Giant Calcified Renal Artery Aneurysm: Traditional RX versus Three-Dimensional Computed Tomography

doi:10.4236/act.2013.21004

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Advances in Computed Tomography, 2013, 2, 20-22

http://dx.doi.org/10.4236/act.2013.21004 Published Online March 2013 (http://www.scirp.org/journal/act)

Giant Calcified Renal Artery Aneurysm: Traditional RX

versus Thr ee-Dimensional Computed Tomography

Mauro Gacci1, Omar Saleh1, Annalisa Mantella1, Leonidas Azas2, Paola Romagnani3,

Andrea Minervini1, Sergio Serni1, Marco Carini1

1Department of Urology, University of Florence, Florence, Italy

2Department of Vascular Surgery, University of Florence, Florence, Italy

3Excellence Center for Research, Transfer and High Education (DENOTHE), University of Florence, Florence, Italy

Email: [email protected]

Received November 7, 2012; revised December 16, 2012; accepted December 26, 2012

ABSTRACT

A 65-year-old woman with no history of previous flank trauma, renal stone or upper urinary tract infections, presented

for flank pain and left hydro-uretero-nephrosis seven days after hysterectomy. Percutaneous pielography revealed nar-

rowing of the distal ureter, without endoureteral mass. The plain abdomen film incidentally showed a 3-cm calcified

ring on the left renal shadow, who resulted external to the collecting system at pielography. A 3-dimensional-CT scan

with angiographic reconstruction revealed a 3-cm calcified renal artery aneurysm. The vascular surgeon suggested a

watchful waiting. The patient underwent ur eteral reimplantation with ureteral stenting, allowing a co mplete recovery of

iatrogenic stenosis two months postoperatively.

Keywords: Renal Artery Aneurysm; 3D-CT; Angiographic Reconstruction

1. Introduction

Renal artery aneurysms have been encountered with

increasing frequency over the past decade. It is slightly

more common in women than men and in the right than

left renal artery [1]. Many cases are asymptomatic and

found incidentally, and their occurrence has been recen-

tly increasing with the advancement of imaging techni-

ques. Angiography is the gold standard in the diagnosis

of renovascular injuries, and it has the additional advan-

tage to possesses the poten tial of therapeutic intervention

[2]. Therefore, after any invasive urological procedure,

CT angiography can be considered as the first choice for

renal artery injury [3,4]. In the present case, we inciden-

tally discovered a lesion of the left renal artery and we

completed the diagnostic work-up with a 3D-CT scan.

2. Case Report

A 67-year-old woman was referred to the Department of

Urology for left flank pain developed seven days after

hysterectomy for uterine leiomyomatosis. The patient

had no history of previous flank trauma, renal stone or

upper urinary tract infections. Physical examination was

unremarkable, with only minimal flank pain at Giordano

manoeuvre; body temperature was 37˚C, blood pressure

was 120/75 mmHg. White cell count was within the

limits (9 × 109 white blood cells in a litre of blood); ren al

and liver functions were normal (creatinine 0.9 mg/dL,

total bilirubin 0.8 mg/dL). A severe left hydronephrosis

was detected at ultrasound, with no sign of uretheral

stones or masses. The plain abdomen film showed a 3-cm

calcified ring on the left renal shadow (Figure 1(a)).

Percutaneous pielography confirmed hydronephrosis, and

showed no relationship of the calcified mass with th e col-

lecting system (Figure 1(b)).

A 3-dimensional-CT scan revealed a 3-cm round hol-

low mass with calcified walls located in front of anterior

renal surface. The lesion had no connection with renal

pelvis (Figure 2(a)) but was firmly related with renal

artery, and it was compatible with calcified renal artery

aneurysm (Figure 2(b)). The patient was treated with an

open access ureteral reimplantation performed on the

suture of the previous surgical approach. A direct ure-

theral reimplantation on the upper bladder wall was per-

formed, with psoas hitch and double J uretheral stenting.

At the 1 month follow up visit there was a complete

recovery of the obstruction. The vascular surgeon sugge-

sted a watchful waiting by monitoring blood pressure,

renal function, and imaging ever y 6 months.

3. Discussion

Renal artery aneurysms (RAA) are rare, with an estima-

ted incidence below 1%. Hypertension and fibro-mus-

cular disease of the renal artery are the leading classes of

M. GACCI ET AL. 21

(a)

(b)

Figure 1. (a) Plain abdomen film performed showing a left

3-cm calcified ring on the left renal shadow; (b) Pielography

demonstrating no relationships of the calcified mass with

the collecting system.

risk [5]. There is no significant difference in side pre-

sentation (right side in 43%, left in 36% and 21% bi-

lateral). Aneurysm usually involve the main renal artery

or the primary branches. Mean size at diagnosis ranges

from 0.5 to 8 cm, with a mean diameter of 2.1 cm. De-

generative (arteriosclerosis, fibrodysplasia), inflamma-

tory (arteritis) or traumatic diseases, including iatroge-

nic damages after kidney puncture [5], may cause RAA.

RAA can be classified into 4 categories: 1) true macro-

aneurysm; 2) aneurysmal dissections; 3) fusiform micro-

(a)

(b)

Figure 2. (a) CT scan show ing a calcified round mass faci ng

anterior renal surface; (b) 3-dimensional TC re-construc-

tion showing the relationship with renal artery, compatible

with calcified renal artery aneurysm.

aneurysmal dilations; and 4) microaneurysm resulting

from arteritis [6]. They are usually asymptomatic and

serum creatinine levels are mostly within normal range at

diagnosis. Complications, including renovascular hyper-

tension, renal embolization with in farction , thro mbosis or

dissection, and arteriovenous fistula, [5] are rarely repor-

ted.

4. Conclusion

The diagnosis has been recently increased by the spread-

ing use of imaging techniques [7]. Conventional renal

angiography represents the gold standard in the detection

of renal aneurysms, though the spiral CT renal angio-

M. GACCI ET AL.

graphy with three dimensional reconstruction (3D-CT)

adds the benefits of being quicker, more costeffective,

and non-invasive. Moreover, the use of 3D-CT worksta-

tion allows accurate treatment planning, especially for

endovascular proce d ur es [8].

Management options include observation, trans-cathe-

ter-occlusion or surgical interven tion. The indications for

surgery include: symptomatic or enlarging aneurysms,

renal embolization, aneurysms in pregnant females or

those considering pregnancy, renovascular hypertension,

aneurysms >2.5 cm [9].

REFERENCES

[1] J. C. Stanley, L. M. Messina and G. B. Zelenock, “Splan-

ckmc and Renal Artery Aneurysms,” In: W. S. Moore,

Ed., Vascular Surgery: A Comprehensive Review, WB

Saunders, Philadelphia, 1491, pp. 335-349.

[2] Y. H. Rokni and Y. Moharamzad, “Endovascular Treat-

ment of Renal Arteriovenous Fistula Following a Stab

Wound,” Urology Journal, Vol. 5, No. 2, 2008, pp. 129-

131.

[3] L. J. Zhang, G. F. Yang, J. Qi and W. Shen, “Renal Ar-

tery Aneurysm: Diagnosis and Surveillance with Multi-

Detector Row Computed Tomography,” Acta Radiolo-

gica, Vol. 48, No. 3, 2007, pp. 274-279.

doi:10.1080/02841850601161521

[4] F. Y. Dönmez, M. Cokun, A. Uyuur, et al., “Non-Inva-

sive Imaging Findings of Idiopathic Renal Arteriovenous

Fistula,” Diagnostic and Interventional Radiology, Vol.

14, No. 2, 2008, pp. 103-105.

[5] A. Lumsden, T. Salam and K. Walton, “Renal Artery

Aneurysm: A Report of 28 Cases,” Cardiovascular Sur-

gery, Vol. 4, No. 2, 1996, pp. 185-189.

doi:10.1016/0967-2109(96)82312-X

[6] J. C. Stanley, E. L. Rhodes, B. L. Cewertz, C. Y. Chang, J.

F. Walter and W. J. Fry, “Renal Artery Aneurysms: Sig-

nificance of Macroaneurysms Exclusive of Dissections

and Fibrodysplastic Mural Dilations,” Archives of Sur-

gery, 1975; Vol. 110, No. 11, 1975, pp. 1327-1333.

doi:10.1001/archsurg.1975.01360170067009

[7] S. P. Stanl and E. Fishman, “Three Dimensional Ct Angi-

ography: Renal Applications,” Semin Ultrasound CT MR,

Vol. 19, No. 5, 1998, pp. 413-424.

doi:10.1016/S0887-2171(98)90018-X

[8] W. Higashiura, S. Sakaguchi, N. Tabayashi, S. Taniguchi

and K. Kichikawa, “Impact of 3-Dimensional-Computed

Tomography Workstation for Precise Planning of Endo-

vascular Aneurysm Repair,” Circulation Journal, Vol. 72,

No. 12, 2008, pp. 2028-2034.

doi:10.1253/circj.CJ-08-0331

[9] C. Dzsinich, P. Gloviczki, M. A. McKusick, P. C. Pai-

rolero, T. C. Bower, J. W. Hallett Jr. and K. J. Cherry Jr.,

“Surgical Management of Renal Artery Aneurysm,” Car-

diovascular Surgery, Vol. 1, No. 3, 1993, pp. 243-247.

Abbreviation and Acronym

Renal artery aneurysms (RAA) Units