Renal arteries and veins. The renal artery departs from

Anatomy Vessels Arteries of the systemic circulation Arteries of the trunk Abdominal part of the aorta Internal branches of the abdominal part of the aorta

Renal artery, a. renalis (Fig. 776, 777, 778, 779; see Fig. 767), - a paired large artery. It starts from the lateral wall of the aorta at the level of the II lumbar vertebra almost at a right angle to the aorta, 1-2 cm below the discharge of the superior mesenteric artery. The right renal artery is slightly longer than the left, since the aorta lies to the left of the midline; heading towards the kidney, it is located behind the inferior vena cava.

Figure: 777. Arteries and veins of the kidney (photograph of a corrosive preparation. Preparation M. Burykh). 1 - renal artery; 2 - branches of the renal artery; 3 - branches of the renal vein; 4 - renal vein; 5 - inferior vena cava; 6 - renal pelvis; 7 - ureter. Figure: 776. Renal artery, a. renalis, left, and its branches. (Part of the renal parenchyma was removed; the injected vessels were prepared.)

Before reaching the hilum of the kidney, each renal artery gives off a small inferior adrenal artery, a. suprarenalis inferior, which, having penetrated the adrenal parenchyma, anastomoses with the branches of the middle and superior adrenal arteries.

Figure: 778. Vessels of the kidneys and adrenal glands; front view (radiograph).

In the area of \u200b\u200bthe hilum of the kidney, the renal artery is divided into anterior and posterior branches (see Fig. 776, 777).

Front branch, r. anterior, enters the renal gate, passing in front of the renal pelvis, and branches, sending arteries to the four segments of the kidneys: the artery of the upper segment, a. segmenti superioris, - to the top; the artery of the upper anterior segment, a. segmenti anterior superioris, - to the upper anterior; the artery of the lower anterior segment, a. segmenti anterioris inferioris, - to the lower anterior and lower segment artery, a. segmenti inferioris, - to the bottom. Back branch, r. posterior, the renal artery passes behind the renal pelvis and, heading to the posterior segment, gives up the ureteral branch, r. uretericus, which can branch off from the renal artery itself, is divided into posterior and anterior branches.

FIRST SAINT PETERSBURG STATE MEDICAL UNIVERSITY named after AK. I.P. PAVLOVA

Department of Clinical Anatomy and Operative Surgery named after prof. M.G. Weight gain

Head department professor Akopov Andrey Leonidovich

"Surgical anatomy of renal arteries and the applied value of options ( topographic anatomy arteries of the kidneys). Accessory arteries of the kidneys. Technique for performing kidney resection and nephrectomy. "

Performed:

4th year student, gr. 402

Petukhova Galina Alexandrovna

Checked:

Makeeva Tatiana Konstantinovna

St. Petersburg,

Introduction

The study of the structural features of both outside and intra-organ vessels of the kidneys and pelvis is not only of theoretical interest, but also of significant practical importance in connection with the widespread use of various reconstructive operations performed on the vessels of this organ (vascular plastic, heterotopic autotransplantation, kidney prolapse, etc.). etc.).

Of particular importance are the details of the structure and topography of the renal arteries and veins when performing allograft transplantation, as one of the promising methods of treating chronic renal failure.

Kidney disease is affecting an increasing number of people. In Russia, about 4 percent of the population already has kidney disease. According to statistics, the symptoms of kidney disease are more often observed in women, however, in men, kidney diseases are, as a rule, in severe and neglected forms. Thus, it is difficult to overestimate the importance of knowledge about the individual variability of the structure of the vessels of the kidney and the technique of kidney surgery.

Topographic and variant anatomy of the blood vessels of the kidneys

Arterial bed of the kidneys. In the renal pedicle, the renal vein is most superficial and high, behind and below it is the renal artery, behind the vessels is the renal pelvis. This variant of syntopy of renal pedicle elements occurs in 49% of cases. In 40% of cases, the renal artery is located in front of the vein, in other cases, there is a complex interlacing of the branches of the arteries and veins located in front of the pelvis. The blood supply to the kidneys is carried out by the renal arteries extending from the abdominal aorta at an angle close to a straight line at the level of the lower half of the I lumbar or upper edge of the II lumbar vertebrae 1-2 transverse fingers below the superior mesenteric artery. However, on the right, the angle of origin of the renal artery can vary from 60 ° to 135 °, on average it is 90 °, on the left - from 50 ° to 135 ° and on average is 85 °. The right renal artery departs from the aorta 1-2 cm lower than the left. The renal arteries can branch off at the same level, this branching variant, according to various authors, is observed in 29.8-45% of cases. The diameter of the aorta is 23-26 mm, the diameter of the renal arteries is 4-8 mm. The topography of the renal arteries is as follows. The right renal artery is longer, it crosses the legs of the lumbar diaphragm and the psoas major muscle, located behind the inferior vena cava. It is covered by the head of the pancreas and the descending part of the duodenum. The length of the right renal artery ranges from 40 mm to 91 mm, averaging 65.5 mm. The left renal artery is shorter than the right, goes behind the left renal vein and is often located in the area of \u200b\u200bthe hilum close to the splenic artery, which runs at the upper edge of the tail of the pancreas. The length of the left renal artery is 35-79 mm, with an average of 55.1 mm. The renal arteries give off extraorganic and intraorgan branches. From both renal arteries, the thin lower adrenal arteries extend upward, and the ureteral branches extend downward. At the hilum of the kidneys, the renal arteries, giving off thin branches to the pelvis, cups and fibrous capsule of the kidney, are usually divided into anterior and posterior zonal branches, then dividing into segmental arteries at the hilum of the kidneys. The anterior branch, which forms the anterior lohase vascular system, is larger in 75% of people and supplies blood to most of the kidney parenchyma, its length is 5-35 mm, on average 12.7 mm. It usually gives off three segmental arteries: the superior polar, superior and inferior pre-pelvic arteries. The posterior branch, the length of which is 5-45 mm, on average 18.4 mm, forms the retilochanteric vascular system, from which the inferior pole and posterior segmental arteries depart. The zone where the system of the anterior zonal branch of the renal artery borders on the posterior one is most often located 1 cm posterior to the middle of the outer edge of the kidney (Tsondeka line) (Fig. 1).

Fig. 1 The length of the segmental arteries ranges from 20 mm to 58 mm, the longest of which is usually lower. In accordance with the intrarenal distribution of arteries by the International Anatomical Nomenclature, the arterial segments of the kidney are distinguished: upper, upper anterior, lower anterior, lower and posterior. The five-segmental structure of the kidney is the most common, but it has been established that the number of segments can range from 4 to 12. The upper and lower segments are the most constant, but in 10% of cases they are divided into anterior and posterior. The number of anterior and posterior segments can range from 1 to 5. Segmental arteries do not anastomose with each other. Branches, called interlobar branches, branch off from the segmental arteries. Interlobar (interlobar) arteries lie in the renal columns and penetrate to the base of the renal pyramids, where they divide into arcuate (arcuate) arteries, which do not anastomose with each other and, in turn, give off interlobular (interlobular) arteries, radially branching and heading to the cortex ... The interlobular arteries in the cortical substance give off the intralobular arteries, from which the bringing arterioles depart, heading to the renal corpuscles and giving rise to a wonderful network of capillaries that forms vascular glomeruli. The capillaries of the glomeruli are collected in the efferent arterioles, which in the cortical nephrons are approximately 2 times smaller in diameter than the efferent arterioles. In this regard, the blood pressure in the capillaries of the glomeruli of the cortical nephrons reaches 70-90 mm. rt. Art. The efferent arterioles give rise to the secondary peritubular capillary network of the cortical and medulla, and in the deep layers of the medulla they have a direct course (straight vessels). The share of glomerular and cortical peritubular arterial networks accounts for 86%, medullary - only 14% of the vascular bed of the kidneys. Special attention should be paid to the vascular system of juxtamedullary nephrons. About 80% of the nephrons are almost entirely located in the cortex - these are cortical nephrons. The remaining 20% \u200b\u200bof the nephrons are located in such a way that their capsules, proximal and distal parts lie in the cortex, and the nephron loops with ascending and descending parts lie in the medulla. In juxtamedullary nephrons, the diameter of the inflow and outflow arterioles is approximately the same, and the blood pressure in the capillaries of the glomeruli is not more than 40 mm. rt. Art. From the efferent arterioles, blood mainly enters the direct vessels and, bypassing the secondary network of capillaries, into the direct venules. Naturally, the juxtamedullary vascular system is an easier and shorter route for blood to flow through the kidneys. Juxtamedullary arteriovenous blood shunting is important in conditions of intensive blood circulation and in a number of pathological conditions kidneys.

Accessory renal arteries can occur in 30-35% of cases. In this case, one (19.2%), two (2.1%) and three (0.7%) accessory renal arteries can be observed; on the right more often than on the left; in women more often than in men. Accessory renal arteries more often supply blood to the lower (15.7%) than the upper (3.8%) segment of the kidney. In relation to the renal pelvis, they are more often observed anterior to it (12%) than posteriorly (5%).

Accessory renal artery is the most common type of renal vascular anomaly. It can branch off from the aorta, renal, diaphragmatic, adrenal, celiac, iliac arteries and go to the upper or lower segment of the kidney. Accessory arteries to the lower segment of the kidney very often interfere with the outflow of urine from the kidney. At the intersection of the urinary tract and the vessel in the wall of the ureter, irreversible sclerotic changes occur, leading to the development of hydronephrosis, pyelonephritis, and the formation of stones. Violation of urodynamics is more pronounced if the accessory vessel is located anterior to the urinary tract. Treatment is aimed at restoring the outflow of urine from the kidney and consists in crossing the accessory vessel and due to the occurrence of the ischemic zone - resection of the kidney, as well as resection of the sclerotic zone of the urinary tract and ureterouretero- or ureteropyelostomy. If the additional vessel feeds most of the kidney and its resection is impossible, resection of the narrowed part of the urinary tract and antevasal plastic are performed.

Double and multiple renal arteries are a type of abnormality in which the kidney receives blood supply from two or more trunks of equal caliber. Multiple arteries can be detected in a normal kidney, but more often they are combined with various kidney anomalies (dysplastic, doubled, dystopic, horseshoe kidney, polycystic, etc.). The most common source of formation additional arteries is the abdominal aorta, however, there are options for the discharge of these vessels from the common iliac, external or internal iliac, lumbar, sacral arteries, celiac trunk, middle adrenal and right colonic artery. Among the additional arteries of the kidney, it is customary to distinguish between accessory and perforating. Accessory artery always enters the parenchyma of the kidney in the area of \u200b\u200bits gate, while the perforating artery is called, penetrating into the substance of the kidney in any part of the surface of the organ outside its gate. One of the works devoted to the issues of additional arteries of the kidney is the work of S.G. Eremeeva (1962). In it, the author notes that accessory arteries in 54.2% flowed into the upper pole of the kidney, and in 45.8% of cases they supplied blood to the lower pole of the kidney, while the accessory artery to the lower pole is 2-3 times larger in diameter than the upper pole. N.M. Podlesny (1965, 1978) found additional arteries supplying the kidney in 25.2% of cases. The diameter of these vessels was 0.3-0.4 cm. The accessory arteries were 54.7%, and the perforating ones were 45.3%. The excretory urogram reveals a narrowing in the form of a filling defect, an S-shaped bend of the ureter, respectively, the projection of the vessel. According to academician N.A. Lopatkin, the presence of accessory renal arteries first cause periodic disturbances in the passage of urine from the pelvis due to dyskinesia of the pelvic-ureteric segment, and then lead to its scar damage due to continuous pressure on it. Accessory renal artery stenosis can also cause hypertension. Taking into account the number and level of an accessory vessel discharge is also important in patients before surgery, since its intersection can cause life-threatening bleeding.

The structure of the vessels of the kidney

The renal arteries branch off from the abdominal aorta just below the superior mesenteric artery - at level II of the lumbar vertebra. Anterior to the renal artery is the renal vein. At the hilum of the kidney, both vessels are located anterior to the pelvis.

The PPA runs behind the inferior vena cava. The LPV passes through the "forceps" between the aorta and the superior mesenteric artery. Sometimes there is a ring-shaped LPV, then one branch is located in front and the other behind the aorta.

Click on the pictures to enlarge.

A 2.5-7 MHz convex probe is used to study the kidney vessels. The position of the patient is supine, the sensor is placed in the epigastrium. Assess the aorta from the celiac trunk to the bifurcation in B-mode and CDC. Trace the PPA and LAA from the aorta to the renal hilum.

Picture. In the CDC mode on the longitudinal (1) and transverse (2) sections, the PPA and LPA depart from the aorta. The vessels are directed to the hilum of the kidney. The renal vein is located anterior to the renal artery (3).

Picture. The renal veins drain into the inferior vena cava (1, 2). Aortomesenteric tweezers can compress the LPV (3).

Picture. At the hilum of the kidney, the main renal artery is divided into five segmental arteries: posterior, apical, superior, middle, and inferior. Segmental arteries are divided into interlobar arteries, which are located between the pyramids of the kidney. The interlobar arteries continue into arcuate → interlobular → bringing arterioles of the glomeruli → capillary glomeruli. The blood from the glomerulus leaves along the efferent arteriole into the interlobular veins. The interlobular veins continue into the arcuate → interlobar → segmental → main renal vein → inferior vena cava.

Picture. Normally, with CDC, renal vessels can be traced to the capsule (1, 2, 3). The main renal artery enters through the renal hilum, accessory arteries from the aorta or iliac artery may approach at the poles (2).

Picture. Ultrasound examination of a healthy kidney: along the base of the pyramids (corticomedullary junction), linear hyperechoic structures with a hypoechoic pathway in the center are determined. These are arcuate arteries that are mistakenly regarded as nephrocalcinosis or stones.

Video. Arcuate arteries of the kidney on ultrasound

Doppler of renal vessels is normal

The diameter of the renal artery in adults is normally 5 to 10 mm. If the diameter<4,65 мм, вероятно наличие дополнительной почечной артерии. При диаметре главной почечной артерии <4,15 мм, дополнительная почечная артерия имеется почти всегда.

The renal artery should be assessed at seven points: at the exit from the aorta, in the proximal, middle and distal segments, as well as the apical, middle and inferior segmental arteries. We estimate the peak systolic (PSV) and end-diastolic (EDV) blood flow velocity, resistance index (RI), acceleration time (AT), acceleration index (PSV / AT). See more details.

The normal spectrum of the renal arteries has a pronounced systolic peak with antegrade diastolic flow throughout the entire cardiac cycle. In adults, normal on the main renal artery PSV 100 ± 20 cm / sec, EDV - 25-50 cm / sec, in young children PSV 40-90 cm / sec. In segmental arteries PSV drops to 30 cm / sec, in interlobar ones up to 25 cm / sec, in arc arteries up to 15 cm / sec and interlobular ones up to 10 cm / sec. RI at the hilum of the kidney<0,8, RI на внутрипочечных артериях 0,34-0,74. У новорожденного RI на внутрипочечных артериях достигает 0,8-0,85, к 1 месяцу опускается до 0,75-0,79, к 1 году до 0,7, у подростков 0,58-0,6. В норме PI 1,2-1,5; S/D 1,8-3.

Picture. Normal spectrum of renal arteries - high systolic peak, antegrade diastolic flow, low peripheral resistance - RI normal<0,8.

Picture. The spectrum of renal vessels in newborns: renal artery - pronounced systolic peak and antegrade diastolic flow (1); high resistance on the intrarenal arteries is considered normal for newborns - RI 0.88 (2); renal vein - antegrade flow at a constant rate throughout the entire cardiac cycle, minimal respiratory fluctuations (3).

Doppler for renal artery stenosis

Renal artery stenosis can be found in atherosclerosis or fibromuscular dysplasia. In atherosclerosis, the proximal segment of the renal artery is more often affected, and in fibromuscular dysplasia, the middle and distal segments.

Direct signs of renal artery stenosis

Alizing indicates the location of the turbulent high velocity flow where measurements should be made. In the area of \u200b\u200bstenosis PSV\u003e 180 cm / sec. In young people, the aorta and its branches may normally have high PSV (\u003e 180 cm / sec), and in patients with heart failure, PSV is low even in the area of \u200b\u200bstenosis. These features are leveled by the renal-aortic ratio RAR (PSV in the area of \u200b\u200bstenosis / PSV in the abdominal aorta). RAR for renal artery stenosis\u003e 3.5.

Indirect signs of renal artery stenosis

Direct criteria are preferred; the diagnosis should not be based solely on indirect evidence. In the post-stenotic section, the flow dies out - the tardus-parvus effect. With renal artery stenosis on the intrarenal arteries, PSV too late (tardus) and too small (parvus) - AT\u003e 70 ms, PSV / AT<300 см/сек². Настораживает значительная разница между двумя почками — RI >0.05 and PI\u003e 0.12.

Table. Ultrasound criteria for renal artery stenosis

Picture. A 60-year-old patient with refractory arterial hypertension. PSV in the abdominal aorta 59 cm / sec. In the proximal part of the PPA with CDC, aliasing (1), PSV is significantly increased 366 cm / sec (2), RAR 6.2. In the middle segment of the PPA with CDC, alizing, PSV 193 cm / sec (3), RAR 3.2 On segmental arteries without a significant increase in the acceleration time: upper - 47 ms, middle - 93 ms, lower - 33 ms. Conclusion:

Picture... A patient with acute renal failure and refractory arterial hypertension. Ultrasonography of the abdominal aorta and renal arteries is difficult due to gas in the intestines. On the segmental arteries on the left RI o, 68 (1), on the right RI 0.52 (2), the difference is 0.16. The spectrum of the right segmental artery has a tardus-parvus shape - acceleration time is increased, PSV is low, and the apex is rounded. Conclusion: Indirect signs of stenosis of the right renal artery. CT angiography confirmed the diagnosis: atherosclerotic plaques with calcification, moderate stenosis in the orifice of the right renal artery.

Picture. A patient with arterial hypertension. PSV in the aorta 88.6 cm / sec (1). In the proximal part of the PPA, aliasing, PSV 452 cm / sec, RAR 5.1 (2). In the middle section, PPA aliasing, PSV 385 cm / sec, RAR 4.3 (3) In the distal PAD PSV 83 cm / sec (4). On the intrarenal vessels of the tardus-parvus, the effect is not determined, on the right RI 0.62 (5), on the left RI 0.71 (6), the difference is 0.09. Conclusion: Stenosis in the proximal part of the right renal artery.

Renal vein Doppler

The left renal vein runs between the aorta and the superior mesenteric artery. Aortomesenteric forceps can compress a vein, leading to renal venous hypertension. In a standing position, the "tweezers" are compressed, and in a prone position, it opens. With Nutcracker syndrome, outflow along the left testicular vein is difficult. This is a risk factor for developing left-sided varicocele.

Because of the compression, the LPV spectrum is similar to the portal vein - the spectrum is above the baseline, constant low speed, smooth wave contour. If the ratio of the LPV diameter in front of and in the narrowing zone is more than 5 or the flow rate is less than 10 cm / sec, we make a conclusion about the increase in venous pressure in the left kidney.

A task. On ultrasound, the left renal vein is dilated (13 mm), the area between the aorta and the superior mesenteric artery is narrowed (1 mm). High velocity blood flow in the stenosis zone (320 cm / sec), reverse blood flow in the proximal segment. Conclusion: Compression of the left renal vein with aortomesenteric forceps (Nutcracker syndrome).

Compression of the renal vein is possible due to an abnormal position behind the aorta. The diameter ratio and flow rate are evaluated according to the above rules.

The nature of the blood flow in the right renal vein approaches the caval one. The shape of the curve changes with holding the breath; it can be flatter. Blood flow velocity 15-30 cm / sec.

Take care of yourself, Your Diagnostician!

Renal artery - paired terminal blood vessel, extending from the lateral surfaces of the abdominal aorta and supplying blood to the kidney. The renal arteries carry blood to the apical, posterior, inferior, and anterior segments of the kidney. Only 10% of the blood goes to the medulla of the kidney, and most (90%) to the cortex.

Renal artery structure

There are right and left renal arteries, each of which is divided into posterior and anterior branches, and these in turn are divided into segmental branches.

Segmental branches branch into interlobar branches, which disintegrate into a vascular network, consisting of arched arteries. Interlobular and cortical arteries, as well as medullary branches, from which blood flows to the lobes (pyramids) of the kidney, depart from the arcuate arteries to the renal capsule. All together they form arcs from which the bringing vessels depart. Each bringing vessel branches into a tangle of capillaries, enclosed by the glomerulus capsule and the base of the renal tubule.

The outflowing artery also splits into capillaries. Capillaries entwine the kidney tubules and then pass into the veins.

The right artery from the aorta runs forward and straight, and then goes to the kidney, obliquely and down, behind the inferior vena cava. The path of the left artery to the hilum is much shorter. It moves horizontally and from behind the left renal vein flows into the left kidney.

Renal artery stenosis

Partial occlusion of an artery or its main branches is called stenosis. Stenosis develops as a result of inflammation or compression of the artery by a tumor, dysplasia or atherosclerotic vasoconstriction. Fibromuscular dysplasias are a group of lesions in which there is a thickening of the middle, inner or subadential membranes of the vessel.

With stenosis of the renal arteries, the kidney function is disrupted due to its inadequate blood supply. Kidney dysfunction often leads to the development of renal failure. Renal artery stenosis sometimes manifests itself as a sharp increase in blood pressure. But most often this disease is asymptomatic. Prolonged arterial stenosis can lead to azotemia. Azotemia manifests itself in confusion, weakness, and fatigue.

The presence of stenosis is usually determined using CT angiography, Doppler ultrasonography, urophragia, arteriography. Additionally, to identify the causes of the disease, urine analysis, biochemical and general analysiss blood, determine the concentration of electrolytes.

To reduce pressure in stenosis, a combination of antihypertensive drugs with diuretics is usually prescribed. When narrowing the lumen of the vessel by more than 75%, use surgical techniques treatment - balloon angioplasty, stenting.

Renal artery denervation

To achieve a persistent antihypertensive effect, endovascular surgeons use the method of catheter sympathetic denervation of the renal arteries.

Renal artery denervation is an effective bloodless treatment for resistant hypertension. During the procedure, a catheter is inserted into the patient's femoral artery, which penetrates the arteries. Then, under short-term anesthesia, radiofrequency cauterization of the mouths of the arteries is performed from the inside. Cauterization destroys the connection of the afferent and efferent sympathetic nerves of the arteries with nervous system, which leads to a weakening of the effect of the kidneys on blood pressure indicators. After cauterization, the conductor is removed, and the puncture site of the femoral artery is closed with a special device.

After denervation, there is a stable decrease in blood pressure by 30–40 mm Hg. Art. throughout the year.

Renal artery thrombosis

Renal artery thrombosis is the blockage of renal blood flow by a thrombus that has come off the extrarenal vessels. Thrombosis occurs with inflammation, atherosclerosis, trauma. In 20-30% of cases, thrombosis is bilateral.

With renal artery thrombosis, an acute and strong pain in the lower back, kidney, in the back, which spreads to the abdomen and side.

In addition, thrombosis can cause a sudden, significant increase in blood pressure. Very often, with thrombosis, nausea, vomiting, constipation appear, and body temperature rises.

Treatment of thrombosis is complex: anticoagulant treatment and symptomatic therapy, surgical intervention.

Renal artery aneurysm

A renal artery aneurysm is a saccular expansion of the lumen of a vessel due to the presence of elastic fibers in its wall and the absence of muscle fibers. Aneurysm is most often unilateral. It can be placed both intrarenally and extrarenally. Clinically, this pathology can be manifested by vascular thromboembolism and arterial hypertension.

For renal artery aneurysm, surgery is indicated. There are 3 types of surgery for this type of anomaly:

• artery resection;
• excision of the aneurysm with the replacement of its defect with a patch;
• aneurysmography - suturing of the arterial wall with the tissues of the aneurysm, left after preliminary excision of its main part.

Aneurysmography is used for multiple vascular lesions and large aneurysms.

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Accessory renal artery

The accessory renal artery is the most frequent sight anomalies of renal vessels (84.6% of all detected malformations of the kidneys and upper urinary tract). What is called an "accessory renal artery"? In the early works of NA. Lopatkin wrote: "In order to avoid confusion, each vessel extending from the aorta in addition to the main renal artery should be called additional, and the term" multiple arteries "should be used when it means the entire supply of the kidney in such cases." In later publications, the term "accessory artery" is not used at all, but the term "accessory artery" is used.

Such arteries "have a smaller caliber in comparison with the main one, go to the upper or lower segment of the kidneys both from the abdominal aorta and from the main trunk of the renal, adrenal, celiac, diaphragmatic or common iliac artery." There is no clear difference in the interpretation of these concepts. A.V. Ayvazyan and A.M. Voino-Yasenetsky strictly distinguished the concepts of "multiple trunk", "additional" and "piercing" arteries of the kidney. "Multiple main arteries" originate from the aorta and flow into the renal notch. Common and external are the source of "accessory arteries". celiac, middle adrenal, lumbar arteries. But they all drain through the renal notch. "Perforating vessels" - penetrating into the kidney outside its gate. We have found another interpretation of abnormalities in the number of renal arteries in Campbell's urology (2002). In it S.B. Bauer, referring to a large number of works, describes "multiple renal arteries" - that is, more than one main artery, "abnormal or aberrant" - extending from any arterial vessel, except the aorta and the main renal artery, "accessory" - two or more arterial trunk feeding one renal segment.

In this way. we did not find a unified terminological approach to renal vascular anomalies of the number and therefore the vessels supplying the kidney, in addition to the main artery, and extending from the aorta or any vessel, except for the main artery, were considered "additional or additional vessel". We called "aberrant arteries" the vessels that extend from the renal artery and enter the kidney outside the renal sinus. The accessory renal artery can branch off from the aorta, renal, diaphragmatic, adrenal, celiac, iliac vessels and go to the upper or lower segment of the kidney. There is no difference in the location of additional arteries.

Double and multiple renal arteries

Double and multiple renal arteries are a type of renal vascular anomaly in which the kidney receives blood supply from two or more trunks of equal caliber.

Accessory or multiple arteries in the overwhelming number of observations are found in a normal kidney and do not lead to pathology, but quite often they are combined with other kidney anomalies (dysplastic, doubled, dystopic, horseshoe kidney, polycystic, etc.).

Solitary renal artery

The solitary renal artery supplying both kidneys is extremely rare view abnormalities of the renal vessels.

Dystopia of the renal artery origin

Location anomalies - an anomaly of the renal vessels, the main criterion in determining the type of kidney dystopia:

• lumbar - with a low discharge of the renal artery from the aorta;
• iliac - when leaving the common iliac artery;
• pelvic - when leaving the internal iliac artery.

Renal artery aneurysm

A renal artery aneurysm is an expansion of the vessel due to the absence of muscle fibers in the vessel wall and the presence of only elastic fibers. This anomaly of the renal vessels is quite rare (0.11%). It is usually one-sided. The aneurysm can be located both extrarenally and intrarenally. Clinically manifested by arterial hypertension, diagnosed for the first time in adolescence. Can lead to thromboembolism of the renal arteries with the development of renal infarction.

Fibromuscular stenosis

Fibromuscular stenosis is a rare vascular anomaly of the renal vessels (0.025%). It represents several successive narrowings in the form of a "string of beads" in the middle or distal third of the renal vessel, resulting from the excessive development of fibrous and muscle tissue in the wall of the renal artery. Can be double-sided. It manifests itself in the form of arterial hypertension, which is difficult to correct, without a crisis. Treatment is prompt. The type of surgery depends on the prevalence and location of the defect.

Congenital arteriovenous fistulas

Congenital arteriovenous fistulas are less common (0.02%). They are more often localized in arcuate and lobular vessels and can be multiple. Manifested by symptoms of venous hypertension (hematuria, proteinuria, varicocele).

Congenital changes in renal veins

Congenital changes in the renal veins can be divided into abnormalities in the number, shape and location, structure.

Right renal vein anomalies are mainly associated with doubling or tripling. The left renal vein, in addition to an increase in number, may have an abnormality in shape and position.

The accessory renal vein and multiple renal veins, according to some data, occur in 18 and 22% of cases, respectively. Usually accessory renal veins are not associated with accessory vessels. Accessory veins, as well as arteries, can intersect with the ureter, disrupting urodynamics and leading to hydronephrotic transformation. Anomalies in the development of the left renal vein are more common due to the peculiarities of embryogenesis. The right renal vein practically does not undergo any changes during embryogenesis. The left renal vein can pass in front, behind and around the aorta, not flowing into the inferior vena cava (extracaval confluence and congenital absence of the ordering department).

Structural anomalies include renal vein stenosis. It can be permanent or orthostatic.

The clinical significance of these defects is that they may develop venous hypertension, and as a result, hematuria, varicocele, impairment menstrual cycle... The influence of venous anomalies on the risk of developing kidney tumors has been proven.

Previously, angiography was the "gold standard" for diagnosing renal vascular anomalies, but recently it has become possible to diagnose these defects with less invasive methods - digital subtraction angiography, color Doppler ultrasound, MSCT, MRI.

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Causes of PA stenosis

Most common reasons narrowing of the renal artery - atherosclerosis and fibromuscular dysplasia of the artery wall. Atherosclerosis accounts for up to 70% of cases of the disease, fibromuscular dysplasia accounts for about a third of cases.

Atherosclerosis renal arteries with narrowing of their lumen are usually found in older men, often with existing ischemic disease heart, diabetes, obesity. Lipid plaques are more often located in the initial segments of the renal vessels, near the aorta, which can also be affected by atherosclerosis; the middle section of the vessels and the branching zone in the organ parenchyma are much less frequently affected.

Fibromuscular dysplasia is a congenital pathology in which the wall of the artery thickens, which leads to a decrease in its lumen. This lesion is usually localized in the middle part of the PA, is diagnosed 5 times more often in women and can be bilateral.

About 5% of spas are caused by other reasons, including inflammatory processes vascular walls, aneurysmal dilatation, thrombosis and embolism of the arteries of the kidneys, compression by a tumor located outside, Takayasu's disease, prolapse of the kidney. In children, there is an intrauterine developmental disorder of the vascular system with PA stenosis, which manifests itself as hypertension already in childhood.

Possible both unilateral and bilateral renal artery stenosis. The defeat of both vessels is observed in congenital dysplasia, atherosclerosis, diabetes and is more malignant, because two kidneys are in a state of ischemia at once.

If the blood flow through the renal vessels is impaired, the system that regulates the blood pressure level is activated. The hormone renin and angiotensin-converting enzyme contribute to the formation of a substance that causes spasm of small arterioles and an increase in peripheral vascular resistance. The result is hypertension. At the same time, the adrenal glands produce excess aldosterone, under the influence of which fluid and sodium are retained, which also contributes to an increase in pressure.

If even one of the arteries is damaged, right or left, the above described mechanisms of hypertension are triggered. Over time, a healthy kidney "rebuilds" to a new level of pressure, which continues to maintain even if the diseased kidney is removed completely or blood flow is restored in it by angioplasty.

In addition to activating the pressure maintenance system, the disease is accompanied by ischemic changes in the kidney itself. Against the background of a lack of arterial blood, tubule dystrophy occurs, it grows connective tissue in the stroma and glomeruli of the organ, which eventually inevitably leads to atrophy and nephrosclerosis. The kidney becomes denser, shrinks and is unable to perform the functions assigned to it.

SPA manifestations

For a long time Spas may be asymptomatic or as benign hypertension. Vivid clinical signs of the disease appear when the narrowing of the vessel reaches 70% ... Among the symptoms, the most common are secondary renal arterial hypertension and signs of disruption of the parenchyma (decreased urine filtration, intoxication with metabolic products).

Persistent pressure rise, usually without hypertensive crises, in young patients prompts the doctor to think about possible fibromuscular dysplasia, and if the patient has crossed the 50-year mark, atherosclerotic lesion of the renal vessels is most likely.

Renal hypertension is characterized by an increase in not only systolic, but also diastolic pressure, which can reach 140 mm Hg. Art. and more. This condition is extremely difficult to treat with standard antihypertensive drugs and creates a high risk of cardiovascular accidents, including stroke and myocardial infarction.

Among the complaints of patients with renal hypertension are:

• Severe headaches, tinnitus, flashing "flies" before the eyes;
• Decreased memory and mental performance;
• Weakness;
• Dizziness;
• Insomnia or drowsiness during the day;
• Irritability, emotional instability.

A constant high load on the heart creates conditions for its hypertrophy, patients complain of chest pains, palpitations, a feeling of interruptions in the work of the organ, shortness of breath appears, in severe cases, pulmonary edema develops, requiring emergency care.

In addition to hypertension, severity and pain in the lumbar region, blood in the urine, and weakness are possible. In case of excess release of aldosterone by the adrenal glands, the patient drinks a lot, excretes a large amount of non-concentrated urine not only during the day, but also at night, convulsions are possible.

When initial stage diseases, kidney function is preserved, but hypertension already appears, which, however, is treatable with medication. Subcompensation is characterized by a gradual decrease in renal function, and in the stage of decompensation, signs of renal failure are clearly traced. Hypertension in the terminal stage becomes malignant, the pressure reaches its maximum numbers and does not "go astray" medicines.

SPA is dangerous not only for its manifestations, but also for complications in the form of cerebral hemorrhages, myocardial infarction, pulmonary edema against a background of hypertension. In most patients, the retina of the eye is affected, its detachment and blindness are possible.

Chronic renal failure, as the final stage of pathology, is accompanied by intoxication with metabolic products, weakness, nausea, headache, a small amount of urine that the kidneys can filter on their own, and an increase in edema. Patients are prone to pneumonia, pericarditis, inflammation of the peritoneum, damage to the mucous membranes of the upper respiratory tract and the digestive tract.

How to identify renal artery stenosis?

Examination of a patient with suspected stenosis of the left or right renal artery begins with a detailed clarification of complaints, the time of their appearance, the response to conservative treatment hypertension, if it has already been prescribed. Next, the doctor will listen to the heart and large vessels, prescribe blood and urine tests and additional instrumental examinations.

At the initial examination, it is already possible to reveal the expansion of the heart due to hypertrophy of the left sections, an increase in the second tone over the aorta. A murmur is heard in the upper abdomen, indicating a narrowing of the renal arteries.

The main biochemical indicators in SPA will be the level of creatinine and urea, which increase due to insufficient filtration capacity of the kidneys. Erythrocytes, leukocytes, protein casts can be found in urine.

Additional diagnostic methods are used Ultrasound (kidneys are reduced in size), and dopplerometry allows you to fix the narrowing of the artery and the change in the speed of blood movement along it. Information about the size, location, functional ability can be obtained through radioisotope research.

The most informative diagnostic method is recognized arteriographywhen localization, degree of PA stenosis and hemodynamic disturbance are determined using contrast radiography. It is also possible to carry out CT scan and MRI.

Treatment of renal artery stenosis

Before starting treatment, the doctor will recommend that the patient give up bad habits, start a diet with reduced salt intake, limit fluids, fats, and readily available carbohydrates. In obese atherosclerosis, weight loss is necessary, since obesity can create additional difficulties in planning surgery.

Conservative therapy for renal artery stenosis is of an auxiliary nature,it does not eliminate the underlying cause of the disease. At the same time, patients need correction of blood pressure and urination. Long-term therapy is indicated for the elderly and people with widespread atherosclerotic vascular lesions, including coronary arteries.

Since the main manifestation of renal artery stenosis is symptomatic hypertension, treatment is aimed primarily at lowering blood pressure. For this purpose, diuretics and antihypertensive drugs are prescribed. It should be borne in mind that with a strong narrowing of the lumen of the renal artery, a decrease in pressure to normal values \u200b\u200bcontributes to the aggravation of ischemia, because in this case even less blood will flow to the parenchyma of the organ. Ischemia will cause the progression of sclerotic and dystrophic processes in the tubules and glomeruli.

The drugs of choice for hypertension against the background of PA stenosis are ACE inhibitors (capropril), however, they are contraindicated in atherosclerotic vasoconstriction, including for persons with congestive heart failure and diabetes mellitus, so they replace:

1. Cardioselective beta-blockers (atenolol, egilok, bisoprolol);
2. Slow calcium channel blockers (verapamil, nifedipine, diltiazem);
3. Alpha blockers (prazosin);
4. Loop diuretics (furosemide);
5. Imidazoline receptor agonists (moxonidine).

Doses of medicines are selected individually, while it is desirable not to allow a sharp decrease in pressure, and when choosing the correct dosage of the drug, the level of creatinine and potassium in the blood is controlled.

Patients with atherosclerotic stenosis need statins to correct disorders of fat metabolism; in diabetes, lipid-lowering drugs or insulin are indicated. In order to prevent thrombotic complications, aspirin, clopidogrel are used. In all cases, the dosage of drugs is selected taking into account the filtration capacity of the kidneys.

With severe renal failure against the background of atherosclerotic nephrosclerosis, patients are prescribed hemodialysis or peritoneal dialysis on an outpatient basis.

Conservative treatment often does not give the desired effect, because stenosis cannot be eliminated with drugs, therefore, the main and most effective measure can only be surgery, the indications for which are:

• Severe stenosis, causing hemodynamic disturbance in the kidney;
• Narrowing of an artery with a single kidney;
• Malignant hypertension;
• Chronic failure organ with damage to one of the arteries;
• Complications (pulmonary edema, unstable angina pectoris).

Types of spa interventions:

1. Stenting and balloon angioplasty;
2. Bypass surgery;
3. Resection and prosthetics of the renal artery section;
4. Removal of the kidney;
5. Transplantation.

Stenting consists in installing a special tube made of synthetic materials into the lumen of the renal artery, which is strengthened at the site of stenosis and allows blood flow to be established. In balloon angioplasty, a special balloon is inserted through the femoral artery through a catheter, which inflates in the area of \u200b\u200bstenosis and thereby expands it.

Video: angioplasty and stenting - minimally invasive SPA treatment

With atherosclerosis of the renal vessels, shunting will give the best effect, when the renal artery is sutured to the aorta, excluding the site of stenosis from the bloodstream. Removal of a section of the vessel and subsequent prosthetics with the patient's own vessels or synthetic materials is possible.

If it is impossible to perform reconstructive interventions and the development of atrophy and sclerosis of the kidney, removal of the organ (nephrectomy) is indicated, which is performed in 15-20% of cases of pathology. If stenosis is caused congenital causes, then the question of the need for kidney transplantation is considered, while such treatment is not carried out in vascular atherosclerosis.

In the postoperative period, complications are possible in the form of bleeding and thrombosis in the area of \u200b\u200banastomoses or stents. Restoration of the acceptable level of blood pressure may require up to six months, during which conservative antihypertensive therapy continues.

The prognosis of the disease is determined by the degree of stenosis, the nature secondary changes in the kidneys, the effectiveness and the possibility of surgical correction of pathology. With atherosclerosis, slightly more than half of patients after surgery return to normal blood pressure, and in the case of vascular dysplasias surgery allows you to restore it in 80% of patients.

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More about renal artery stenosis

Renal artery stenosis is a narrowing of the vessel lumen due to various pathological conditions. The disease is referred to as nephropathic pathologies. The renal arteries are large vessels that supply blood to organ tissue. With stenosis, they noticeably decrease in diameter. As a result, the process of blood supply to the kidneys is disrupted. This pathology leads to such serious disorders as secondary arterial hypertension, chronic renal failure. There are 2 mechanisms for the development of stenosis. Among them:

1. Atherosclerotic variant. It is observed in most of the patients suffering from this pathology. A similar mechanism for the development of stenosis consists in the gradual blockage of the lumen of the vessel with cholesterol plaques. Often, severe vascular occlusion is observed in old age.
2. Fibromuscular dysplasia. This variant of the development of pathology is less common. It can occur in middle-aged women as well as young girls. Muscle dysplasia is a hereditary birth defect.

Only after instrumental examination a diagnosis of renal artery stenosis can be made. ICD is a classification of pathologies used all over the world. It includes many diseases, each of which has a specific code. Renal artery stenosis is coded in 2 ways, depending on the cause of its occurrence. One of the options is the code I15.0, which means “renovascular hypertension”. Another ICD code is Q27.1. It stands for "congenital renal artery stenosis". Both conditions require treatment by a urologist or vascular surgeon.

Renal artery stenosis: causes of pathology

Narrowing of the lumen of peripheral arteries is referred to as pathologies of the vascular system. There are various causes of stenosis. The most common of these is atherosclerosis. As you know, in most cases it is observed in people who are overweight, lead a sedentary lifestyle or suffer from diabetes. Atherosclerosis can develop over a long period of time. However, it is rarely diagnosed before symptoms of clogged arteries appear. Other causes of stenosis include:

1. Fibromuscular dysplasia. This term means a congenital genetic defect, as a result of which there is a lack of muscle fibers in the vascular wall. Pathology is observed in women of any age.
2. Aneurysm of the arteries of the kidneys.
3. Tumors peripheral vessels.
4. Congenital and acquired vasculitis.
5. Compression of the renal artery by neoplasms originating from the tissues of neighboring organs.

The listed reasons are rare. Therefore, their diagnosis is started only after the exclusion of atherosclerosis.

The mechanism of development of hypertension

The main symptom of renal artery stenosis is an increase in blood pressure. Therefore, in this clinical syndrome, an examination of the renal system is necessary. How are renal artery stenosis and arterial hypertension related? Two mechanisms are involved in increasing blood pressure:

1. Renin-angiotensin system activation. Under the influence of these biological substances, narrowing of the arterioles develops. As a result, the resistance of the peripheral vessels increases. In this way, blood pressure in the arteries rises.
2. Action of aldosterone. This hormone is produced in the adrenal cortex. Normally, it is constantly present in the body. However, with stenosis of the artery, its production is enhanced. Due to the excess amount of aldosterone, fluid and sodium ions accumulate in the body. This, in turn, also causes an increase in blood pressure.

As a result of chronic hypertension there are changes from outside of cardio-vascular system... The left ventricle is gradually hypertrophied and stretched. This is another cause of hypertension.

Renal artery stenosis: disease symptoms

Narrowing of the arteries of the kidneys has many consequences. The symptoms of stenosis do not appear immediately, but only with severe occlusion. Moreover, conservative treatment is not always effective. In addition to vascular disorders, arterial stenosis leads to ischemic changes in the kidney. As a result, the filtration and concentration function of the organ suffers. Taking this into account, there are 2 clinical syndromes that develop with stenosis. The first is arterial hypertension. This syndrome is characterized by a number of clinical manifestations. Among them:

1. Increased blood pressure. It can be both episodic and permanent. An increase in diastolic blood pressure (over 100 mm Hg) is of particular importance for diagnosis.
2. The appearance of tinnitus.
3. Dizziness.
4. Nausea that has no connection with food intake.
5. Flashing "flies" before the eyes.
6. Headache in the area of \u200b\u200bthe temples, forehead.
7. Irritability.

The second clinical syndrome is ischemic nephropathy. Due to the violation of the renal blood flow, the "nutrition" of the organ stops. Bilateral renal artery stenosis is especially dangerous. Hypertension is a condition that can be partially controlled with medication. Unfortunately, severe organ ischemia cannot be corrected with drugs. The symptoms of "oxygen starvation" of the kidney include: pain in the lumbar region, changes in urination. A decrease in the amount of fluid secreted, general weakness is often observed. An admixture of blood, a cloudy sediment may appear in the urine.

Diagnostics

Only after examination can the diagnosis of renal artery stenosis be made. Diagnosis of pathology includes the collection of complaints and anamnesis of the disease, laboratory tests and instrumental methods. Most often, the leading syndrome is arterial hypertension, which does not respond well to antihypertensive therapy. Also, patients may complain of discomfort in the lower back (on one or both sides), a change in the nature of urination. The survey plan includes:

1. KLA and general urinalysis.
2. Biochemical analysis blood. The disease can be suspected with an increase in creatinine and urea levels.
3. Ultrasound of the kidneys.
4. Special tests: urine analysis according to Nechiporenko, Zimnitsky.
5. X-ray contrast study of blood vessels - renography.
6. Doppler ultrasonography of the renal arteries.
7. Angiography.
8. CT and MRI.

Differential diagnosis

Considering that the hypertensive syndrome is the leading one, renal artery stenosis is differentiated from cardiac pathologies, aortic atherosclerosis. Also, symptoms may resemble Itsengo-Cushing's disease and pheochromocytoma.

If the signs of ischemic nephropathy prevail, then the stenosis is differentiated from inflammatory pathologies of the kidneys. These include pyelo- and glomerulonephritis. Also, similar symptoms can be observed with complications of diabetes mellitus.

Conservative therapy for renal artery stenosis

Treatment of renal artery stenosis begins with conservative methods. For hypertension caused by vasoconstriction, a combination of several drugs is required. Angiotensin converting enzyme inhibitors are preferred. But these drugs are not recommended to be taken with severe atherosclerotic vascular lesions. The combination is made up of the following groups of medicines:

1. Beta blockers. These include drugs "Metoprolol", "Coronal", "Bisoprolol".
2. Loop diuretics. The drug of choice is the drug "Furosemide".
3. Calcium channel blockers. Among them are medicines "Verapamil", "Diltiazem".

In addition, the patient must take medications necessary to treat the underlying disease (atherosclerosis, diabetes mellitus).

Surgical treatment of stenosis

Unfortunately, in most cases, antihypertensive therapy is ineffective. In addition, lowering blood pressure only aggravates ischemic nephropathy. Therefore, you have to resort to surgical intervention. Depending on the extent of the lesion, a method of surgical treatment is chosen. Most often, stenting is performed on the artery that supplies the kidney. If the entire lumen of the vessel is obturated over a large extent, bypass surgery is performed - replacing a section of the vessel with a graft. When the kidney tissue dies, nephrectomy is performed.

Prognosis after surgical treatment of stenosis

Regardless of which side was the lesion (stenosis of the left renal artery or right), the prognosis after surgery depends on adherence to the doctor's recommendations and the patient's somatic condition. Often, surgical treatment can achieve positive result... After a few months, blood pressure normalizes in 60-70% of patients.

Complications of renal stenosis

Unfortunately, renal artery stenosis is diagnosed only at a late stage of development. Therefore, you cannot neglect the doctor's recommendations. Indeed, without proper treatment, formidable complications can develop. Among them - myocardial infarction and stroke against a background of hypertensive crisis, acute and chronic renal failure. If you do not complete surgery, the patient may lose an organ.

Prevention

Preventive measures include constant monitoring of blood pressure in the presence of complaints of dizziness and tinnitus, quitting smoking and alcoholic beverages. To avoid the progression of atherosclerosis, it is necessary to follow a special hypocholesterol diet and lead an active lifestyle. Some patients need to take special medications called statins.

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General information

The essence of this disease is that the blood accumulates cholesterol plaques... With the bloodstream, they spread through the vessels, stick to their walls. The plaque gradually blocks blood flow to the kidneys. The functioning of the kidneys directly depends on the amount of blood that flows to them. Therefore, if a person develops atherosclerosis, the body produces the hormone renin, which increases blood flow. As a result, the vessels are overfilled with blood, stretched to the maximum possible limits, become thinner, and become inelastic. In the advanced state of arterial sclerosis, rupture of blood vessels is possible.

By itself, the blockage of blood vessels leads to kidney failure, because the kidneys do not receive enough oxygen and necessary substances. At the earliest stage of development of atherosclerosis, a person does not feel any deterioration in health. Symptoms appear only after the first complications. If arteriosclerosis is left untreated, it will result in necrosis of the kidney tissue.

Renal artery stenosis (SPA) is a serious illness, accompanied by a narrowing of the lumen of the vessel that feeds the kidney. Pathology lies in the jurisdiction of not only nephrologists, but also cardiologists, since the main manifestation usually becomes a strong, difficult to correct.

Patients with renal artery stenosis are mainly older people (after 50 years), but stenosis can also be diagnosed in young people. Among elderly people with atherosclerosis of blood vessels, there are twice as many men than women, and with congenital vascular pathology, women predominate, in whom the disease manifests itself after 30-40 years.

Every tenth person suffering from an elevated condition has stenosis of the major renal vessels as the main cause of this condition. Today, more than 20 different changes are already known and described, leading to a narrowing of the renal arteries (PA), an increase in pressure and secondary sclerotic processes in the organ parenchyma.

The prevalence of pathology requires the use of not only modern and accurate diagnostic methods, but also timely and effective treatment. It is recognized that the best results are achieved with surgical treatment of stenosis, while conservative therapy plays a supportive role.

Causes of PA stenosis

The most common causes of renal artery narrowing are atherosclerosis and fibromuscular dysplasia of the artery wall. It accounts for up to 70% of cases of the disease, fibromuscular dysplasia accounts for about a third of cases.

Atherosclerosis renal arteries with a narrowing of their lumen are usually found in older men, often with ischemic heart disease, diabetes, obesity. Lipid plaques are more often located in the initial segments of the renal vessels, near the aorta, which can also be affected by atherosclerosis; the middle section of the vessels and the branching zone in the organ parenchyma are much less frequently affected.

Fibromuscular dysplasia is a congenital pathology in which the wall of the artery thickens, which leads to a decrease in its lumen. This lesion is usually localized in the middle part of the PA, is diagnosed 5 times more often in women and can be bilateral.

atherosclerosis (right) and fibromuscular dysplasia (left) are the main causes of PA stenosis

About 5% of SPA is caused by other reasons, including inflammation of the vascular walls, aneurysmal dilatation, and renal arteries, compression by a tumor located outside, prolapse of the kidney. In children, there is an intrauterine developmental disorder of the vascular system with PA stenosis, which manifests itself as hypertension already in childhood.

Possible both unilateral and bilateral renal artery stenosis. The defeat of both vessels is observed in congenital dysplasia, atherosclerosis, and proceeds more malignantly, because two kidneys are in a state of ischemia at once.

If the blood flow through the renal vessels is impaired, the system that regulates the blood pressure level is activated. The hormone renin and angiotensin-converting enzyme contribute to the formation of a substance that causes spasm of small arterioles and an increase in peripheral vascular resistance. The result is hypertension. At the same time, the adrenal glands produce excess aldosterone, under the influence of which fluid and sodium are retained, which also contributes to an increase in pressure.

If even one of the arteries is damaged, right or left, the above described mechanisms of hypertension are triggered. Over time, a healthy kidney "rebuilds" to a new level of pressure, which continues to maintain even if the diseased kidney is removed completely or blood flow is restored in it by angioplasty.

In addition to activating the pressure maintenance system, the disease is accompanied by ischemic changes in the kidney itself. Against the background of a lack of arterial blood, tubular dystrophy occurs, connective tissue grows in the stroma and glomeruli of the organ, which eventually inevitably leads to atrophy and nephrosclerosis. The kidney becomes denser, shrinks and is unable to perform the functions assigned to it.

SPA manifestations

For a long time, SPA can exist asymptomatically or in the form of benign hypertension. Vivid clinical signs of the disease appear when the narrowing of the vessel reaches 70% ... Among the symptoms, the most common are renal arterial hypertension and signs of parenchymal dysfunction (decreased urine filtration, intoxication with metabolic products).

Persistent pressure rise, usually without hypertensive crises, in young patients prompts the doctor to think about possible fibromuscular dysplasia, and if the patient has crossed the 50-year mark, atherosclerotic lesion of the renal vessels is most likely.

Among the complaints of patients with renal hypertension are:

• Severe headaches, tinnitus, flashing "flies" before the eyes;
• Decreased memory and mental performance;
• Weakness;
• Dizziness;
• Insomnia or drowsiness during the day;
• Irritability, emotional instability.

The constant high load on the heart creates conditions for it, patients complain of chest pains, palpitations, a feeling of interruptions in the work of the organ, shortness of breath appears, in severe cases, pulmonary edema develops, requiring urgent help.

In addition to hypertension, severity and pain in the lumbar region, blood in the urine, and weakness are possible. In case of excess release of aldosterone by the adrenal glands, the patient drinks a lot, excretes a large amount of non-concentrated urine not only during the day, but also at night, convulsions are possible.

At the initial stage of the disease, kidney function is preserved, but hypertension already appears, which, however, is treatable with medication. Subcompensation is characterized by a gradual decrease in renal function, and in the stage of decompensation, signs of renal failure are clearly traced. End-stage hypertension becomes malignant, the pressure reaches maximum figures and is not "knocked out" by drugs.

SPA is dangerous not only for its manifestations, but also for complications in the form of cerebral hemorrhages, myocardial infarction, pulmonary edema against a background of hypertension. In most patients, the retina of the eye is affected, its detachment and blindness are possible.

Chronic renal failure, as the final stage of pathology, is accompanied by intoxication with metabolic products, weakness, nausea, headache, a small amount of urine that the kidneys can filter on their own, and an increase in edema. Patients are prone to pneumonia, pericarditis, inflammation of the peritoneum, damage to the mucous membranes of the upper respiratory tract and the digestive tract.

How to identify renal artery stenosis?

Examination of a patient with suspected stenosis of the left or right renal artery begins with a detailed clarification of complaints, the time of their appearance, the response to conservative treatment of hypertension, if it has already been prescribed. Next, the doctor will listen to the heart and large vessels, prescribe blood and urine tests and additional instrumental examinations.

stenosis of both renal arteries on an angiographic image

At the initial examination, it is already possible to reveal the expansion of the heart due to hypertrophy of the left sections, an increase in the second tone over the aorta. A murmur is heard in the upper abdomen, indicating a narrowing of the renal arteries.

The main biochemical indicators in SPA will be the level and, which increase due to insufficient filtration capacity of the kidneys. Erythrocytes, leukocytes, protein casts can be found in urine.

Additional diagnostic methods are used Ultrasound (kidneys are reduced in size), and dopplerometry allows you to fix the narrowing of the artery and the change in the speed of blood movement along it. Information about the size, location, functional ability can be obtained through radioisotope research.

The most informative diagnostic method is recognized when the localization, degree of PA stenosis and hemodynamic disturbance are determined using contrast radiography. It is also possible to carry out CT scan and MRI.

Treatment of renal artery stenosis

Before starting treatment, the doctor will recommend that the patient give up bad habits, start a diet with reduced salt intake, limit fluids, fats, and readily available carbohydrates. In obese atherosclerosis, weight loss is necessary, since obesity can create additional difficulties in planning surgery.

Conservative therapy for renal artery stenosis is of an auxiliary nature,it does not eliminate the underlying cause of the disease. At the same time, patients need correction of blood pressure and urination. Long-term therapy is indicated for the elderly and people with widespread atherosclerotic vascular lesions, including coronary arteries.

Since the main manifestation of renal artery stenosis is symptomatic hypertension, treatment is aimed primarily at lowering blood pressure. For this purpose, diuretics and are prescribed. It should be borne in mind that with a strong narrowing of the lumen of the renal artery, a decrease in pressure to normal values \u200b\u200bcontributes to the aggravation of ischemia, because in this case even less blood will flow to the parenchyma of the organ. Ischemia will cause the progression of sclerotic and dystrophic processes in the tubules and glomeruli.

The drugs of choice for hypertension against the background of PA stenosis become (capropril), however, with atherosclerotic vasoconstriction, they contraindicated including those with congestive heart failure and diabetes mellitus, therefore, they are replaced:

1. Cardioselective (atenolol, egilok, bisoprolol);
2. (verapamil, nifedipine, diltiazem);
3. Alpha blockers (prazosin);
4. Loop (furosemide);
5. Imidazoline receptor agonists (moxonidine).

Doses of medicines are selected individually, while it is desirable not to allow a sharp decrease in pressure, and when choosing the correct dosage of the drug, the level of creatinine and potassium in the blood is controlled.

Patients with atherosclerotic stenosis need to be prescribed for the correction of lipid metabolism disorders; in diabetes, lipid-lowering agents or insulin are indicated. In order to prevent thrombotic complications, aspirin, clopidogrel are used. In all cases, the dosage of drugs is selected taking into account the filtration capacity of the kidneys.

With severe renal failure against the background of atherosclerotic nephrosclerosis, patients are prescribed hemodialysis or peritoneal dialysis on an outpatient basis.

Conservative treatment often does not give the desired effect, because stenosis cannot be eliminated with drugs, therefore, the main and most effective measure can only be a surgical operation, the indications for which are considered:

• Severe stenosis, causing hemodynamic disturbance in the kidney;
• Narrowing of an artery with a single kidney;
• Malignant hypertension;
• Chronic organ failure with damage to one of the arteries;
• Complications (pulmonary edema, unstable angina pectoris).

Types of spa interventions:

Stenting consists in installing a special tube made of synthetic materials into the lumen of the renal artery, which is strengthened at the site of stenosis and allows blood flow to be established. In balloon angioplasty, a special balloon is inserted through the femoral artery through a catheter, which inflates in the area of \u200b\u200bstenosis and thereby expands it.

Video: angioplasty and stenting - minimally invasive SPA treatment

With atherosclerosis of the renal vessels, shunting will give the best effect, when the renal artery is sutured to the aorta, excluding the site of stenosis from the bloodstream. Removal of a section of the vessel and subsequent prosthetics with the patient's own vessels or synthetic materials is possible.

A) Renal artery replacement and B) Bilateral PA bypass with a synthetic prosthesis

If it is impossible to perform reconstructive interventions and the development of atrophy and sclerosis of the kidney, removal of the organ (nephrectomy) is indicated, which is performed in 15-20% of cases of pathology. If the stenosis is caused by congenital causes, then the issue of the need for kidney transplantation is considered, while such treatment is not carried out with vascular atherosclerosis.

In the postoperative period, complications are possible in the form of bleeding and thrombosis in the area of \u200b\u200banastomoses or stents. Restoration of the acceptable level of blood pressure may require up to six months, during which conservative antihypertensive therapy continues.

The prognosis of the disease is determined by the degree of stenosis, the nature of secondary changes in the kidneys, the effectiveness and the possibility of surgical correction of pathology. With atherosclerosis, a little more than half of patients after surgery return to normal blood pressure, and in the case of vascular dysplasias, surgical treatment allows it to be restored in 80% of patients.