Presegmental Arterial Pattern of Human Kidneys in Local Population
Rehmah Sarfraz et al
Original Article
Presegmental Arterial Pattern of
Human Kidneys in Local Population
Objective: To investigate the variations in the presegmental arterial pattern of human
kidneys obtained from cadavers of the local adult population.
Materials and Methods: This study was conducted at Anatomy Department of
University of Health Sciences, Lahore, for a period of one year (October 2006-October 2007).
Forty four adult human kidneys were obtained after autopsy; they were randomly divided in
two groups A and B of right and left kidneys respectively. Simple blunt dissection and
corrosion cast techniques were used to study the presegmental arteries. Statistical analysis
was carried out by using SPSS version 16.0 and STATA version 8.0.
Results: Presegmental arteries were present in 100% of specimens of groups A and B.
Variations were seen in the site of origin (extrahilar, hilar and intrarenal) of presegmental
arteries of both groups.
Conclusion: The presegmental branches of renal artery in local population showed
variations different from those reported in the earlier work carried out in other countries.
Key Words: Presegmental Arterial Pattern; Human Kidneys
Introduction
Recent advances and refinements in renal
surgery as well as radiological interventional procedures
have revived interest in renal arterial anatomy.1,2 Renal
arteries arise from abdominal aorta and supply the
kidneys through a number of its subdivisions. Near the
renal hilum, each renal artery divides into anterior and
posterior divisions (presegmental arteries), which further
divide into segmental arteries (apical, upper, middle,
inferior and posterior) supplying the renal arterial
segments.3-5
In conservative surgical procedures, a serious
consequence of renal arterial lesion is the development
of hypertension.6,7 The lesion of any branch of renal
artery, regardless of its diameter, origin or destination
will lead to ischemia of the related renal parenchyma,
subsequently leading to renal hypertension.6 Selective
renal arterial occlusion or ligation, particularly of the
presegmental and lower polar segmental arteries may
allow laparoscopic partial nephrectomy to be performed
with minimal ischemic risk to the remnant renal tissue.8
Ligation of a segmental artery will not produce ischemia
or interference with the blood supply of the neighboring
segments.9
Clamping segmental artery produces a highly
selective interruption of renal blood flow to its segment.
Presegmental renal arteries are also amenable to
clamping. Occlusion of a presegmental artery offers less
Ann. Pak. Inst. Med. Sci. 2008; 4(4): 212-215
Rehmah Sarfraz
Mohammad Tahir*
Waqas Sami
Department of Anatomy and Histology
University of Health Sciences, Lahore
Address for Correspondence:
Prof. Muhammad Tahir
Department of Anatomy and Histology
University of Health Sciences, Lahore
Email:kh_pims@yahoo.com
selective renal blood flow interruption because two or
more segments of the kidney will be affected.
Additionally, if access to a segmental artery is
challenging, presegmental arterial ligation can still spare
most of the kidney from an ischemic challenge.
Clamping a presegmental artery may be advantageous
for larger tumors or tumors that overlap a number of
renal segments. For these tumors, presegmental artery
can be selectively clamped before partial resection of
the organ.8 In partial nephrectomy, the branches of the
renal arteries are defined so that the surgeon can safely
excise
the
morbid
renal
substance
without
compromising the vascular supply of the remaining part
of the kidney.3
The extrarenal arterial anatomy consists of
presegmental and segmental branches of renal artery.8
The Anatomical Society of Great Britain and Ireland
made the first systematic attempt to study the frequency
of occurrence of renal vascular variations.10,11 The work
of Brödel, a German anatomist, was most influential in
stimulating the development of renal surgery in America.
He took forty human cadaveric kidneys, used the
corrosion cast technique, and gave the concept that the
kidney could be divided into an anterior and a posterior
division, each division being supplied by separate end
arteries.10,12 Graves was the first to classify the renal
parenchymal segments and their respective segmental
artery. He studied the plastic casts and arteriograms of
the intrarenal branches in humans and observed that
there was constant segmental arrangement of these
212
Presegmental Arterial Pattern of Human Kidneys in Local Population
vessels which was without collateral arterial circulation
between them.9,10 In one of the studies performed by
Chatterjee and Dutta on neoprene casts of human
kidneys, it was observed that the renal artery divided
into five branches, four from the anterior division and
one from the posterior division; their observations were
consistent with those of Graves.13 Weld et al., defined
the renal artery as the artery travelling from aorta to the
renal hilum; the presegmental artery was defined as a
branch of the renal artery that divided into two or more
branches which were named as segmental arteries,
these then entered the renal parenchyma.8 The first
divisions of renal artery were defined by Shoja et al., as
the primary branches and the subsequent divisions as
secondary or tertiary branches.14
Ethnical and geographical variations in the renal
arterial system have been reported earlier.1,11 A study
was performed by Lloyd on the racial differences in the
course of renal artery in Whites and American Negros;
the results showed that a larger proportion of Whites
presented variations in the renal arterial supply than
those in Negroes.11 It had been reported by Özkan and
co-workers that the renal arterial variations are more
common in Africans and Caucasians than those in
Hindus.15 A study of the arrangement of the branches of
renal arteries in African, European and Indian population
by Fine and Keen has revealed a large variety of
patterns.16
In view of the previous reports on the variations
of renal vascular pattern and paucity of work in this field
on local population of Pakistan, the present study was
designed to investigate vascular distribution using right
and left cadaveric kidneys.
Rehmah Sarfraz et al
respectively; twenty two specimens were present in
8
each group (n=22). The kidneys were irrigated with
normal saline for flushing out of blood and formalin from
the organ.18,19 The presegmental branches of renal
arteries were studied by using simple blunt dissection
and corrosion cast technique. After performing blunt
dissection, the renal artery and its branches were
painted with red oil paint (Figure I). Batson’s No.6 17
corrosion kit (Polysciences) was used to make the renal
arterial corrosion cast.20 For maceration purpose, the
kidney was placed in 20% solution of potassium
hydroxide in a glass jar at room temperature; the
amount of potassium hydroxide solution used was two
to three times the volume of the renal mass.17,19,21-23
After about ten days, the macerated tissues were
removed; the specimen was washed with tap water and
air-dried. The exclusion criteria consisted of: presence
of renal abnormalities on gross inspection, evidence of
renal trauma or renal surgery, and presence of
abdominal growths. 6,21,24-27
The statistical analysis was carried out using
computer software Statistical Package for Social
Sciences (SPSS) version 16.0 and STATA version 8.0.
The significance of the data between the groups was
calculated by Pearson Chi-square test and Fisher exact
test; the association was regarded statistically significant
if the ‘p’ value was <0.05.
Materials and Methods
Forty four unclaimed adult human cadaveric
kidneys were obtained from forty four cadavers from the
Forensic Medicine Department of King Edward Medical
University, Lahore. The kidneys were removed in
compliance with the ethical committee of University of
Health Sciences, Lahore. The human cadaver was put
in a supine position on the autopsy table. A median
incision was given to open the front of abdomen; it was
made from the manubrium sterni to the pubic
symphysis. and then extended at the upper end towards
the acromiclavicular joints, following the line of
clavicles.17 The abdomen was opened; liver, stomach,
intestines and spleen were lifted along with the
peritoneum and the kidneys were identified and taken
out from the cadaver. The specimens were transported
in plastic jars containing 10% formalin solution11,18 to the
Anatomy Department of University of Health Sciences,
Lahore. The kidneys were randomly divided into two
groups, A and B, having right and left kidneys
Ann. Pak. Inst. Med. Sci. 2008; 4(4): 212-215
Figure I: Extrahilar origin of left anterior
presegmental arteries. Ant: Anterior, PSA:
Presegmental artery, RA: Renal artery, RP:
Renal pelvis, RV: Renal vein, SA:
Segmental artery.
Results
Presegmental arteries (PSA) were present in all
the specimens (100%) of groups A and B. Total number
of PSA was 174; 90 in group A and 84 in group B.
213
Presegmental Arterial Pattern of Human Kidneys in Local Population
Although variations were observed in the number of
Presegmental arteries in groups A and B, no statistically
significant association was found between the two
groups. Group A showed total number of 90 PSA out of
which 53 (58.9%) were anterior while 37 (41.1%) were
posterior. Group B showed total number of 84 PSA out
of which 48 (57.1%) were anterior while 36 (42.9%)
were posterior (Figure II). No statistically significant
association was found between the two groups in the
number of anterior and posterior PSA. The site of origin
of most of the anterior PSA in both groups showed
extrahilar origin (Figure I) with the following variations: In
group A, total number of anterior PSA was 53, out of
which 40 (75.5%) were extrahilar, 11 (20.8%) were hilar,
whereas 2 (3.8%) were intrarenal. In group B, total
number of anterior PSA was 48, out of which 34 (70.8%)
were extrahilar, 9 (18.8%) were hilar, while 5 (10.4%)
were intrarenal.
Group A
Groups B
8
Frequency
6
4
2
1
2
5
3
6
4
0
Number of presegmental arteries
Figure II: Variations in the number of
presegmental arteries in groups A and B.
No statistically significant association was
found between groups A and B in the site of origin of
anterior PSA.
The site of origin of posterior PSA in both the
groups showed the following variations: In group A, total
number of posterior PSA was 37, out of which 28
(75.7%) were extrahilar, 8 (21.6%) were hilar, while 1
(2.7%) was intrarenal in origin. In group B, total number
of posterior PSA was 36, out of which 19 (52.8%) were
extrahilar, 9 (25%) were hilar and 8 (22.2%) were
Ann. Pak. Inst. Med. Sci. 2008; 4(4): 212-215
Rehmah Sarfraz et al
intrarenal in origin. Statistically significant association
was found between the extrahilar and intrarenal origins
of posterior PSA of groups A and B (p-values: 0.04 and
0.01 respectively); however no statistically significant
association was found between the two groups in the
hilar origin of posterior PSA.
When the sites of origin of total number of
anterior and posterior PSA was compared between the
two groups, statistically significant association was
found in the intrarenal origin of PSA (p-value: 0.005); no
statistically significant association was present in the
hilar and extrahilar origin of total number of PSA of both
the groups.
No accessory renal artery was observed in any
specimen, either of group A or of group B.
Discussion
In our study, the presegmental arteries were
present in all the specimens (100% of cases) of groups
A and B; this finding is in accord with those from the
previous reports .5,9,21,25,28-30 Our findings indicate that
no specimen of group had a single presegmental artery,
whereas one of the specimens of group B showed a
single presegmental artery Figure II). In a previous study
performed by Sampaio et al., forty nine polyester resin
corrosion endocasts of renal vasculature were made
and it was observed that in all cases with a single renal
artery, the main renal artery bifurcates into anterior and
posterior branches.25 However, in a study performed by
Weld et al., at Washington University School of
Medicine on seventy three human cadaveric kidneys,
contrary to our observations, 50% of the specimens
showed the presence of presegmental arteries while
they were absent in rest of the specimens.8
In the current study, variations were observed in
the number (one to six) and sites of origin (extrahilar,
hilar or intrarenal) of presegmental arteries; 75% of
anterior and posterior presegmental arteries of group A
showed extrahilar origin while 70.8% and 52.8% of
anterior and posterior presegmental arteries respectively
of group B were extrahilar in origin. These findings were
comparable with those of the observations made by
Longia et al., and Ajmani in which 71% and 68% of
specimens showed extrahilar origin of presegmental
arteries respectively.29,30 21% of specimens of group A
showed hilar origin of anterior and posterior
presegmental arteries; 18.8% of specimens of group B
showed hilar origin of anterior presegmental arteries
whereas 25% of specimens of group B showed hilar
origin of posterior presegmental arteries. Studies by
Longia et al., and Ajmani showed 11% and 14% of
specimens with hilar origin of anterior and posterior
presegmental arteries respectively.29,30 In the present
study, the intrarenal origins of presegmental arteries
214
Presegmental Arterial Pattern of Human Kidneys in Local Population
were observed in 3.8% and 2.7% of specimens in group
A, whereas 10.4% and 22.2% of specimens of group B
showed intrarenal origin of presegmental arteries.
Statistically significant association was present in the
extrahilar and intrarenal origins of posterior
presegmental arteries. These findings were not
comparable with the observations made by Ajmani, who
observed 18% and 16% of specimens having intrarenal
origin of presegmental arteries in Nigerian population.30
Conclusion
The presegmental branches of renal artery from
local population showed variations from those reported
in the earlier work carried out in other countries. It would
provide a reliable scientific referral data, which will be
used by the anatomists, surgeons, radiologists and
endoscopists.
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