34 - Pathologic and Surgical Implications of the Hilar Relationship of the Renal Artery and Vein

Poster Board Number: 34
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Abstract Body : The classically reported relationship of the renal vessels at the renal hilum is that the renal vein is located anterior to the renal artery. Variations of renal vessels have been noted in literature, including accessory renal veins and arteries, early renal artery branching patterns, circum-aortic left renal vein, left retro-aortic renal vein, and capsular arteries. Anatomical variations in these vessels could result in anomalous blood flow, and in surgical settings, increase the likelihood of complications. The purpose of this case report is to document a bilateral variation in the arrangement of the renal vessels at the renal hilum and to discuss its clinical and surgical implications.

This bilateral arrangement of the renal arteries was discovered during an educational dissection of a 72 year old male cadaver provided by the Texas A&M School of Medicine. Extraneous components were carefully cleaned around the kidneys and renal vessels. This arrangement was documented by photographing the vessels in situ. A review of relevant literature was conducted to discuss the clinical implications of this renal vessel variation for clinical and surgical practice.

The renal arteries arise from the abdominal aorta at approximately the L1/L2 level. The renal veins course at the same level anterior to the renal artery and empty into the inferior vena cava. In this atypical presentation, the renal arteries bifurcated into prominent anterior and posterior divisions at the renal hilum, with the renal veins situated in between these divisions (i.e., the anterior-to-posterior arrangement of the vessels at the renal hilum was the anterior division of the renal artery, renal vein, and posterior division of the renal artery, respectively). In addition, the cortical surface of the kidney was notable for an abnormal granular appearance. The presence of a granular renal cortex is indicative of chronic kidney disease and is more prevalent in patients with the condition.

Renal vessel anomalies must be documented because they can potentially lead to pathologies including chronic kidney disease, varicoceles, pelvic congestion syndrome, renal hypertension and hematuria, impaired renal perfusion, and a potential new presentation of anterior nutcracker syndrome. Moreover, acknowledgment of such variations can improve patient outcomes during surgical operations allowing for proper planning before surgery and adaptations in surgical technique. For instance, in Laparoscopic Partial Nephrectomy and Kidney Transplantation, a urologist must be able to accurately identify and access the appropriate vessels in the hilum and employ either cross-clamping or individual vessel clamping techniques. With atypical vascular arrangements, surgeons may face increased difficulty during dissection, which may impair vessel identification and/or cause iatrogenic trauma. Specifically regarding renal transplantation, it has been previously reported that donor kidneys with vascular damage are often rejected due to an increased risk for complication (e.g., thrombosis, hemorrhage, or compromised renal function).