History and Physical Examination

Asymptomatic

Most renal artery aneurysms (RAAs) are asymptomatic and are found incidentally during investigation of other intra-abdominal pathologies with diagnostic imaging studies such as computed tomography (CT), duplex ultrasonography (US), angiography, magnetic resonance imaging (MRI), or magnetic resonance angiography (MRA). In a small series by Dzsinich et al, only 34% (11 of 32) patients who underwent surgery were symptomatic.^[8]

In asymptomatic patients, complications from RAA are relatively infrequent. In one study, 62 asymptomatic patients who had solitary saccular aneurysms with a mean size of 1.5 cm (range, 0.3-4.0 cm) were followed over a mean period of 5.7 years (median, 8 years). No ruptures, need for operations, or new symptoms developed. Eight patients (12%) did expire, but all of these deaths were unrelated to the aneurysm.^[11]

In another series, 34 RAAs were managed nonoperatively and followed with serial arteriograms. Over a mean interval of 35 months, no changes were found in 28 (82.4%) RAAs, and slight changes were found in the other six (17.6%). Again, no ruptures were found during follow-up.^[35]

Morita et al published an additional study with similar results. They followed 30 patients for a median follow up of 69 months with conservative management only. At the end of the study, only two patients showed growth in their aneurysm, and only two other patients required an increase in blood pressure medications.^[36]

Symptomatic

Hypertension is the most common symptom found in RAA, with reported incidence as high as 90%. Often, renal artery stenosis is associated with a poststenotic fusiform aneurysm. In this case, the hypertension can be attributed to the renal artery stenosis and activation of the renin-angiotensin system, with increased angiotensin II levels resulting in fluid retention and vasoconstriction.^[23]

Hypertension in RAA without a renal artery stenosis is not as well understood. Possible causes of hypertension in these cases may be related to renal ischemia secondary to thromboembolization distal to the aneurysm; in cases of large aneurysms, anatomic kinking of the renal artery has been reported.^[37]Saccular and intrarenal aneurysms are less likely to be associated with hypertension.

In case series, 8-25% of patients presented with abdominal pain.^{[8, 11, 13]}Patients with RAAs caused by dissection may present with flank pain, though most of those with spontaneous dissections are asymptomatic. New or worsening pain may also be indicative of a rapidly expanding aneurysm or impending rupture.

Hematuria may be another manifestation of dissecting RAA. Intraparenchymal aneurysms, which rupture into the collecting system, may also manifest as hematuria.

Collecting system obstruction is a rare presentation but has been documented in patients with larger aneurysms.

Renal infarction may be visualized on CT and is the result of embolization from the aneurysm sac.

Fewer than 3% of patients with RAAs experience a rupture.^[6]Patients with RAA rupture typically have signs and symptoms of an abdominal catastrophe and may be in frank shock.^[10]

Workup

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Media Gallery

Schematic of renal artery anatomy. The aneurysm location can be classified as extraparenchymal or intraparenchymal.
(A) Aortogram with calcified left renal artery aneurysm (RAA). (B-C) Same RAA in magnified view, demonstrating the RAA is saccular, arising from the main renal artery.
(A) Computed tomography scan and (B) arteriogram of the same patient with a saccular left renal artery aneurysm at a segmental renal artery branch.
Magnetic resonance imaging of a patient with 2 left renal artery aneurysms. Both are saccular, one is at a segmental branch (closed arrow) and the other is intrarenal (open arrow). Of note: this patient also has a congenital absence of the right kidney.
(A) Extraparenchymal saccular aneurysm. (B) Tangential excision with patch angioplasty.
(A) Fibromuscular dysplasia with string-of-beads appearance and wide-necked extraparenchymal saccular aneurysm. (B) Aneurysm excision with reconstruction using a bypass graft.
Arteriogram of saccular renal artery aneurysm after coil embolization.
Subsequent expansion of aneurysm 6 months after coil embolization.
(A) Renal artery stenosis with poststenotic fusiform aneurysm. (B) Exclusion of aneurysm and dilatation of stenosis with endovascular stent graft.

of 9

Author

Lindsay Gates, MD Assistant Professor of Surgery, Washington State University College of Medicine

Lindsay Gates, MD is a member of the following medical societies: Society for Vascular Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey E Indes, MD, FACS Assistant Professor of Surgery and Radiology, Associate Program Director, Vascular Surgery Residency/Fellowship, Director, Non-Invasive Vascular Laboratory, Director, Yale Vein Center, Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine; Attending Surgeon, Yale-New Haven Hospital and VA Connecticut Healthcare System

Jeffrey E Indes, MD, FACS is a member of the following medical societies: American College of Phlebology, American College of Surgeons, Association for Academic Surgery, Connecticut State Medical Society, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Eastern Vascular Society, Society for Clinical Vascular Surgery, International Society of Endovascular Specialists, Society for Vascular Ultrasound, New England Society for Vascular Surgery, Yale Surgical Society, Association of Program Directors in Vascular Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Integrated Vascular Surgery Residency and Fellowship, Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Additional Contributors

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, International Society of Urology, American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

Nicholas D Garcia, MD Chief of Surgery, Exeter Hospital; Chair, Board of Directors, Core Physicians, LLC

Nicholas D Garcia, MD is a member of the following medical societies: American College of Surgeons, New Hampshire Medical Society, and Society for Vascular Surgery