Laboratory Studies

The following studies should be performed before any surgical intervention for a renal artery aneurysm (RAA):

Complete blood count (CBC)
Chemistry panel
Coagulation profile
Urinalysis

Special attention should be paid to the blood urea nitrogen (BUN) and creatinine levels because these values are indicative of renal function and can be followed to confirm that no renal damage exists if the decision is made to manage an RAA nonoperatively.

In a patient with hypertension, RAA, and no renal artery stenosis, studies should be ordered to exclude other endocrine sources of hypertension, including the following:

Pheochromocytoma - 24-hour urine collection for vanillylmandelic acid, metanephrine, and normetanephrine
Primary aldosteronism - Serum potassium
Cushing syndrome - Cortisol levels
Carcinoid - Urinary 5-hydroxyindoleacetic acid

Imaging Studies

Because most RAAs are asymptomatic and are found incidentally during a workup for other intra-abdominal pathology, imaging studies are required only for preintervention planning or longitudinal follow-up care.

Ultrasonography

Ultrasonography (US) with duplex examination is the least invasive imaging study.^[31]Two-dimensional (2D) US forms an anatomic picture based on the time delay of ultrasonic pulses reflected from structures. Vessel walls reflect ultrasound waves and appear white; blood absorbs and scatters ultrasound waves, appearing black. Normal vessels appear as dark-filled, white-walled structures.

Duplex studies use Doppler-shift measurement to detect the direction and velocity of blood flow. This can be useful in identifying renal artery stenosis. US can also be used in determining the how functional a kidney is by measuring its size. It should be kept in mind that the quality of imaging is highly operator-dependent and may be limited by the patient's body habitus.

Computed tomography

Computed tomography (CT) is the most widely available and reproducible imaging modality. It is the test of choice for diagnosis and follow-up. Its anatomic resolution is superior to that of US (see the image below).

(A) Computed tomography scan and (B) arteriogram of the same patient with a saccular left renal artery aneurysm at a segmental renal artery branch.

View Media Gallery

The advent of CT angiography (CTA) and three-dimensional (3D) reconstruction has facilitated accurate preinterventional planning. Because intravenous (IV) iodinated dye must be used, the only real limitation of this modality is in patients who have a life-threatening dye allergy or impaired renal function. Non-life-threatening dye allergies can be managed with premedication with diphenhydramine (histamine-1 receptor antagonist), cimetidine (histamine-2 receptor antagonist), and methylprednisolone sodium succinate (glucocorticoid).

Magnetic resonance angiography

Magnetic resonance angiography (MRA) with gadolinium enhancement and 3D reconstruction can produce images similar in quality to those obtained with arteriography (see the image below). However, this technology is not as readily available as US or CT, and it is more expensive.^[32]

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.

View Media Gallery

Arteriography

Arteriography is the most invasive test but can be useful for helping define unclear anatomy seen on prior examinations (see the images below). For the most part, arteriography as a diagnostic test has been supplanted by CTA and MRA.

(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.

View Media Gallery

(A) Computed tomography scan and (B) arteriogram of the same patient with a saccular left renal artery aneurysm at a segmental renal artery branch.

View Media Gallery

Treatment & Management

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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.

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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 Associate Professor of Surgery, Site Director, Vascular Surgery, Einstein Campus, Program Director, Vascular Surgery Residency and Fellowship, Department of Cardiothoracic and Vascular Surgery, Division of Vascular and Endovascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine

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, Association of Program Directors in Vascular Surgery, Connecticut State Medical Society, Eastern Vascular Society, International Society of Endovascular Specialists, New England Society for Vascular Surgery, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society for Vascular Ultrasound, Vascular and Endovascular Surgery Society, Yale Surgical Society

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, FACS Professor and Chief, Division of Vascular and Endovascular Surgery, Gonda (Goldschmied) Vascular Center, University of California, Los Angeles, David Geffen School of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Richard A Santucci, MD, FACS Senior Surgeon, Crane Surgical Services

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

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