RENOVASCULAR ANATOMY AND ANGIOGRAPHY

1. RENAL VASCULAR
ANATOMY AND
ANGIOGRAPHY
Dept of Urology
Govt Royapettah Hospital
Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai.
2

3. HISTORY
 Work of vesalius
 Michael angelo’s paintings on sistine
chappel
 Took pace after the invention of
arteriogram
 Grave’s did pioneer work.
3
Dept of Urology, GRH and KMC,
Chennai.

4. 4
Dept of Urology, GRH and KMC,
Chennai.

5. RENAL VASCULATURE
 Below the origin of SMA
 Between lower 2/3 of L1 and upper 1/3 of
L2
 Vein anterior to artery ….pelvis posterior
 Right renal artery at a higher level than left.
 Right renal artery caudal slope
 Left renal artery course directly lateral
 Splits to 5 segmental branches
5
Dept of Urology, GRH and KMC,
Chennai.

6. 6
Dept of Urology, GRH and KMC,
Chennai.

7. SEGMENTAL BRANCHES
 End arteries
 First and most constant branch POSTERIOR SEGMENTAL
BRANCH
 Four anterior branches
 APICAL
 UPPER
 MIDDLE
 LOWER
 Posterior segmental branch passes posterior to pelvis
 PUJ OBSTRUCTION
7
Dept of Urology, GRH and KMC,
Chennai.

8. GRAVE’S LOBES
(RENAL SEGMENTS)
 5 segments
 1.apical
 2.upper
 3.middle
 4.lower
 5.posterior
Anterio
r
branch
Posterior
branch
8
Dept of Urology, GRH and KMC,
Chennai.

9. BRODEL’S LINE /HYRTL’S LINE
 Slightly behind the convex border at the
posterior aspect of kidney (approximately 2/3
rd way from lateral border )
9
Dept of Urology, GRH and KMC,
Chennai.

10. Segmental circulation – significance
Anatrophic Nephrolithotomy
10
Dept of Urology, GRH and KMC,
Chennai.

11.  Arteries that should not be missed
 INFERIOR SUPRA RENAL ARTERY
 ARTERY TO RENAL PELVIS AND
UPPER URETER
11
Dept of Urology, GRH and KMC,
Chennai.

12. The Golden triangle
 Left
 Renal hilum
 Lower pole of Kidney
 Junction of L Gonadal
and L Renal vein
 Right
 Renal hilum
 Lower pole of Kidney
 Junction of renal vein and
IVC
 Ureteral branch of renal
artery placed
(Salvatierra et al 1974)
12
Dept of Urology, GRH and KMC,
Chennai.

13. INTRA RENAL BLOOD SUPPLY
Figure 26.5c, d
13
Dept of Urology, GRH and KMC,
Chennai.

14. Figure 26.5a, b
14
Dept of Urology, GRH and KMC,
Chennai.

15. Intra renal arterial anatomy(applied)
Infundibular puncture in PCNL
15
Dept of Urology, GRH and KMC,
Chennai.

16. Intra renal arterial anatomy(applied)
 ACCESS THROUGH THE INFUNDIBULUM:
 SUPERIOR POLE: Most dangerous…….
 Posterior segmental artery(retro pelvic artery) .
 MIDDLE KIDNEY: Middle branch of posterior
segmental artery injured
 INFERIOR POLE: Posterior aspect of lower
infundibulum ---considered safe..
 Chance of injuring-------”calicyceal necks”.
 Upper pole puncture----injures arteries
 Lower pole puncture----injures veins
16
Dept of Urology, GRH and KMC,
Chennai.

17. Infundibular access and vascular injury
Arterial injury -13%
Arterial injury-23%
injury to infundibular vessel - 67%
Artery in 26%
Anterior Posterior
Safe zone
Injury to venous
anastamoses around
the calyaecal necks 17
Dept of Urology, GRH and KMC,
Chennai.

18. Forniceal calyx puncture in PCNL
irrespective of region of
kidney it’s usually safe
18
Dept of Urology, GRH and KMC,
Chennai.

19. ENDO INCISION OF RENAL INFUNDIBULUM
 Based on the circumference of
infundibulum incision be made in
superior or inferior quadrant.(not
close to vessels).
 Anterior and posterior quadrants lie
close to intralobar vessels.
19
Dept of Urology, GRH and KMC,
Chennai.

20. Intrarenal endourological surgery
Infundibular incision
safest
Most dangerous
20
Dept of Urology, GRH and KMC,
Chennai.

21. Options for endo-incision::
 I choice : superior quadrant
 II choice : inferior quadrant
 III choice: between superior and
posterior quadrant
 IV choice: between inferior and
posterior quadrant
 V choice: posterior quadrant.
 Never in anterior quadrant
21
Dept of Urology, GRH and KMC,
Chennai.

22. VASCULAR ANATOMY IN RELATION
TO ENDOPYELOTOMY
Based on intubated
pyeloplasty.(upj
incision followed by
stenting)
22
Dept of Urology, GRH and KMC,
Chennai.

23. Anterior incision-----Inferior
segmental artery injured
23
Dept of Urology, GRH and KMC,
Chennai.

24. Medial incision---pedicle injury
Posterior/posterolateral incision-
-retro pelvic vessel injury
Hilar vessels
Retro pelvic artery
24
Dept of Urology, GRH and KMC,
Chennai.

25. VASCULAR ANATOMY IN RELATION
TO ENDOPYELOTOMY

SAFE INCISION JUST LATERAL
25
Dept of Urology, GRH and KMC,
Chennai.

26. EMBRYOLOGY &
RENAL VASCULAR
VARIATIONS
26
Dept of Urology, GRH and KMC,
Chennai.

27. Embryology of Renal Arterial Tree
 Polar/Multiple renal A – failure of complete
degeneration of primitive vascular channels
 multiple vessel pattern in renal ectopia -
arrested embryonic state for that particular
renal position
Cranial group :2 pairs – Phrenic A
Middle group : 3 pairs – Adrenal A
Caudal group :4 pairs – Renal A
27
Dept of Urology, GRH and KMC,
Chennai.

28. definitions
 “multiple renal artery”-----any kidney
supplied by more than one vessel.
 “anomalous / aberrant vessel”---artery
that originates other than aorta or main
renal artery.
 “accessory vessel”-----two or more
arterial branch supplying the same renal
segment.
28
Dept of Urology, GRH and KMC,
Chennai.

29. Multiple renal arteries
29
Dept of Urology, GRH and KMC,
Chennai.

30. Aberrant /anomalous vessel
31
Dept of Urology, GRH and KMC,
Chennai.

31. Accessory vessel
32
Dept of Urology, GRH and KMC,
Chennai.

32. incidence
 71-85 % single renal artery supplying
entire parenchyma.
 Arterial anomalies more common on
left .
 Venous variations more common on
right.
 Aberrant vessels more common in
renal ectopia(horsh shoe kidney).
33
Dept of Urology, GRH and KMC,
Chennai.

33. points to remember
 Greatest variation in origin”apical
segment vessel”
 Most constant branch”posterior
segment vessel”
 Accessory renal vesselmore common in
lower renal segment
34
Dept of Urology, GRH and KMC,
Chennai.

34. When to suspect multiple renal
artery/an aberrant vessel in ivu???
1. Superior infundibulum shows hydronephrosis
with sharp cut-off.
2. An angulated ureter near renal pelvis with PUJ
obstruction.
3. When a filling defect in renal pelvis correlates
with abnormal vascular pattern.
4. In a hypertensive patientdifference in timing
and concentration of dye excretion in one
segment / entire kidney.
35
Dept of Urology, GRH and KMC,
Chennai.

35. Renal Vascular Anomalies- significance
 Extrinsic PUJ Obstruction
36
Dept of Urology, GRH and KMC,
Chennai.

36. Renal Vascular Anomalies
significance in lap nephrectomy
 Distended renal vein after renal A is clipped –
arterial inflow thro’ accessory renal A
 Persistent renal hilar bleed after division of
renal artery and vein - overlooked accessory
renal A
37
Dept of Urology, GRH and KMC,
Chennai.

37. Multiple vessels in lap nephrectomy
38
Dept of Urology, GRH and KMC,
Chennai.

38. Renal Vascular Anomalies
Significance in renal transplant
Polar accessory artery
Backtable implantation of polar A into
main renal A
Epigastric A – Inferior polar
A anastamosis
39
Dept of Urology, GRH and KMC,
Chennai.

39. Multiple arteries in renal transplant
40
Dept of Urology, GRH and KMC,
Chennai.

40. Renal Vascular Anomalies
Significance in renal transplant
Multiple hilar arteries in a live donor
Equal sized hilar arteries – conjoined anastamosis
41
Dept of Urology, GRH and KMC,
Chennai.

41. Conjoined anastamosis
42
Dept of Urology, GRH and KMC,
Chennai.

42. Renal Vascular Anomalies
Significance in renal transplant
Multiple hilar arteries in a cadaveric donor
Carrel patch
43
Dept of Urology, GRH and KMC,
Chennai.

43. Renal Vascular Anomalies
Significance in renal transplant
Multiple hilar arteries in a live donor
Branched hypogastric artery
autograft conduit
44
Dept of Urology, GRH and KMC,
Chennai.

44. Vasculature of anomalous kidneys
Horseshoe kidneys
 Single renal A to each side
– 30%
 Duplicate / triplicate renal
arteries
 Isthmus – renal A,Aorta
above/below isthmus
 Inf. Mesentric,
common/ext iliac, sacral A
Blood vessels enter the ventromedial aspect
PCNL - Dorsal / Dorsolateral puncture - safer
45
Dept of Urology, GRH and KMC,
Chennai.

45. Vasculature of anomalous kidneys
Ectopic kidneys
 Caudal ectopia
 Vascular pattern depends upon the
resting place of the kidneys
 Distal Aorta / Aortic bifurcation /
Common, ext iliac / Inf mesentric A
46
Dept of Urology, GRH and KMC,
Chennai.

46. Vasculature of anomalous kidneys
Ectopic kidneys
 Cephalad
ectopia
 Rarely
anomalous
 Cephalad origin
 Thoracic kidneys
 Cranial origin
 Vasculature
enter thro’
foramen of
Bochdalek 47
Dept of Urology, GRH and KMC,
Chennai.

47. Renal vein
 Post glomerular capillaries
 Interlobular veins
 Arcuate veins
 Interlobar veins
 Lobar veins
 Segmental veins
 Renal vein
Communicates with subcapsular
venous plexus(stellate veins) and
veins in perinephric fat
48
Dept of Urology, GRH and KMC,
Chennai.

48.  Right renal vein 2 to 4 cm.
 Left renal vein 3 times longer than right.
 Left vein posterior to SMA and anterior to
aorta.
 Superiorly----left adrenal vein
 Posteriorly---left lumbar vein
 Inferiorly---gonadal vein
49
Dept of Urology, GRH and KMC,
Chennai.

49. Multiple renal veins(most common
on right side).
50
Dept of Urology, GRH and KMC,
Chennai.

50. Circum-aortic renal vein(most
common on left side)
51
Dept of Urology, GRH and KMC,
Chennai.

51. Venous variants
 15% to 30% ---multiple renal
veins(most common variant)
 More common on right side.
 Most common anomaly of left venous
system is circum aortic renal
vein(17%).
 adrenal vein—preaortic limb
 gonadal vein—retroaoric limb
52
Dept of Urology, GRH and KMC,
Chennai.

52.  Less common variant--- completely
retroaortic renal vein seen in 3%
 Potential nightmare in lap donor
nephrectomy.
53
Dept of Urology, GRH and KMC,
Chennai.

53. Retroaoric left renal vein::
54
Dept of Urology, GRH and KMC,
Chennai.

54. ANGIOGRAPHY OF
KIDNEY
55
Dept of Urology, GRH and KMC,
Chennai.

55. RENAL ARTERIOGRAPHY
 Sven seldinger -- mid 1950’s
 Small catheters and modern contrast
media has made it safe for OP use
and in renal insufficiency.
 Gold standard when compared to CTA
and MRA.
56
Dept of Urology, GRH and KMC,
Chennai.

56. CATHETER MATERIALS AND GUIDEWIRES
 Polyethylene /polyurethane/teflon
 5 fr or smaller
 Coated with hydrophilic polymer
 Special stearable guidewires used in
micro catheter system(segmental art.)
 Puncture 18 gauge /smaller
 Decreased size –decreases peri
catheter leak.
57
Dept of Urology, GRH and KMC,
Chennai.

57. Contrast media
 Iodinated contrast risks 0.6%-1.4%
 Risks
 renal failure
 diabetes mellitus
 dehydration
 multiple myeloma
58
Dept of Urology, GRH and KMC,
Chennai.

58. Nephro toxicity reduced by
 Low osmolar contrast
 Proper hydration
 Pretreatment with prednisolone
59
Dept of Urology, GRH and KMC,
Chennai.

59. Carbon-di-oxide as contrast!!!!
 In renal insuffficiency
60
Dept of Urology, GRH and KMC,
Chennai.

60. Gadolinium for angiogram???!!!
 No known deleterious effects on renal
function…
 Even in renal failure
 Better than co2.
61
Dept of Urology, GRH and KMC,
Chennai.

61. Approaches :::
 Retrograde femoral approach:
 Land mark for puncture—over
femoral head(easy for compression)
 Strong valsalva 8 sec before
injection—better film(decrease CO).
62
Dept of Urology, GRH and KMC,
Chennai.

62. Seldinger’s technique
63
Dept of Urology, GRH and KMC,
Chennai.

63. ALTERNATIVE APPROACHES
 Axillary artery
 Left brachial artery
 Translumbar aortography
64
Dept of Urology, GRH and KMC,
Chennai.

64. Translumbar puncture
65
Dept of Urology, GRH and KMC,
Chennai.

65. Better imaging techniques
 Digital subtraction angiography
 Direct magnification arteriography
 Pharmacoangiography
66
Dept of Urology, GRH and KMC,
Chennai.

66. Digital subtraction arteriography
 Subtracting bone,gas,soft tissues
 Super imposing image before contrast
injection on arteriographic image.
 Breathing..movement degrades the
image.
 Does “road mapping”
 Intra venous DSA– obsolete.
67
Dept of Urology, GRH and KMC,
Chennai.

67. DSA “STRING OF BEADS”
68
Dept of Urology, GRH and KMC,
Chennai.

68. Direct magnification arteriography
 Moving patient closer to X Ray tube
and away from the film.
 Divergence of X Rays magnifies
image on film.
 X2…x3 magnification
69
Dept of Urology, GRH and KMC,
Chennai.

69. 44y old hypertensive pt(MRA)
70
Dept of Urology, GRH and KMC,
Chennai.

70. DMA(fibromuscular dysplasia)
71
Dept of Urology, GRH and KMC,
Chennai.

71. Pharmacoangiography
 Injecting vasoconstrictor/vasodilator
into renal vessel to alter circulation of
blood.
 Use of vasoconstrictor(epinephrine)
 Diversion of contrast into tumour.
 Use of vasodilators(acetylcholine)
 Haemodynamic significance of renal
artery stenosis.
72
Dept of Urology, GRH and KMC,
Chennai.

72. Indication for renal arteriography
 Role reduced. only for interventional
procedures.(PTRA,embolisation)
1.renovascular hypertension
2.renal trauma
3.renal tumour
73
Dept of Urology, GRH and KMC,
Chennai.

73. Normal renal arteriogram
 Three phrases
1.arterial phase(<2 sec)
2.nephrogenic phase(early,late)
3.venous phase(4 sec to 10 sec)
74
Dept of Urology, GRH and KMC,
Chennai.

74. Arterial phase(<2 seconds)
75
Dept of Urology, GRH and KMC,
Chennai.

75. Nephrogenic phase::
76
Dept of Urology, GRH and KMC,
Chennai.

76. Percutaneous trans catheter therapy
 Percutaneous transluminal renal
angioplasty(PTRA).
 Percutaneous transluminal stent placement.
 Percutaneous transluminal
 PTRA with antiproliferative agents
 PTRA with brachytherapy.
 Renal artery thrombolysis
 Transcatheter embolisation
 Transcatheter ablation
77
Dept of Urology, GRH and KMC,
Chennai.

77. CT ANGIOGRAPHY
78
Dept of Urology, GRH and KMC,
Chennai.

78. Protocol for CT Angiography
 Attention to proper patient
positioning,preparation,contrast
material injection
 Tailoring imaging parameters to
clinical region of interest
79
Dept of Urology, GRH and KMC,
Chennai.

79. Procedure :
1. A large-bore (18-gauge) intravenous line is
placed in the antecubital fossa.
2. Water orally used as a negative contrast agent
3. Require a 30- to 40-second breath hold
for obtaining optimal images of the renal hilum
multidetector helical CT scanners are much
faster and a breath hold of only 10–20 seconds
is needed.
4.Use of narrow collimation (1–3 mm) is crucial.
A pitch up to 2 is used to ensure adequate
coverage
5.contrast material is injected at 3–4 mL/sec
for a volume of 120–150 mL.
80
Dept of Urology, GRH and KMC,
Chennai.

80.  Delay of 20–25 seconds after the start of
the contrast material injection.
 For evaluation of the renal hilum,
use of 1-mm interscan spacing is
ideal (especially for assessing renal
artery stenosis).
For routine anatomic evaluation,
3-mm interscan spacing is suitable.
81
Dept of Urology, GRH and KMC,
Chennai.

81. Post processing techniques::
 Surface rendering
 Maximum intensity projection(MIP)
 Volume rendering
 Volume rendering ---post processing
technique of choice.
 Provides an additional view.”seeing
from within the vessel”.
82
Dept of Urology, GRH and KMC,
Chennai.

82. Norml ct angio picture(3D volume
rendered)
83
Dept of Urology, GRH and KMC,
Chennai.

83. Ct angio-volume rendered(virtual
angioscopic view)
84
Dept of Urology, GRH and KMC,
Chennai.

84. Coparision of MIP and volume
rendering:
 MIP processing  Volume rendering
85
Dept of Urology, GRH and KMC,
Chennai.

85. CT Angiography and
Normal Anatomy
 arterial branches can be identified to
at least the segmental level.
 Detection of vessels smaller than 2 mm
is limited .
 The sensitivity of volume-rendered
CT angiography for the demonstration
approaches 100% .
 Surgical and CT findings correlate in over
95% of patients.
86
Dept of Urology, GRH and KMC,
Chennai.

86. Clinical Applications of
CT Angiography
87
Dept of Urology, GRH and KMC,
Chennai.

87. Renal arterial disorders
88
Dept of Urology, GRH and KMC,
Chennai.

88. Atherosclerotic disease
89
Dept of Urology, GRH and KMC,
Chennai.

89. Renal Artery Aneurysms
 Approximately 1% of patients .
 Atherosclerotic aneurysms can become large and
often develop rim calcification.
 Polyarteritis nodosa aneurysms do not calcify and are
more prone to rupture .
 small and peripheral in the distal branches or the
interlobar arteries and beyond, these aneurysms
may not always be detectable with CT angiography.
90
Dept of Urology, GRH and KMC,
Chennai.

90. Ct angio vs traditional angio for RAA
91
Dept of Urology, GRH and KMC,
Chennai.

91. Other Conditions::
 the left renal artery, are frequently
involved in aortic dissection. In such
cases, CT angiography demonstrates
an intimal flap
 Arteriovenous fistulas are often the
result of prior trauma or biopsy
92
Dept of Urology, GRH and KMC,
Chennai.

92. Renal Vein Disorders
93
Dept of Urology, GRH and KMC,
Chennai.

93. Renal Vein Thrombosis:
 Most important cause of renal vein
thrombosis is tumor thrombus from renal
cell carcinoma or, in rare cases, adrenal
carcinoma.
 The renal veins are well depicted on the CT
angiogram during early corticomedullary
phase of enhancement
 seen as a hypoattenuating filling defect
within an enlarged renal vein .
94
Dept of Urology, GRH and KMC,
Chennai.

94. RENAL VEIN THROMBOSIS
95
Dept of Urology, GRH and KMC,
Chennai.

95. PRE-TRANSPLANT DONOR ASSAY
pre-hilar branching
96
Dept of Urology, GRH and KMC,
Chennai.

96. Post-transplant Evaluation
 Graft renal artery stenosis:
 3%–15%, usually within the first 3
years after transplantation .
97
Dept of Urology, GRH and KMC,
Chennai.

97. MAGNETIC
RESONANCE
ANGIOGRAPHY
98
Dept of Urology, GRH and KMC,
Chennai.

98. Principles of MRA imaging
 Conventional MRA bright blood
techniques are
1 . Time of flight sequence(TOF)
2 . Phase contrast sequences
99
Dept of Urology, GRH and KMC,
Chennai.

99. Time of flight::
 Flowing blood produces a high signal
 Called “flow related enhancement”
 Images inferior compared to 3D
phase contrast.
100
Dept of Urology, GRH and KMC,
Chennai.

100. Phase contrast technique::
 Flowing vessel develops a phase shift
 Stationary tissues do not undergo any
phase shift
 Flowing blood easily differentiated
from surrounding stationary tissue.
 Proportional to velocity of blood
brightness of signal increases.
101
Dept of Urology, GRH and KMC,
Chennai.

101. Dynamic enhanced gadolinium MRA
 Continuous infusion of gadolinium during
T1 weighted gradient echo scan lasting 5
minutes.
 Advantage :
turbulence may cause loss of signal in
phase contrast.large signal loss is seen in
stenosis….partly due to stenosis and parlty
due to post stenotic turbulance.
Not seen in GADOLINIUM DTPA MRA.
102
Dept of Urology, GRH and KMC,
Chennai.

102. Gadolinium enhanced 3D phase
contrast
103
Dept of Urology, GRH and KMC,
Chennai.

103. Points to ponder::
 CT angio –investigaton of choice for pre-
transplant donor assessment.
 Renal arteriography—for smaller vessels in
the parenchyma & for percutaneous
transluminal intervensions
 MRA – Same as CT..but…can also be used
in renal failiure.
104
Dept of Urology, GRH and KMC,
Chennai.

104. Rank Order of Renal Imaging
105
Dept of Urology, GRH and KMC,
Chennai.

105. 106
Dept of Urology, GRH and KMC,
Chennai.