.3% in patients who underwent aortography, and 1.5% in a series of kidney donors3. Poutasse has classified these malforma-tions into saccular, fusiform, dissecting, false and intrarenal aneurysms4. On average, pa-tients, age ranged from 40–60 years. Extrapa-renchymal aneurysms predominate, compri-sing approximately 85% of RAA, and the rest (15%) are intraparenchymal. Of the extrapa-renchymal type, 70% are saccular, 20% fu-siform and 10% dissecting. Of patients with RAA, 20% present with bilateral and 30% with multiple aneurysms. RAA occurs equal-ly in men and women, although ruptures are more common in reproductive-aged women. Most often, RAA is asymptomatic. Some-times patients present with hypertension, he-maturia, lumbar pain and, rarely, a palpable mass. They may present with hemorrhagic shock and pain due to dissection, thrombo-sis, renal infarct, rupture or bleeding into the excretory system with hematuria1,3. Factors predisposing to complications are hyperten-sion, pregnancy, absence of calcification of the wall, and diameter >1.5 cm1,3. During pregnancy the risk of rupture is increased due to increased blood flow, intra-abdominal pressure and vascular changes secondary to increased steroid production. Rupture may cause mortality for both mother and foetus5,6. RAA can be secondary to Takayasu arte-ritis, fibro-muscular dysplasia, Kawasaki di-Fig. 1: CT scan shows intrarenal aneurysm of the right renal artery.22RENAL ARTERY ANEURYSM PRESENTING WITH HEMATURIAciated with pregnancy, and when the size of the aneurysm has increased on sequential an-giography3. The objective of surgery is patch angioplasty using autologous saphenous vein, internal-iliac artery graft or prosthetic mate-rial24. It can be performed in vivo to reduce ischaemic time3,25 or ex vivo, especially for intrarenal aneurysms, with auto-transplanta-tion in the iliac fossa3, 25-29. RAA resection and reconstruction have been guided by a robot-assisted laparoscopic approach30. Nephrecto-my is indicated for multiple intrarenal aneu-rysms, renal atrophy, infarct or prior failed revascularization, and may be inevitable for ruptured RAA3,28. The prognosis after rupture of RAA has improved in the last few deca-des, but rupture during pregnancy still carries a high mortality rate (56% for the mother and 78% for the fetus)6.RAA is rare, and often incidentally discovered during imaging. The treatment of choice is endovascular (angio-embolization or stent grafting under angiographic control). Follow-up with angiography is recommended to avoid emergency nephrectomy for rupture of RAA.                         REFERENCES                                                        Nguinkeu BN, Eucher P, Vandenbossche P, Lacrosse M, 1. Van Cangh PJ, Lorge F. Ruptured renal artery aneurysm: a rare cause of macroscopic haematuria. Progrès en urologie 2002, 12, 454-458.Von Ronnen JR. The Roentgen diagnosis of calcified 2. aneurysms of the splenic and renal arteries. Acta Radiol (Sokh) 1953; 39: 385-400.Ortenberg J, Novick AC, Straffon RA, Stewart BH. 3. Surgical treatment of renal artery aneurysms. Brit J Urol 1983, 55, 341-346.Poutasse EF. Renal artery aneurysm. J Urol 1975; 113: 4. 443-49.Soliman KB, Shawky Y, Abbas MM, Ammary M, 5. Shaaban A. Ruptured renal artery aneurysm during pregnancy, a clinical dilemma. BMC Urol 2006, 6: 22.Pliskin MJ, Dresner ML, Hassell LH, Gusz JR, Balkin 6. PW, Lerud KS, Larson AW. A giant renal artery aneurysm diagnosed post-partum. J Urol. 1990; 144: 1459-1461.Matsubara K, Matsumoto K, Kameyama K, Obara H, 7. Kitajima M. Large renal artery aneurysm in Takayasu arteritis. J Vasc Surg. 2006 Nov, 44(5): 1107-9.Asztalos L, Olvaszto S, Fedor R, Szabo L, Balazs G, 8. Lukas G. Renal artery aneurysm at the anastomosis after kidney transplantation. 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Case Report: Renal Artery Aneurysm Presenting with Hematuria

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Case Report: Renal Artery Aneurysm Presenting with Hematuria

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