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·FROM THE ROENTGEN DIAGNOSTIC DEPARTMENT OF THE UNIVERSITY
HOSPITAL LUND SWEDEN
(DIRECTOR PROFESSOR OLLE OLSSON)
ANGIOGRAPHIC STUDIES OF
THE ANATOMY OF SINGLE AND MULTIPLE
RENAL ARTERIES
by
ERIK BOIJSEN
STOCKHOLM 1959

·TRAVSLATED BY MRL JAMES BROWN
LUND 1959
HANAN 011LSSONS BOKTRYCKERI

·CONTENTS 5 6 Introcluctron 6 6 13 13 18 23 23 Part I A single renal artery Introduction Earlier investigations Author a investigations Soincnclature Material and methods Rekults Course of the renal artery from aorta toru nal hulum Ramification of the renal artery Orgin course and segmental dustribution of the branches of the renal artery Ds4CUARION anl conclusions Coune of the renal erters from aorta to renal hilum Ramification of the renal ertery Ongst ourse and segmental distrihutuin of the branches of thu renal artery Summary 42 42 43 45 52 54 55 59 59 00 co 60 73 l'art 11 Vultiple renal arterns Introduction l'arlier in tigations Author investigatina Material anıt methods Results Frequenez ef multiple arteries Preklu 3f surirls intography and nine freqlu ney of supplementary arterim Cirigun and use of supplementary arterien 1)፡rton Frequency of multiple erteru Fulls of supply tnpxraj hs and relatiue frequency of surpk mentary nrterus Origin and count of supplementary Attersee 79 79 6. 91 ·95 97 Conclusions Summary Appendix Variation in the number of renal arteries with different types of renal pelse 100 103 103 103 107 Part III ytrarenal arteriee arrsing from the renal artery Introductron Farlier inuestigations Authors intestigations Waterial and methi de Results Anatomic studies of hunoya from cadavers Anatomic stud ey of selective renal angiograms Angiographic appearance of capsular and renal peluc arteries in somna pathologie conditione Discussion and conclusions Summary Ceneral summary Acknowledgements References 107 107 107 113 218 121 128 130 1319 131 ·INTRODUCTION Renal angiography the performance of the examination and aseessment of the findings requires a thorough and detailed knowledge of the renal arteries and of their normal range of variation The anatomy of the renal arteries has previously been studied mainly by classical anatomic methods in autopay specimens The pattern of the intrarenal primary and secondary branches and of the supplementary arteries has not been related to modern concepts of the internal topography of the hidney In the present investigation which 19 based on clinical material from the Roentgen dingnostic Department of the University Hospital Lund renal angrography is used to study the anatomy in situ This will broiden the basis of the classical anatomy and convert it into clinical anatomy The investigation is concerned with the course and distribution of single and multiple renal arteries and their branches and of branches supplying adjacent renal structures non ·PARTI A SINGLE RENAL ARTERY INTRODUCTION About 70 % of all kidneys are supplied by a single renal artery This part of the in estigation is concerned with the following features of the renal artery (a) course from the aorta to the renal hulum, (b) ramification, and (c) orgin, course and segmental distribution of its branches which are anatomic cha racteristics of importance to the technical and diagnostic aspects of renal angiography The level of origin of the renal artery is anatomically (HELM 1896, HEIDSIECK 1928 TANIQLCHI 1931) and angiographically (EDSA 1957) clear the artery arises from the aorta at the level of the lower third of L I with a variation of about one vertebral body in a cranial or caudal direction In the present material all of the renal arteries originated at a level described by EDSVAV (1957) as normal EARLIER INVESTIGATIONS COURSE OF THE RENAL ARTERY FROM AORTA TO RENAL HILUM A thorough search of the literature revealed only scanty anatomic studies and no angiographic investigations The course is often described as tranqı erse or horizontal (ALGIER 1923 Rauber KopscH 1941 and others), descending (ALGIER 1923 Hot JE SEV 1930 Nar4til 1951 and others) or, in rare cases (GREIG SUTI 1888 ALGIER 1923) as ascending RAMIFICATION AND ORIGIN, COURSE AND SEGMENTAL DISTRIBUTION OF THE BRANCHES OF THE RENAL ARTERY The main branches given off by the renal artery are usually described according to their origin from the proximal medial, or distal third of the renal artery on its passage from the aorta to the renal lulum Cases in which the artery does not diride until it reaches the us of the kidney are usually assigned to the last mention 11, Hot Jr SF 1030) sse segmental arteries in 35% SCHT ·7 e 111 Terat on in or gn idoral artery from yt nal artery (after ALBARRAY & PAPIY 1908) of 80 kidneys and bifurcation in the sinus of the kidney in 6° GÉRARD (1911) examined 207 kidneys and found a proximal origin in 18. a medial in 14 and a distal or sinue origin in 68 % Hot -JENSEN (2030) found similar figures for ro kidneys but P'ALUUBO (1932) found in 34 kidneys a proximal ongin in 6% modal in 12% anul a distal or sinus bifurcation in 82 The branches of the renal artery have been described according to their tiell of supply as polar sentral and cioral The sentral and dorsal arteries have also been described in relation to the kidney peiris The dorsal arfery sually given off before the renal artery enters the hilum but in rare cases it may branei from a ventral artery in the sinus (L.RARRAN & Party 1904 Hou JENSEN 1930 VERKLE & VICHFLS 1958) (tig ) The dorsal artery seldom divides before reaching the hilum It enfers the upper part of the sinus either sranual donal or ciudal to the sen tral artery (L'AILYBO 1952) The vessel then runs cranial to the confluence of the kidney pelus or immediatels dorsal to its upper part after which it describes an are with the contenty facing craniolaterally as a rule the dorra! artery first runs horizontally into the sinus but then bends un caudal direction after a hich it often runs parallel to the dorsal bilir lip (ALBARRAN & Parn NOR HELLSTROM 1929 liol JEVSES 1030 GRAJES 1954 and others) ·8 (Fig ?) When the sessel descends in caudal direction it often crosses the upper caly r (GRAVES 1951) Branches are given off from the consex aspect and run to the dorsal part of the kidney Opinions differ on the fiell of supply of the dorsal artery GREGOIRE (1906) was the first to trace the pattern of the arteries from their entry into the hilum and their field of supply in the parenchyma He claimed the existence of a separate artery for the dorsal and the ventral haltes orcluding the poles, each of which was supplied by a separate artery The artery supplying the upper pole, however stemmed from the dorsal artery Other authors (20VDEK 1903, ALBARRAN & PAPIN 1908) expressed the view that the dorsal artery supplied not only the center of the dorsal part of the kidney, but also the dorsal part of the upper pole, uhle BRODEL (1901) believed that the ventral artery suppliecl the pars superior Gral ES (1954) found that the dorsal artery nourished the dorsal half of the kidney with the exception of the most apical part and of the pars inferior The central artery is, as a rule much greater in caliber than the dorsal artert and they are seldom of equal width (BRODEL 1901, ZOIDEA 1903 ALBARRAN & Parin 1908 and others) As a rule, the artery arborizes into three or four branches immediately before or within the Julum These branches usually enter the upper part of the hilum cranial to the confluence of the kidney pelvis, whence they spread radially in the sinus over the ventral side of the confluence (ALBARRAY & PAPIN 1909, GÉRARD 1912, HOU JENSE 1930, MERK LIN & MICHELS 1958) The ventral arteries branch further in the sinus and follow the calyces to the level of the papıllae, after wluch they enter the columnae Bertint as interlobar arteries The central branches of the sentral artery supply the middle of the kidney (ALDARRAS & PAPIN 1908, GERARD 1912) PRIW ES (1935) claimed that an artery, which he designated a cen trals, usually supplied the rentral middle part of the hidney BELLOCQ (1914) showed that the louer pole was supplied by branches of the ventral artery, while other investigators (BRUDFL 1901, GRAES 1954 and others) claimed that the upper renal pole was also supplied by the ventral artery GRA ES (1954) who divided the kidney into 5 segments, was able to show that the central artery usually supplied 4 segments (Fig 3), winch he callerl apicul, upper, middle and lower segments The last three were regularly supplied by the sentral artery, while the nutrition of the amcal segment (re presenting the upper medal part of the kidney) varied The pempheral arterial branches were dependent, to a certain extent, on the topography of the calyces (PRIW ES 1935, GRALES 1954) GR11 es reported that the arterial supply of the nuddle segnient of the hidnej nrıses ng a branch from the artery to the upper segment in 53 3 % of ·9 BO'LIH An 1 ramil cati n i lorul artery in alter Hor JENYF 1930) hudness s 30", from the artery to the louer segment and in 166°, from the sune location as the tro arteries to the upper and lower se, ments Polar arteries -- As mentionedi opinions differ on the arter, t) su li to the upwr pole Tlus disagreement due munds to the inexact definition of the boundaries of the user jole of the wines It may be sand that the upper pole is supplied by both sentral anel dors al arteries According to (IRATES the mediul up er fart of the pole is supplied bs brinches of the sentral artery in 131, of kidneys in 133 of kidneys it a branch originating at the bifurcation of the ventral and coreal Arteries by a branch i rosunal to the Bufurcation in 233 orl, branches from the donal artery in 20. of kuincia The remaining part of the upper pole is supplied by branches ninning crannalla from the entral and I real arterieCura D40 (19,5) would not acrept the name polar arteries on the ground that there were no ugyker anel louer polar regions of Bly to be recognized He admitted that arteries ocrisionalls ·10 APICAL APICAL UPPER POSTERIOR MIDDLE LOWER LOWER Posterior Anterior Fig 3 Dagram of rglth Iney show ng the five arter al segment. The ap onl ani lower segmente occupy the ventral as well as the dorsal hakes of the h dney (after CRAVES 193+) ran to the poles but that thes were not so common as to justifs classification as normal variants It is widely agreed that the louer renal pole 19 supplied by a sentral artery dividing at the level of the lower caly into a ventral and a dorsal branch (BRODEL 1901 GRÉGOIRE 1906 BELLOCQ 1914 GRAFs 1934) Hou Jesses (1030) confirmed this fact in 23 of 30 kidneys but in the remainder the lower pole was duided into a sentral and a dorsal part the latter being supplied by a branch of the dorsal artery The various secondary branches which thus supply different segments in the kidnej gire off the interlobır arteries These arteries enter the parenchynia between two pyramids and usualls supply adjacent parts of the latter The segmental artery with its interlobur arteries can however supply onls one pyrnnud (SCHVERDER 1895 GERIRD 1912 HOU JE\SEN 1930) At the bases of the pyramids the vessels bend to form the arcuate arteries and ghe off the interlobular arteries to the corter The interlobular arteries are readils de ·11 你太人 a 6 C tag Digram of variat on inc arap ant ram fication of renal artery a Typus mag tradus $ Typ us magural Tyus chispersatus (moli eil after hurrianOrr 1924) monstrated in angiograms of operative or post mortem specimens but they cannot be follon edl angtographically in 2020 HURTL (1872) who used corrosion preparations as the first to show that the sentral and dorsal arteries were end arteries suprlying their own separate areas of the kidney This has since been serified by niany in autopay studies (BRODEL 1901 ALBAKRAN & Parts 1908 lor-JEVSE 1930 Pick & Aiso 1940 MARATII 1951 GRAIES 1914 Striturs 1956 and others) and at operation (HELLSTRUNI 1928 BEROENDAL 1936 and others) and by rena) angiogrimg (1 DSX 1957 and others) By demonstrating the miependent nutrition of the sentral and dorsal parenchyma of the kidney HURTL (187") presented his thesis on the natur hche Teilbarkeit of the kidney Lihe BRODEL (1901) he beltered these vascular regione to be completely separate from one another Hot Jr SEX (1930) FC (1931) Anul I ( FOREY (1919) however found that the ventral parenchy mal arteries were sometimes demonstrable among the dorsal and that there wag thus no aunscular zone between the two fields of suppls BRODIL (1901) HOL TEVEN (1930) LOFORE (1949) and Cu4L HAVO (19 5) found the field of supply of the entral artery to be larger in that the Texel also supplied the sentral parts of the dorsal piramids Zo\DEK (1903) arried at the same conclusion he found that the border between the fields of the dorsal and entral arteries was 0-luem posterior to the lateral ·12 border of the kidney Lofarev (1949) found that the shape of the hulum indicated which part of the kidney was the least vascularised, the part under consideration being sitnated dorsally to the spatium longitudinale KUPRIJANOFF (1924) who injected contrast medium into the renal plyn and artrita charted the ramification of the latter but not make any distinction between sentral anil dorsal arteries On the basis of his investigatione he divide i tho vascular tree into two mam types (Fig. 4) magistrals and dispersaturs A Typus magistralis - lhe main artery enters undiu del into the hulum of the type thero are two inrionts first (Type I) in which the main artery enters the upper part of the hulum after whuch it runs parallel to the lateral surface of the huney and give off branches on its way YARATA (1951) therefore called the type of veveel Typris magistrale longitudinal Secondly (Type II) the renal artery enter the mulillo of the litlum and then continues at right angle, to the longitudmal axis of the kuney gning off road branches on its way NARATII (1951) called the form typu magistrale transveranli B Typus (18 peretilus - The main artery dundy before it reaches the Palum LUTRIJANOFF found this typo in about 35 of casca Ilio magistral type wag on in 65 of which Type I was seen in somewhat more than two thirds He described the dispersed type 14 being more common in thr presence of extrarenal pelte or kidney lobulation and claimed that it represented a lower state of desclopment than the mngistral Intermedinry formy were seen by KUPRIJANOFF m nbout 1 Priu ES (1935) was unable to confirm KUPRIJANOFM s findinge in every rospect but found the dispersed type in hulneys with ampullary ronal pohr, who the pols war better les cloped in hidneys of the magistral type Apart from the observation that the peripheral arborizatiil of the vessels AS n certain extent (lependent on the number of onlycem, in man he was unable to demonstrate any definito relationshup between the shapu. of the renal pelun and the arborization of the artery In animals, however, he often found the vnacular pattern to vary with the shapo of the renil pels 10 CHALDANO (1955) studel extirpated hadnc yn angiographically He found thr arterus to break up mainly into groups pamels branche running parallel to the BIDIN and branches running at right angles to the sinus Apart from t1114 loe could finut no ay stoinntıc tena ncy of the arborization of the cases SMITHUIH (1956) found acentually the same pittern SUMMARY Etensive investigations by various authors have demonstrated varied courses of the renal artery to the hidney and of the ramification through the sinua Different opinions are on record regarding the regions supplied by branches of the renal artery GR 11 FS (1954) was the first to describe a segmental arrangement of the areas supplied by the renal artery In clinical renal angiograms the course of the renal arters its ramification and the segmental arrangement of the kidnes area supphed have not been investigated ·AUTHOR'S INVESTIGATIONS From a roentgen diagnostic point of view knowledge of the segmental distribution of the varioue branches of the ren al artery is of particular impor tance GRALFS as mentioned appears to be the only investigator to have described the vascular pattern in relation to the various parts of the renal parenchy ma which he divided into 5 segments His studies are bused on Apecimens removed post mortem and cannot be applied directly to renal angiography because of the position of the kidney in 1110 Meither were they based on the topographical arrangement of the pyramidal systent which 19 the determining factor for the form of the kidney Since primary and secondary branches divide into interlobir arteries running in the columnae Bertını it might appear logical to describe the pattern of such branches in relation to the position of the pyramids The description of the destribution of the arteries is based on the fundamental mi estigation of the topographic arrangement of the pyramids by LOFORES (191.)) The arterial branches supplying the pyramids also supily enclosing cortical substance so that description of the distribution of the branches among tba pyramids will in reality be a description of the branches to the rencula NOMENCLATURE LUXGREY regned three parts of the kidney nimel; para suponor pe intermedim and jers inferior (Fig 5) the last tno parts together forming t., lobris rimordiain iferior Between these three parts grooves called me interportralis superior and inferior are seen in more than 80% of all ki in adulte These sulei radiate slightly from the lateral upper and lowane angle and the prrs intermediu lies between these two Thic kidney 19 innde up of 7 pairs of Pyramids each pur const met sentral (1) and a dorsal (D) psramid (PT) Three un ate situatat the part superior (hereinafter referred to as put ! 31D) ? in pars je pongo ( + 51 D) and 2 in pis mferior (pir 671D) (high) The pytanie - considerably in shape and size espre cially in the pars superior and -- ·but their positions in the kidney are fairly regular The pyramids in the pers intermedia nay be angular beciuse of the shape of the hilum Thus if the bulum is on the dorsal side the lateral parts of pyt 4-5 D will bend ventrally so that the lateral part of the bases of the pyramids will form part of the Tentral surface of the kidney Renal angiography will as a rule demonstrate the topograplıy of the renal vessels A thorough study of the nephrogram has shown that it is possible in most cases to observe the above mentioned sulci and the hulum The sulcı appeur as faint indentations on the lateral surface of the kidney At the end of the artermi phase and early in the nephrographic phase accumulation of contrast medium 19 seen in the corter and columnae Bertim pernutting distinc tion of the different pyramids (Fig 6) The dorsal and ventral pyramids of each pur are essentially on the same crimo crudal les el but do not completely coincide antero posteriorly because of some latcro medial displacement The fields of supply of the various arteries Wcre studied on the basis of the abore topographic data No generally accepted nomenclature is available for the primary and secondary branches of the renal artery lhe essential point of any nume used is that it clearly indicates the field of supply and its relation to the renal pelus The renal artery is called a renalis until the departure of the dorsal artery (a dors ) after which it is termed the rentral artery (a ventr ) These main branches are primary branches and course dorsal and sentral to the i idney pelvis Further primary branches are also given off to different parts of the kidney most frequently to the poles (r sup or r inf) before the departure of the dorsal artery or together with the latter to form a tri or quadrıfurcation In an attempt better to define the area of supply of the primary branches the pyramid numbers are also given as well as the letter I or D to denote whether the 1 yramids are located in the ventral or dorsal part of the hidney There are thus 4 types of primary branches They may be defined in the following way (Fig 7a) renal artery - Isrl.ID -8 d Nr 3 61) -a ventryr 3 ut -- in ur 61D The dorsal and sentral primary branches give off secon lary brancl ex (r dors and r intr ) If the arteries to the renal poles are from the dorsal or entral arteries they are secondary branches All of the secondary brinches are segmental arteries (or subse, mental arteries) since they only supply certain fimite parts of the rennl parenclıy ma If the segmental arteries stem from Tentral or dorsal arteries the susculature may be delmed as follows itig 7b) ·Ventral Dorsal Pars superior 4 4 Pars intermedia 5 5 Pars inferior Diagram of tupraphy of left bxley based on the stuloy qurformed by LOFORF 11949) \umer 17 indicate surfaces corresponding to the entral and dorsal pyramiche Ptery Arteriry -TC -4 rue 1:1 151) Sne or (4ub segmental Arteriet home pr 1 !VD) - don T 3-4 D - dory pic 5D Tvinir 1"}7 3 + 1 -1 Vente per 1 Frent 's 6 ID rutal artery patris 31671) segmental arteries are further disided into subsegmental arteries which supply portion of A Regment egr (ors për 5 D These subsegmental arteries also brunch directls from the primary arteries or from the renal artery The interlobnr arteries leport from the subseginental arteries in the sinus anul enter the parenchima between ? 13 ramids The numler varies, but as a rule there are suffisent for each pim to be supplied by a subsegmental arters Is the puramuls represent the basic segments of the kulney, there 14 A segmental supply but each interlolıt artery usunlly gives off branches to adjacent piramide The division of the reginents can therefore not lie

·0
F g Ga-c Select se ret al ang ogrom (left
h lney) Frontal Jew The f mula of ar
tot al tree 24
a res alus
-Teur IT 131
-& spyr I 3D
-a ventry #71
G--D
c

·17
d
F1graf Ol lipi
13 Ayut the
mj cting the tor al artery apan ini
melully than in frontal seu In the nat heo
STAM nerumulition of contract in cortex
en ! columnan Bertini outline the tytamuts
As well as the hulum
e
+ RONJWA

·L.
Fig. 6a, Selectis e renal angiogram (Irt
kuney) Frontal wew. The formula of ar.
terial the
6. renal!
-T. sup r 1-31
-1 durs T'T. 1-5 D
8. ventr. PT. 4-71,
6-7 D

·17
d
Fugd Oblque sien Because of the
projection the dorsal artery appears more
medially than in frontal tiem In the nephro
gram accumulation of contrast in cortex
and columnae Bertinı outl ne the pyramide
as well as the hilum
2 BOB

·0
F. Ca-c Select se renal ang ogram (left
h Iney) Frontal 1 ex The form la ofar
ter al tree y
A renalis
TRUL PT 131
-A for Pr 1 5D
-& sentr 1 JT 4*1
6-7 D
C

·17
1
re
d
Fig rdf Oblique view Because of tho
projection the dorsal artery appears more
med ally than in frontal view In the nephiro
gram accumulation of contrast in cortes
and columnac Bertini outline tio pyramid
as well as the hilum

·18
பாம்
Hence
Fig 7 Diagram of left kidney showing nomenclature of different segmental arteries in
fortnula below
-12) r sup pur 1 2ID
(1) A renal
-(3) a dors pvt 36D
(4) a ventr JT 351
-(5) r inf PT 671, 7D
(4) rr clore per 1-2VD
(2) adors pyr 121 1 6D -(5) r dore dyr 3D
-(6) r dors PT 5D
U (1) a renale,
(7) ? rentr pıt 3-1
(3) a ventr pyr 371 6-7 D--1-(8)r ventr pr 51
(9) r ventr rir 6-71D
cract On the other hand, the secondary branches usually supply more
than one pyramid permitting division of the kidney into greater segmente
and then the poor definition due to the interlobar arteries will be of less
Importance
MATERIAL AND METHODS
AUTOPSY MATERIAL
Twenty three kidnej 9, each with a single renal artery, were studied regarding
the regions supplied by the arteries

·19 The kidneys were removed together with the renal capsule and the aorta the latter being slit up from the sentral side in order to check that the kidney was supplied by a single artery A suspension of colloidal BASO, (Collobar Aetra) was injected into the renal artery which was ligated at its origin The arterial vasculature was then studied in three different projections (1) the kidney lying flat on the support (truo frontal projec tion) (2) with the kidney tilted about 15° so as to obtain an image corresponding to that obtained in a frontal ven a lito (3) with the hidney rotatel so that the dorsal surface faced medially, I e a view corresponding to a truse lateral projection (Fig 8) The contrast medium (Coll bar suspension or 50 Umbradıl) was then injected into the renal pelvis and the 3 above mentioned projections were repeated CLINICAL MATERIAL Thirty three kidneys (10 right 23 left) were examined in two projections by selective angiography according to the method of ODYLAN (1956) Frontal films were taken with the patient in the supine position (corresponding to projection 2 above) and oblique films with the patient tilted to the side to be studied (projection 3 above) In some cases lateral films were taken instead of oblique In these projections it is possible to distinguish between dorsal and ventral arteries (IT EYDE 1954 FRIVAA N DAJIL 1958) Selective angio grams also permit evaluation of the columnae Bertını and the outline of the hilum, and can therefore be used with advantage in the investigation of the renal arteries in The findings from these renal angiograms were then compared with the data obtained from the autopsy studies It was soon realized that the frontal films alone were sufficient to decide which of the arteries were dorsal the arteria dorsalis being of characteristic course and appearance (Figs 28) « The dorsal artery was often found to arise as the first branch from the renal artery (which distal to that point was called the sentral artery) b Its caliber was as a rule smaller than that of the ventral artery c It coursed in the sinus in a typical way with the descending part often running vertical and parallel to the posterior hılar lip d Its branches crossed characteristic vessels of the ventral artery e Owing to the position of the kidney on riuo between the frontal and sagittal plane the field of supply of the dorsal artery was located more medial than that of the sentral artery In the pars intermedia the peripheral branches of the central artery always cxtended out to the lateral part of the kidney but never those of the dorsal artery, provided the kidney was not malrotated Thus the material could be extended to include examinations of other patients of whom films had been taken in only one plane A further 100 kidneys (51 right 49 left) were there fore studied with regard to the region of supply of the segmental arteries Origin course and segmental distribution of the branches of the renal ·20 0 ·21 Fig & Autopsy specimen (left kidney) examined in three projections a d True frontal projection with kidney flat on examination table Branches of lorsal artery do not croes one another neither do those of sentral artery except in lower pole The course of dorsal artery is characteristic cd law comparable to frontal projection in stiu Dorral artery and its branches appear more medially in this semi lateral view True lateral projection se view comparable to ohl que projection in situ artery were thus studied in 156 kidneys with a single renal artery which were accounted for above namely 23 removed post mortem 33 examined by selective renal angiography in two planes and 100 kidneys of which renal angrograms had been taken only in one plane An attempt to divide the supply of the kidney into the previously mentioned parts (pur 1 31D pyt 4-5 VD fyr f71D) confirmed the findings by SWITHTIS (1956) that they did not coincide with the fields of supply of the segmental arteries For example the subseg mental artery to pur 3V which belongs to the pars superior often encroached upon parts of psr 4V which belongs to the pars intermedia and the artery to pyr 51 often supplied the cranial portion of pyr 6! The arteries to the intermediate sentral and dorsal segments had one characteristic in common

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·23 Table 1 Course of renal artery from aorta to renal hilum (clin cal ang ngraphic material) Ascending Horizontal S de um ber Total Per cent Vum ber Per cent Descen ling or Num Por which ber cent ptosis Of anch ptosis Right Left 86 401 64 66 39 5 434 41 4 81 25 51 3 16 5 23 9 162 152 61 2 Total 75 239 130 2 109 347 32 314 RESULTS COURSE OF THE RENAL ARTERY FROM AORTA TO RENAL HILUM All of the angiograms were taken during the expiratory phase with the patient supine In the classification of the course of the renal artery three types were recognized namely ascending horizontal and descending In young persons the renal artery runs a fairly straight course to the kidney Vost of the subjects in the present material however consisted of elderly persons Though the aorta in such age groups may be of normal appearance the renal artery may be of larger caliber and more tortuous than in younger people The course of the renal artery was judged simply by the relationship between the origin from the aorta and the level of its entry into the hilum A total of 314 kidneys (162 right 152 left) were examined in this way and the results are given in Table 1 In about 10 per cent of the hidneys renal ptosis was observed mainly on the right side Here a kney affected with ptosis is to be understood as one ente heln tranen of Ingol marh 1 en II.IT ul - u 1 1 kidney 19 abnormally low the renal artery runs a fairly strarght caudal course and subtends a small acute angle with the aorta In these cases the vessel is distinctly elongated (Fig 10) RAMIFICATION OF THE RENAL ARTERY The first division of the renal artery may occur in the proximal middle or distal third or even in the sinus 427 hidneys were esamined in this respect and the results are given in Table ?

·Table? Ramification of renal attery in the clinical angiograpluc interut Proximni Verical 13 Suo Num l'or cent Total Distai Num Per ber ront Numn ber ber T'er sont Num Per Crnt ber Right Left 11 10 33 20 165 03 11+ 00 635 421 45 04 211 439 913 214 31 73 194 201 178 139 427 Tahle 3 Number of branching of renal artery beforo tunel hilum in the clinical anglo graphie Inaterial No ramification artrtics 3 arteries or nur arteri Sude Tota um Aum um. Wuns ber f Pir cent Per cent lir cent ber l'er cort bar ? 213 Rigit Luft 45 94 NO 211 430 100 01 23 ) 103 17 7 42 139 326 101 73 171 2+ 427 The number of branches into wluch the artery divided before entering the hidney was also studied and the results are gisen in Table 3 Corresponding analysis of the topography of the arteries in the 23 kidney remored post mortem shower that + or more branches were found before the fulum in 16 kidncys and in only I hxiney «d the renal artery branch in the sinus Proximal divisjon of tho artery wag noteci in 4 hidneye, metla in and datal in 12 wulo in I, as mentioned, the artery Hd not du ke until at reached the sinus ORIGIN, COURSE, AND SEGMENTAL DISTRIBUTION OF THE BRANCHES OF THE RENAL ARTERY IN 158 XIDNEYS I'yr 1-21'- aried considerably (Table and Fig was Bupplied by arterice emanating arterine In two thirds of these kidneys r sentr r J-V was just as widlo as r dors PyT 11) (Figs 12 and 23) In the other kidntys the branches of the central arters were defitely wuler, słucht implice that r sents was responsible for ·05 Fg 10 Select ve renal ang agram of a Jeft ptotic k dney Renal artery 4 el gate 1 stra gl tened and has a steeply lescen I ng course Field of supply of lorsal artery includes pur 1 UD Renal artery d des into three arteries a dors psr 1911 6D -& ventr 1 yr 341 - inf pr 571 7D a renal the main supply of the segment The branches of the dorsal artery often multiple were frequently small and supplied only those parts of the per 12 D near the sinus In 11 5 °, the segment was supplied only by vessels from the ventral arter (Fig 13) and in 212 % by vessels from the dorsal arters (Figs 10 lo and 1") The sentral artery and the dorsal artery entered the hilum immediately caudal to pr 1-2 ID so that r ventr or r dors pyr 121D had a short main trunk which soon dirided into sentral and dorsal subsegmental arteries which followed the caly to the papillac On their way the segmental arteries gare off ·26 Fig 11 Diagram of left upper renal pol showing common variations of arterial gurpis of psr I PID Talle Variations in origin of arteries to pyr 121D in the client an lautnyy material Origin from a renalis and sentrals and A daralia Idney's studied A renalis sentr don & ventr 2 dor A vent ta dors sentr equally larpnet Inrget 3 4 10 3 19 21 10 31 Angiograms in one pline (100) Ingiograms in two planes (33) l'ost mortem specimen 23) 0 0 + 5 0 7 10 1 0 0 0 1 3 12 5 1 Total (150) 33 18 26 52 26 Per cent 12 89 26 11 5 212 33 3 GA ·27 Fig 1. Select se renal angiogram (left kidney) Pyt 1 210 g Burplied by a dorsal As well as a ventral artery -a dore pyr 1-5 D la renalis? & ventr fyt 1-71,67D branches to neighbouring parenchyma The segment was often supplied by several small arteries instead of one large one In 26 of the kidneys one or more branches left the renal artery before the dorsal artery to supply pyt 1-2 VD (Fig 21) In 147% at least one branch left the renal artery before or at the same level as tlie dorsal artery, but the segment was also supplied by vessels from the ventral and dorsal arteries (Fig 61 In 145 (93%) kidneys the supply was limited to this segment In II the supply also covered nyt 3 V, and in 5 of them the pyr 3 D as well Pyr 6-7 I'D - One artery to the lower pole was always demonstrable Its arra af supply varied, as did the level of origin from the renal or the sentral artery (Fig 14, Table 5) ·28 They MUMS Fig 13 Selectae renal Angiogram (left ki Inez) - Frontal projection entral artery supplies pyr 1 21D dor al artery dorsal part of parg inferior Ventral artery to lower pole arisey at last artery and runy parall I to lateral kidney surface & dors pyt 37 D a renalis -& ventr pr 171 12D In 60 (38 5 %) kidneys the artery to the louer pole arose from the renal artery either before (29 cases) or at the sime lerel as (31 cases) the dorsal artery (Fig 10) In 96 (61 5°) kidneys the artery to the lower pole originated from the ventral artery most frequently where the latter entered the kidney hilum (Figs , 19 and 22) In 55 (573 %) of these kidneys the arteri ran to the lower pole as the first branch of the ventral artery (Figs &, 12 and 15) and in 27 (281%) hidners as the last branch (Fig 13) In the remainmg 14 (148%) kidneys the origin from the entral artery raried the lower polar artery usually arose ·99 Fag 13€ Oblique projection Obserse increased distance between dorsal and sentral artery 89 compared with frontal projection immediately distal to the origin of r ventr nyt 12V(D) or at the same Jocation and then as a member of a trifurcation in which the r ventr nyt 351 was the third component (Fig It Table 5) The course of the loner polar artery in the sinus saried with its origin (Fig 14) is mentioned the renal artery or its main branches nearly almaya rin in the upper pirt of the hilum cranial to the renal pelus or at the level of the upper part of the confluence of the kidney pelvis In the majority of kidneys (more than 80% of the material) where the lower polar artery eman ated from the renal artery or early from the central artery the vessel rai) fatero caudal course to the lateral lower hilir angle The more central the origin of the loner polar artery in the sinus the more vertical has its course In the 27 kidneys in which the artery to the lower pole was the last branch of the sentral Artert both often ran a characteristic longitudinal counse in most cases parallel

·*
7
17
Fig 1 Diagram of lower part of left kidney showing common variations in origin,
course and field of supply of artery to lower pole
o the dorsal artery The ventral artery in these cases entered the upper hilum,
here it ran an almost horizontal course, after which it turned caudalls in
clateral part of the sinus and then ran parallel to the lateral surface of the

·31 Talle 5 Variations in field of supply and origin of lower polar artery (clinical and autopsy material) Ongin from renal artery Origin from ventral attery Total Pyramids surple 1 Before 1r 1 st d Nal artery Quadri um fure ber 2 n Tri branch branch) furc Last Yum Yum branch ber ber Pec tent Su2rc 1 2 2 2 1 3 3 2 3 12 1 1 2 19 5 9 23 45 15 6 3 3 1 4 71 5 71 671 671 6-7 D 6 7 17 D 571 5-7 D 6-71 67D 5-7 D 4" 6-TD 471 D) Vumber Per cent 0 + 5 19 7 1 18 5 1 0 5 18 76 11 0 23 6 13 58 14 7 28 8 115 07 26 3 70 33 07 1 9 2 1 4 8 3 1 1 41 21 1 19 5 2 1 2 1 1 29 26 5 60 55 5 27 96 156 188 187 32 395 35 2 58 3 173 615 kidney During its course it gave off branches first to pyt 1-2 (D) then to 3-5 and finally to 6-7 I (D) (Fig 13) In none of the kidneys (56) examined in more than one projection did the artery to the lower pole run dorsally to the renal pelvis Before the artery divxled and entered the parenchyma it ran adjacent to the lower calyx as far as the level of the papillae In the cases in which it supplied dorsal pyramids the artery gare off a branch to pyt (6)-7 D as a rule at the Jerel of the lower caly, but occasionally proximal thereto The lower polar artery is above all a ventral artery and therefore regularly supplied pyt 6-7 V Its field of supply often included për 5 V (Figs 8 and 10) and rarely pur +1 (Fig 19 Table 5) In 122 (78 %) of 156 kidneys the lower polar artery supplied not only the two ventral pyramids but also pyr 7D (Figs 8 10 and 21) and m 92 (59 0 %) it supplied the entire pars inferior (Figs 6 12 15 and 19) Only in one kidney did the supply include not only pars inferior but also pyr 5 V and D When the lower polar artery did not supply the dorsil pyramids in the pars inferior this part was supplied by the dorsıl artery (kige 13 and 17) In the 27 kidneys in which the artery to the loner pole was the last branch from the sentral artery its field of supply was more sentral than otherwise In 10 (592) of these kidneys it therefore supplied ventral pyramids only as against only 18 (110 %) of 129 in the rest of the material (Table 5 Fig 13) ·Fig 15 Seleetno renal angiogram of a normal left kidney extirpated later because of sovero haematuria Q- Frontal clinical angiogram Dorsal artery runs in an ordinary way to upper part ef hilum and supplies dorint part of pars intermedia and entire per 121D wale the ventral artery has an unusual course to lower part of bulum a renale s lors pyr 121 1-5 D A ventr fyr 3-71, 6-7 D c/ Angiogram of operatite specimen in true frontal (c-d) and lateral » * le 1) confirmy findings in clinical Angiogram Ventral arteries are filled with water alusi, contrast medium the dorsal artery with colhidal Baso, Pyr 3-5 ! --- The subsegmental supply to the indusual pramids was more predominant in the rentral part of the pars interinedia than in any other part of the kidney The subsegmental supply to pyr 3 V' was also often prominent but only in relatiels fes cases (8 kidney 8251 %) was each of the 3 pyramids supplied by its own subsegmental artery from the sentral

·33
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d
3
Bu wa

·34 Fig 16 Diagram of left kidney slowing common variations in origin, certise and fre of supply of segmental arteries to pur 361 artery More commonly (86 kidney s=55 1 %) one pytanud (3 1' or 51') wa supplied separately, wlule the other ? nero supplied by a common segments artery (4 5 V' or 3-4 V) (Figs & and 10) In 51 (397 %) kidneja për 3-5 were supplied by a common branch of the rentral artery (Figs 16, 17, Table 6) In the remaining cases (11 kidney8=71%) the supply was somewhat differen in that a branch of the ventral artery to pyt 1-1 also gupplied 3 1'. Pyr 4-6 V in these kidneys were supplied either by separate branches (Fig. 6) or by a common branch of the sentral artery (Table C) ·35 Tuble Variations in the supply of pur 3-5 V hjdnej e student 3 V, 4-51 3-41, 5 V 3-5 V 3 V, HV, 1-3 V, 51 41,5 V 131 4 51 Total 6 49 37 3 3 100 Angiograma in ono plane Angiograme in two planey Post mortem specimen number 3 12 13 2 1 33 4 12 1 3 1 13 73 51 8 * 7 156 Per cent 63 488 32 7 61 26 The range of variation of the vascular pattern of the vessels to pyr 1- VD and 6-7 VD was limited by the outline of the kidney polec The variations in the pattern of the vessels supplying pyr 3-5 V' were dependent on variations in the arteries supplying the two polar segments while pyr 3V mught be supp lied by the artery to pyr 12V (11 hidneys) and 5 V (70 kidneys) and 4V 18 hidneys), by the artery to pyt 6-7 V (D) In addition, the origin of the seg mental arteries to the poles varied with an associated wide variation in the course of the vessels to pur 3 5 V (Fig 16) Despite variations in other arteries the artery to pyt 3-4 V usually showed a characteristic course It formed the direct continuation of the ventral artery, independent of the fact whether r ventr pyr 1-2 V (D) was given off before the segmental artery or not (Fig 17) Exceptions to the rule could, however, Ise Reen (Fig 15) In those kidneys (11) in which pr 3V' was supplied by arteries to pyr 1-21', the artery to pyt 4 V was the continuation of the ventral Artery sometimes in combination with the arters to 5 V In the 27 kidneys, in which the lower polar artery was the last branch the arteries to the pyr 3-5 V in that segment were given off either separately to each pyramid or in various combinations of the type illustrated in Table 6 In these kidney 9 tho Regmental artery was gn en off late because of the lateral position of the entral artery in the ainus (Fig 13) In one kidney an artery stemmed separately from the renal artery to pyr 3 V before the origin of the dorsal artery In 8 kidneys a branch of the renal Artery was given off to pyt 3 + V' and in & hidneys a branch to pyr 3-5 V As a member of a tri or quadrifurcation, where other arteries were represented Ly the dorsal artery and arteries to ryt 1-2 V1) and 6-7 VD (Fig 10) ·36 11 one Frg 17 Selective renal angiogram (left kuiney) Observe doral artery of nbout Aamo caliber as ventral artery but supplied a larger number of Pyram ls Pyr 3-5 18 supplied by a main trunk which is a direct continuation of renal artery R ventr pyr 5 runs paralel to dors al artery and lateral surface of kidney Pyr 6-7 D 24 supplied by a real artery a renala -a dors pyr 121, 1-7 D -& ventr pyr 3 71 The commonest variant of the sentral artery was the one, in which it divided after the origin of the lower polar artery into two branches, one to pyr 1-2 V (D) and one to pyr 3-4(-5) V (76/156=48 7 %) As to r tenir pyr 5 l'the vessel emanated separately from the renal artery in 4 kidneys (2 %) and from the lower polar artery in 70 kidneys (449 %) The course of the branch to pyr 5V in the former casco was caudolateral, while the more caudal the origin from the lower polar artery, the more hori zontal was its course (Fig 18) Occasionally the segmental artery ran cranio laterally when it was given off from a distal part of the lower polar artery ·37 Fig In Diagram of left hidney showing common variations an origin and course of ventr PT 51 This was so in the kidneys in which r sentr TT 4V also emanated from the lower polar artery (Fig 19) In one kidney the subsegmental artery was given off in the angle betueen the arters to pur 3-4 V and the lower polar artery In the remainder of the hidneys the r entr pjr 5 V branched from the artery to 3 + V The r ventr pur 5 V was, as a rule, gu en off last, but some times it stemmed from the ventral artery before the segmental artery to pyt 1-2V (D) (Fig 18) The artery to pyr 3 1 represented the last part of the sentral artery and ·38 Fug 19 Selective renal ang ogram (r ght kr Iney) Rentr fyr 4 an 15 V ar from entr pyt 6-7 ID and are an ascend ng an il or zontal course react soly a rena) -a dors pyt 1 21 15D -a ventr pyt 3 71 6 D in the sinus it usually ran horizontally or somewhat cranially before its lifurer tion in the upper part of the sinus As 1 rule it rin cranial to the renul pek 18 and crossed the basal part of the upper calyx After the bifurcation the r ventr por 3 V ascended somewhat whiler ventr pur 41 rin slightly caudally or horizontally The former ressel ran adjacent to the upper caly r on the lateral side up to its pirmd wluler rentr pr t I followed one of the middle cals ces R ventr pyr 51 when it arose from the artery to pyt 3-4 I usually rin caudally along the lateral border of the sinus of the kidney and finally followed a caly x to its pyramid (Fig 17) Pyr 3-5 D As a rule the dorsal artery originated from the renal artery before the hilum (Fig 20) In 80 (513%) of 156 kidneys thic renal artery

·39
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Daran
Igncorde anlfeld
f 1 ft k ines si oxing common var at non
of supply of d Malerter

·OF 119 21 ·41 divided into a ventral and a dorsal muin branch without giving off any previous branches (Figs & 13 16 and 17) In 39 (250 %) of 156 hidneys the dorsal artery was given off at the same time as 2 or 3 branches to the 3 other segments in the kidney (Fig 10) In 37 kidney s minor branches were given off from the renal artery before the dorsal artery usually to pyt 1 21 D segment (Fig ) or pyr 6-71 D rarely to pyr 351 In 2 kidneys the dorsıl artery was given off distally in tle sinus together with sentr pyr 3-+! (Fig 21) In 3 kuneys the dorsal artery arose from r inf pyt [ 71 Finally in one hidney two dorsal arteries were obsersed one originated from the renal artery and Burpued ryr 1 2D and 6D the other supplied 3 5 D and arose from the loner jolar artery Only in a few kidneys did the dorsal artery daude before the hilum The dorsal artery was in rare cases as wide as the ventral artery (Fig 17) The dorsal artery usually entered the upper part of the hilum as a single vessel and there in most cases ran an almost horizontal course Voat fre quently it gave oft brinches to pyr 1 D which rared from small often multiple vessels supplying adjacent regions of pyr 1 ? D to one wide artery supply ng the entire per l'ID (Figs 10 15 and 17) The artery then turned caudally to run an almost vertical course In the clinical renal angiograms this curie was not always distinct because of the position of the kidney in erro (Fig 8) The cranio lateral convexity usually gave off the branches r clors pyr 3 D sometimes 4 D which followed the calyr to the top of the ps ramad During its further course the dorsal artery gave off branches to pyr 4 and 5D Tliese branches cime from the lateral aspect or the terminal part of the dorsal artery As mentioned (pnge 2-) in 5 hi ineys the pyr 3D was supplied by the artery belonging to per 1 ID segment In 3 of these the vessel arose from the dorsal artery in one from the sentral artery and in one from the renal artery Pyr 6 D was supplied in one hancy by an artery belonging to put 6-7 segment Pyr 4 D was reçularly supplied by the dorsal artery (Table 7 rug '0) It was thus jossible to show that pyt 35 D was nearly always (98) supplied by the dorsal artery ra lort e renal ang ogram (lefth Inez) Pyr l'ID 198 rpcl by arter ca fem reu al artery orsal artery departa late in ons т в ррут 123 - я ррут 1°D don pyt 3-6 D Arnal -a vente 3-1 D

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·13 angiograpluc study showed that more than half of the right renal arteries (02 %) have a descending course and seldom (9 %) ascending However the course of the left renal artery in 10 % was found to be ascending and only 16 % descending with as many as one third of the latter being situated lower than normal If the findings of FDSMAN (1927) are taken into account then it is possible to decide in a plain film the course of the artery to the kidney as being from the level of the intervertebral disc between the first and second lumbar vertebrae to the upper part of the hilum of the hidney This 18 of practical importance in performing selective renal angiography On insertion of the catheter into the renal artery the bent tip should more or less correspond to the course of it to facilitate positioning of the catheter and to prevent the top of the catheter from being directed against the arterial wall When the renal artery has a marhedly descending course it might be difficult to feed the tip of the catheter into the artery unless it is bent in a curte to almost 180° By determining the position of the kidney in relation to the intervertebral disc between L I and L II in plain roentgenograms before angiography it a thug possible to shape the catheter According to the course of the vessel RAMIFICATION OF THE RENAL ARTERY In earlier morphologic studies the renal artery has been found to divide before the hulum as a rule into 4 or 5 branches Similar results were obtained in (5 % of kidneys removed post mortem in the present series The frequency found by clinical angiography was definitely lower (5°. Table 3) On the other hand the origin of the first branches of the renal artery varied less in this respect Table 8 compares these frequencies with those found in the present in estigation The present clinical material differs from the autopsy studie, described by other authors because the renal artery runs not only laterally but also dor sally in clinical angiograms the renal artery appears shorter and particularly its terminal part which is projected over the medial part of the hidney as is clearly shown by the post mortem specimens eramined in different projections (Fog 8) Thus the findings made at autopsy are not strictly comparable with those made by clinical angiograms PALL VBO (1932) using angiograms of kidneis removed post mortem shoued good agreement with our clinical resulte These results differed consı lerably from those reported by eirler authors and from those made in the present praxt mortem inuestigation This differeneo mas be explained by the fact that L'ALIBO examined preparations at an angle corre ponding to the frontal projection on tiro ·Tables Origin of first branches from renal artery in prerous and present autori studies comparer with tłe prezent elocal material Distal on Author Sumber of cases Prowmas orign Herlia! origin in and origin in Sinus 207 69 18. 12° 50 34 20°C 69 Gérard (1913) Hou Jer en (1930) Palumbo (1952) Pre ent 2) Post mortem 2) In vo Gº 19. 23 427 28 12. 57 81 % It is clear from the present clinical angiographuc studice that in about 7°, a branch arises proximally from the renal artery Thuis is important in selective renal angiography because it may result in the tip of the catheter entering the narrow earis branch This may cause a sprem with the risk of complications because the renal arterz 19 an end artery (1622) If a spam does not occur all the contrast medium may be deposited in that segment supplied by the proximal branch with demonstration of onis part of the kidney Consequently the bent tip of the catheter should not extend more thin about 1 cm into the renal artery The tip of the catheter should be situated immediately adjacent to the left border of the vertebral body when catheterizing the left renal artery and about 1 cm medial to the right border of the sertebral body on catheterization of the right renal artery In the present clical series the right renal artery was found to crude proximal to the hilum twice as often as the left Thus may be due to the fact that the right renal artery is somewhat longer than the left (CAILANDER 1939 and others) ORIGIN COURSE AND SEGMENTAL DISTRIBUTION OF THE BRANCHES OF THE RENAL ARTERY - Pyr 1-2 1D This segment which corresponds to the medial ant superior part of the upper renal role and a separate arternal supply in 13 of the neys while in the remamm: 1117) hidneys the arterial beginly secried to ertend to the entire pris superior In G of these hidney et conld not be decided with certaints whether the arterı supplied prt 39 or + 1) LOFOREN (1949) showed that prt 3 D is the one that is usnally least des closed ·1 M 1 arteri Select o renal ang ogram r ght . Inez) Tip of entloter pucer! aL ng suam n tl 4 yetuel Only ventral Artery therefore I L Olxec braneles of entral artery bot er le anul ay An i in sercral cases thus Tyramid is only rudimentars PT Dis thuis more cranially an l the rescel to the piramid is then read is muistake dors pr D It 18 jrobable that in 7 of the cases the pars siper suppi ed by in lependent arteries from the dorsal an lor ventral artery lys { "ID corresponds to what was usually descnber! by earlier ·76 As the upper pole (BRODEL 1901, GREGOIRE 1906, ALBARRAN & Papri 1908, BELLOCQ 1914, HOU-JENSEN 1930 SUITHUIS 1956 and others) Oprions have differed widely on its vascular supply This disagreement can be explained by the fact that there is a wide variation in the blood supply, and also that opinions differ on what should be regarded as the exact limits of the upper pole GRAVES (1954) charted the supply to the upper pole in segments, an apical an upper and a posterior The 2 last mentioned extended down into the pars intermedır on the ventral and dorsal sides respectively The apical segment did not correspond to pyt 1-2 VD but represented either pur 12V or 1-2 D Thus, therefore explains the difference between the pattern of the supply found in the present investigation and that described by GRAVES The reason why preference was given by the present author to a larger segment was that in 35 % of the kidneys pyr 1-2 VD was supplied by only one artery GRAVES found that the dorsal artery supplied the apical segment in only 10% of the hidneys, while the sentral artery did so in 43 3% of kidneys This can be explained by the fact that the upper portion of the ventro medial part of the b.idney usually consists of pyr 1-2V and that sentral branches supply parts of the dorsal pyramids Grales found that arteries to the apicui segment stemmed from the aorta or renal artery in 46 6 % of hidneys is against 173 % to pyr 1-21 D in the present investigation This can be explained by the fact that the present material included only hadness with a single renal artery According to HELLSTROU (1928) and BERGENDAL (1936) arteries are given off by the aorta to the upper pole in about 7% The remaining approximately 22 % of kidneys may be explained by differences in the clnesıfıcation of the origin of the segmental arteries The segmental artery to mr 1-2 VD rises very close to that of the dorsal artery from the renal artery, so that in the present material the origin of r rentr pyr 1-2 V was considered to be from the ventral artery GRAIES on the other hand, considered the artery to branch simultaneously with the dorsal and ventral arteries from the renal artery HELLSTROW (1928) found that in 22 % there was an extrabılar artery from the renal artery to the upper renal pole In the present material 19 hidness (122 %) were found to hare extr hilar arterice running to tho pars superior In 11 kidneys these sequels ran from the renal artery, and in the remainder from the rentral or dorsal arteries Sure these vessels often enter the renal parenchyma quite close to the hilum angiography will not always decide whether the artery runs within or outside the sinus There was thus reason to suppose that many more arteries ran outside the hilum to the upper pole than we found Pyr 6-7 | D - It is known that the artery to the lower role of the Laney usually arises from the entral artery (BELLOCQ 1914, Hor-JENSEN 1930 and ·others) GRAVES (1954) believed that this artery was the most characteristic and consistent in the ascular tree Hou JENSEN (1930) found that in about 77% (23/30 hidneys) both the sentral and dorsal part of the lower pole were supplied by this artery while in the remaining cases the dorsal artery itself wts responsible for the nutrition of the dorsal portion GRAVES (1954) did not mention this variant In 78 % of the kidneys in the present maternal pyr 6 7 1 and 7 D were supplied by the lower 1 olar artery while pyr 671D were supplied in 59 % In 22 % of kidneys the sentral pyramids alone were supplied which was particularly common in those hidneys in which the lower polar artery was given off as the last branch the ventral artery Pyt 6-71D corresponds entirely to the segment GraiES (1954) called lower segment Autrition of the whole segment was seen in almost '9°of kidneys dis tinguished by a sharp demarcation against the pars intermedia (Table 6) In a further 30 of the cares the vessel to the lower pole also supplied nur (4)5 V Gravre (1954) found that the lower yolar artery stemmed from the ventral artery as the first branch in 3% of the cases In the present material it was found that the lower polir artery (r mf pyr 6–71 (D)) originated from the renal artery at the same level (20 %) as the dorsal artery or before (185) wlule in the rest of the hidneys it stemmed from the sentral artery Thus tlie r ventr p3r 6-7 \ D represented the first brinch of the ventral artery in 573°, in the rest of the hidneys In contradistinction hereto in 51 3. the dorsal artery was the first branch given off by the renal artery and in a further 25 . It left the renal artery together with 2 or 3 other arteries Pyr 351 - This segment corresponds to the ventral mid portion of the kidney as described by ALB ARRIN & PAPAN (1908) They found that the two intermediate ventral arteries ran to this portion of the hidney GRAVES (1991) upi and middle segments correspond approximately to pyt 3-4 1 and nyt 5 1 when pyr 1-2 coincides with his apical segment Each piramid in this segment we supplied by a sej arate artery (subsegmental artery) usuallı stemming from a branch (segmental artery) ghen off by the ventral artery Usually the r ventr pyr 3-4 | arose from the sentral artery When r ventr për 5 I was a separate l ranch it arose either from the same trunk as that from which the other two pyramids were supplied or from the lower polar arters the findings agree essentially with those described by GR 41 ES (1931) In a few cases r sentr pir 31 and 5 | arose separately from the reiial artery I further variant noted fyr 31 was sometimes supplied by arteries belongmy to rur 1 21D It 19 remarkablo tlint Pr 31 which belonge to the j irs superior was not supplied by the same sessels as pyr 1-21) As mentioned the border of the solments are not quite distinct and the upper ·48 part of pyr 3 Y 13 therefore supplied by the vessels to pyr 1-2 VD but the mam supply emanates from the branch to pyr 4-5 V Pyr 35D - The area supplied by the dorsal artery varied considerably but it almost always included pur 3-5 D The dorsal artery supplied not only this segment but often extended in both a cranial and caudal direction and in more than 20% of the cases it also supplied pur 1-21 D and occasionally pyr 1 3VD None of the other entral pyramida recerter any supply from the dorsal artery BRODEL (1901) and others believed the ventral artery to supply rentral parts of the dorsal pyrimids The ventral artery can supply the major portion of the dorsal pyramids in the pur 1-2 VD segment as shown (pige 25) and small arteries were seen extending from the dorsal artery to pyr 1-D which supplied those parts of the dors il pyramids near the sinus The sentral arteri to the lower pole was often the only supply to the dorsal pyramids there 4 sentral and a dorsal area of supply were always recognized in the pars intermedia where the segmental arrangement is best preserved The calibers of the sentral artery and its branches were larger than those of the dorsal arters when compared with the number of pyramids supplied This supports the view of BRODEL (1901) Hou JENSCY (1930) and LOFOREV (1049) that the ventral artery also supplies the sentral parts of the dorsal pyramids The branches of the ventral artery rere never found to cross one another in the pars intermedia (Tug 22) as they did in pars superior and inferior where they supplied entire dorsal pyramids Ilus interlacing of the sentral artery and dorsal artery described by Fuchs (1931) and LOFOREV (1949) was thus localized to the poles It is characteristic that segmental or subsegmental artenes supriyong dorsal pyramids cross arteries supplying ventral pyramids Should selectie renal angiography miss such a crossing in any region of the haney A supple mentary artery must be assumed If the huney is examined in more than one projection it will be easier to detect whether any vessely are missing, but once sufficient experience has been gained a single projection will be enough The natural division of the bidney as described by IIURTL (1872) could this be found only withm the pars intermedia posterior to the sulcus longi tudinalis There is httlo nisk of injury to the larger vessels in nesociation with transrenal pyelohthotomy when the field 13 ay prouched dorsal to sulcus longitudinals Th19 sulcus is alsays seen in the middle port (par intermedia) of the kidney The value of preoperatne renal ångography has been confirmed by many surgeons especially of partial resection is contemplated (LJUSCOREN 1932, SFÜR 1953 1953 Schlze BERGMAN 1957 and others) particularly since it ·19 usually is the lower role that is resected (STEWART 1952 1953) Observations made in the present material showed that the lower pole is most accessible to resection because in 60 per cent of all kidneys both the rentral and the dorsal pyramids in the pars inferior are supplied by a single artery which courses ventrally over the renal pelvis (Fige 15 and 23) In half of these cases this artery gives off branches early in the sinus and these branches run to the lower part of the pars intermedia sentrals On resection of the para Inferior in these cases the loner polar artery may be ligated distally to the departure of the r ventr pyr 5V In the remaining 40 per cent of kidneys the dorsal artery supplies the entire dorsal part or the proximal part of the dorsal half of pars inferior Course of arteries in the sinus To divide the vasculature into different tyres as KUPRIJAVOFF (1924) did proved unsuitable On the other hand the individual segmental arteries showed a fairly characteristic course so that the supply to the various segments could be readily recognized If the renal artery passed undivided into a bidney the vessel nearly always entered the cranial part of the sinus independent of whether the vessel had previously ascended descended or run horizontally If the renal artery divided hefore it reached the hilum the sentral artery and dorsal arters entered the upper sinus and gave off branches on their way to the various segments of the kidney The courses of these vessels were fairly constant I entral artery – The r sentr për 1-2 V (D) when present usually stem med early from the entral artery and ran along the upper calyx cramolaterall or cranially R ventr nyt 3 4(5) I was the direct continuation of the central artery and as a rule ran almost horizontally Ifr rentr pyr 51 was present it ran caudally and often parallel to the literal border of the hidney in the lateral aspect of the sinus where it could follow a calyr to it, pyramid The subseg mental arteries to pyr 31 and 4 \ ran radially to their respective pyramids R ventr pyr -71 (D)) usually nrose early from the ventral artery and ay a rule ran cauclolaterally and crossed the confluence of the kidney pelur on the ventral side Sometimes the lower polar artery may anse early from the rental artery and cross the creceru frels se function (Borsses to be published's This is of the greatest importance from a surgical point of view because it furours obstruction of the uretero pels se junction In none of the cases studied in the prevent investigation 189 ans sessel supplying the sentrri part of the lower pole seen to run dorsally to the renal pelure nor did a dorsal artery ever fupply the ventral tyramids The lower polar artery sometimes gare off dorsal branches early to pur (6) 7 D Before reaching the confluence of the hidnes pelusinf or ventr pyr 6-7 ID sometimes care off one branch + Rok ·coursing behind it to the dorsal part of the hidney and another passing in front of it to pur 0-7 V Sometimes a branch left the dorsal artery early and ran to put 6-7 D parallel to r rentr per 6-7P The more central the origin of the lower polar artery in the kidney the more vertically did it run The renal arteries also showed a characteristic course corresponding to that gui en by KUPRIJANOFF (1034) for Typus magistralis I or longitudinalis (Naritit 1951) when r sentr pyr 6-7 1 (D) stemmed as the last veseel from the ventral artery The dorsal and sentral arteries then ran parallel to one another either within (Fig 13) or outside of the siue medal to the hidney giving off segmental arteries on its way but such a course was unusual Ifr ventr ryr 5V stemmed from a proximal part of the lower polar artery It ran canto laterally to the pyramid if it arose from a distal part it ran kori zontally The radiating branches of the sentral artery (escribed by ALDARRA & PAPIN (1908) and HOU JENSEN (1930) can be confirmed hecause the different ventral segmental arteries diserge from a point usually represented by the origin of the lower polar arters from the ventral artery The point was situated within or outside the sinus at the level of the upper part of the hilum This fan lihe appearance wag absent in those cases in which r ventr 1 6-31 (D) was gren off as the last branch The dorsal artery nearly always has a characteristic course In 50% of all cases st was the first vessel to branch from the renal artery and its appearance as seen in the angiograms agreed with that described by earlier investigator (ALBARRAN & PAPIN 1908 Hot JEVSEV 1930 GRADES 1951 and others) provided of course that allowance be made for the position of a kidney in iro HELLSTRON (1028) stressed the importance of the surgeon being acquum ted with the course of this vessel which was often concealed behind the pos tersor bılar luy and could readily be injured in asociation with 1 clotomy Apart from the fact that the segmental artenes voually follow the calces at is not possible to demonstrate any relation between the degree of familica tion of the renal peksis and the vascular pattern in the bious the rentral and dorsal branches of the renal artery kse close to one another so that the vessels under certain circumstances can cause impressions on the renni pelvis (Fig 23) Thus will be the subject of a future paper After having examined angiograms of 23 kidneys removed post mortem st was found that it was not possible to chart the vasculature more esaetts than by angiography in riro Tho findings at autopay were howeser included in the matern for os aluation of the vascular supply to the various segmente Framination of the kineze at autops from different angles demonstrated

·51
0
a
1993 Ants femen (riglt ki Inrs) Tric frontal (a-6) en lateral fre) projection
Otstre clien- of entral and ral Arteriin nu

·50 coursing behind it to the dorsal part of the kidner and another passing in front of it to pyt 6-7 V Sometimes a branch left the dorsal artery early and ran to IGT 6-7 D parallel tor sentr pyr 6-78 The more central the origin of the lower polar artery in the kidney the more vertically did it run The renal arteries also showed a characteristic course corresponding to that given by KUPRIJAVOFF (1924) for Typus magistralis I or longitudinalis (NAR 4TH 1951) when r rentr për 6-7 I (D) stemmed as the last vessel from the sentral artery The dorsa) and sentral arterica then ran parallel to one another ether within (Fig 13) or outside of the sin19 medial to the kidney giring off segmental arteries on its way but such a course nas unusual If r ventr pyr 51 stemmed from a proximal part of the lower polar artery it ran caudo laterally to the pyrımd if it arose from a distal part it ran hori zontally The radiating branches of the ventral artery described by ALDURRAYS LAPIN (1908) and HOU JENSEN (1930) can be confirmed because the different ventral segmental arteries diserge from a point usually represented by the origin of the lower polar artery from the sentral artery The point was situated within or outside the sinus at the level of the upper part of the blum Ti 19 fan like appearance was absent in those cases in which r ventr pyr 6-71 (D) was given off as the last branch The dorsal artery nearly always has a characteristic course In 50% of all provided of course that allowance be made for the position of a hidney in 1110 HELLSTROM (1928) stressed the importance of the surgeon being acquam ted with the course of this vessel which #13 often concealed behind the pos terior bilar lip and could readus be injured in association with pjelotomy Apart from the fact that the segmental arteries usually follow ti o calyces It is not possible to demonstrate any relation between the degree of ramifica tron of the renal pelvis and the vascular pattern in the sinus the sentral and dorsal branches of the renal artery lie close to one another so that the vessels under certain circunstances can cause impressions on the renal pelas (Fig 23) This will be the subject of a future paper After haring examined angiograms of 23 kidneys removed post mortem it mas found that it was not possible to chart the vasculature more exactly than by angiography in tiro The findmgs at autopsy were however included in the material for es aluation of the riscular supply to the parious segments Examination of the kidneys at autopes from different angles demonstrated ·53 Broadly speaking a ventral and a dorsal region of suppls were recognized which were located in the pars intermedia From the pars intermedıa ventral and dorsal arteries extended their supply in both cranial and caudal directions The dorsal artery supplied predominantly in a cranial direction so that the ventral pyramids (pyr 121) could also be encompassed the sentral artery in a caudal direction so that the dorsal pyramids in the pars inferior (P3T ( 7 D) could also be supplied The ventral artery also supplied dorsal pyramids in the pars superior and ventral parts of the dorsal pyramids in the pars Intermedia but was never the only source of supply to the latter Ongin and course of the segmental arteries — The pattern of the various segmental arteries in the sinug was fairly constant The variations observed were due to differences in the level at which they branched from the renal dorsal and ventral arteries In the pars intermedia branches from the dorsal artery did not cross ench other but crossed branches from the ventral artery In the poles however the branches from a primary artery could cross each other The branches of the dorsal artery were localised more medial than those of the ventral artery because of the position of the kidney in ino The dorsal artery was usually smaller than the rentral and was the first to brinch from the renal artery in about 50 % of kidneys It is stressed that detailed knowledge of the vascular anatomy is important in surgery and in diagnostic roentgenology The roentgenologist should be familiar with the course of the artery in lon lying hidneys as well as be aware of the possibility of segmental branches arising early from the renal artery To be able to escludo the possibility of supplementary arteries in a given case it 19 necessary to be familiar with the segmental supply of the kulney It was shown that m about 60, of all cases the Irs inferior se that part of the kidney usually resected 19 supplied by a single artery ·52 the medial position of the dorsal artery in iilo These examinations alo showed that the peripheral branches of the rentral artery never cross each other as long as the sentral artery supplied only the sentral pyramids This is applicable to peripheral branches of the dorsal artery when they suppled only the dorsal pyramids The purpose of this insestigation was to chart the topography of the renal arteries as they appear in clinical angiograms and thus the autopsy examina trons were limited SUMMARY The norma) roentgen anatomy of the kidney having one renal artery was studied in clinical angiograms and in kidney s removed at autopsy The course of the renal artery from its origin to the renal hilum was studied in 314 kidneys in trio and the ramification of the artery in 427 In the clinical angiograms the origin course and segmental supply of the branches of the renal artery were studied in 133 hidneys 33 of which had been examined in more than one projection (selective angiograms) A total of 23 kidneys removed at autopsy were examined in 3 projections Course of the renal artery from aorta lo renal hulum - The renal artery visually ran a horizontal or descending course on the right side and a horizontal or ascending course on the left The renal arterv entered the upper part of the lulum cranial to the renal pelvis In ptosis of the kidney the artery al ways ran a descending course with the exception of a few cases when the artery on the left side may run horizontally even in the presence of slight ptosis Ramification of the renal artery Because of the latero dorsal course of the renal artery and the position of the kidney in eno the branches of the artery medial to the hulum will not be seen as often as in autopsy cases In about 7 % of all kidneys a branch arose carly from the renal artery which was important m selectrie renal angiography Orgin course and segmental distribution of the branches of the renal artery It was found that the characteristic vascular pattern made it possille to distinguish between rentral and dorsal arteries in a film tahen in one plane In nephrograms the pyramidal arrangement could be distingurshed Segmental supply of the renal artery -- On the basis of the topographic arrangement of the pyramids in the hidney it was found that the kidney has a segniental supply not coinciding with the borders of the lobes Four segments vcro recognized namely (1) the two most cranial pairs of pyramids (II) the two most caudal pairs of pyramids (III) the three middle sentral ny ramuis and (IV) the three middle dorsal pyramids ·EARLIER INVESTIGATIONS FREQUENCY OF MULTIPLE ARTERIES Autopsy studies There is divergence of opinion in the literature as to the frequency of multiple arteries This lack of agreement is partially due to differences in nomenclature The frequency given in the literature thug saries between 14% (SCHVERBFR 1895) and 47% (WEINSTEIN COUNTiss & DERBES 1940) Vost authors however give a frequency of 20% to 30% On the basis of a personal series together with data giren by 14 other in vestigators Hou JENSEN (1930) found that of a total of 2 56' kidneys 22 4 % had multiple arteries Later investigations however have revealed a some what higher frequency Thus HELLSTROS (1928) gave 26 5 % Avso RICHARDSON & VIVEAR (1936) 32 5 % BERGENDAL (1936) 30 G. while MELKONLAN (1954) found multiple arteries in only 16 5 and Buscu (1954) in 20 5 % If these recent investigations be added to those collected by Hou JENSEN it will bring the total up to 4 118 kidneys with multiple arteries in 60°. Clinical angiographic studies -- EDSJ14 (1957) studied the frequency of multiple arteries angiographically Of 1 240 kidneys he found multiple arteries in 21. In patients with hydronephrosis and obstruction of the uretero pelvic junction FDSMAN found multiple arteries in 38. In a clinical angio graphic series there is always an orer representation of cases of hy dronephrosis If these lo excluded the frequency found by FDSMAN was 20% FIELDS OF SUPPLY TOPOGRAPHY AND RELATYE FAEQUENCY OF SUPPLEMENTARY ARTERIES Autopsy studies - Two types of suplementary arteries were recognized namely hilar arteries and polar arteries the latter referring to extra hilar arteries running directly to the parenchyma The anatomic studies have not shown which regions are supplied by the hılar arterie, The extra hilar arteries run to either jole THOMPSON (1891) found in 99 kidneys with multiple arteries an extralılar ·PART II MULTIPLE RENAL ARTERIES INTRODUCTION Multiple arteries are said to be present when the kidney 25 supplied by more than one artery from the aorta or iliac artery In the literature such arteries as well as extrahuar branches of a single renal artery are often referred to as aberrant accessory abnormal anomalous or supernumerary It 19 therefore difficult to decide whether an author meang a single renal artery with extrahılar branches or arteries arising from the aorta or lac artery In order to avoid such confusion and because these arteries are end arteries and in addition usually supply as much as 20-50 % of the renal parenchyma these terms are not used at the Roentgen diagnostic Department Unt crsity Hospital Lund There any artery other than the main renal artery and leaving the aorta or iliac artery is called a supplementary artery The term multiple arteries is used then reference is made to the entire supply to the hidney (OLLE Olssov Encyclopedia of Vedical Prdiology in print) As shown (Part 1) the branches of the renal artery supply separato segments of the renal parenchyma though the segment or segments supplied by a gnen branch may vary widely from one kidney to another This variation may be due in part to the arrangement of the pyramids during embryonal life (which is due to the fusion of the pyramids in the purs superior and to a certain extent in the pars inferior) and in part to differences in the level at which the segmental arteries leave the renal artery The course and origin of these segmental arteries may however vary stil! more when the arteries to single pyramids or groups of pyramids are directly from the aorta These arteries are of importance from a rocntgenologic as well as surgical point of view Attention will therefore first be given to their frequency regions of supply origin an 1 course to the kidney ·57 It has been stressed that the lower polar artery might be fairk side and therefore supply a relatirely large portion of the lower half of the Lidney and that the vessel should therefore not be ligated in cases in which it cause, obstruction at the uretero peluse junction (\\ ILDBOLZ 1931, Dewa 1919 O CONOR 1955 and others) VCDONALD & KEYWELLY (1959) showed that a supplementary artery usually supplied 25-50% of the parenchyma Clinical angiographic studies - A thorough search of the literature failed to reveal any roentgen anatomic studies of the fields of supply and relatne frequency of supplementary arteries It has only been stated that selectie catheterization of a kidney with multiple arteries is insufficient from a roent genologic point of view because not all of the renal parenchyma will be filled with contract medium (EDSMAN 1957) and thus the unfilled region diay be mistaken 29 a possyble sign of tumour (EDHOLI & SELDINGER 1956) The caliber of the renal artery varies in proportion with the amount of functioning parenchyma (Doss 1947 IDBOHRN 1934 1956 and others) This also holds for the supplementary artery EDSMAN (1957) found that in 20° of kidneys with multiple arteries the supplementary artery was of the same width as the main renal artery ORIGIN AND COURSE OF SUPPLEMENTARY ARTERIES Autopsy studres As a rule the supplementary arteries originate from the aorta at a level close to that of the mam renal artery but sometimes far caudal to the latter SELDOWITSCH (1909) found that the supplementary artery never originated more than 105 mm distal to the main renal artery HELLSTROV (1928) measured the maximum cstance ag 70 mm A SON RICHARDSON & VINEAR (1930) found the minimum distance between the arteries to be 7 mm and the maximum 89 mm They found that the supple mentary artery left the aorta within 19 mm of the main renal artery in 50 % and within 40 mm in Goº, which agreed with the findings of SELPOWITSCH VET KOVIAN (1954) judged the level of origin of the arteries in relation to the origm of the superior mesenteric artery as well as to the distince between multiple arteries The maximum distance between the origin of the niun renal artery and a supplementary artery arising cranially to it was 38 mm The supplementary arteries may run together with the main renal artery to the hilum or separately to the hilum or directly to the parenchy ma depending on the distance between the origin of the main renal arter and that of the supplementary artery (GRAFS 1956) C'linical angiographic studies - FDSVA (1937) found that the supplementary arteries aro e both crannalls and caudally to the origin of the ntain renal ·56 artery running to the upper renal pole in 30% and to the lower pole in 21% ALBARRAN (1909) found supplementary arteries running to the lower pole to be more common SELDOWITSCH (1909) described an extrahılar vessel running to the upper pole in 9 (17 %) of 53 kidneys and to the lower pole in 5 (9%) while in 81 % of the total kidneys the supplementary arteries entered the hilum From his fairly thorough case reports it is also possible to assess tho frequency of arteries to the lower pole In 55 % of the kidneys tith multiple arteries a supplementary artery supplied the lower pole EISENDRATII & STRAUSS (1910) whose material consisted of 28 kidneys with multiple arteries found a supplementary artery to run to the upper pole in 18% and to the lower pole in 29% EISENDRATA (1920) regarded hilar vessels as normal and therefore recorded polar arteries as supplementary In 45 kidneys with supplo mentary vessels arteries ran to the upper pole in 13 (99 %) and to the lower pole in 32 (71 %) HELLSTROY (1928) stressed the surgical importance of supplementary arteries and of 53 hidneys with multiple arteries he found a sessel to run to the upper pole in 264 % and to the lower role in 84 % while in 81 1% of the total kidneys the supplementary arteries entered the hilum BERGENDAL (1936) whose material consisted of 46 hidneys with multiple arteries found the supplementary artery to run to the upper pole in 19 6 % and to the lower pole in 65% while in 80 5 % of lus hidneys the supplementary arteries entered the hilum HFINSTEI COUNTIss & DERNES (1940) found that of 192 kidneys with multiple arteries supplementary arteries ran to the upper pole in 47 % and to the lower pole in 68 % The frequency exceeds 100% because in some of the kidneys there were more than one supple mentary artery Like the renal artery the supplementary arteries are end arteries As errly as 1901 HOLSTER pointed out that the vessels retained their segmentation even when the kidney was supplied by more than one renal artery At opera tion for hydronephrosis due to supplementary lower polar arteries the latter Bare formerly been ligated often with good results (BFROEVDAL 1936 HECKENBACIL 1939 Dol 1951 and others) Sometimes such ligation has been followed by necrosis in the field of supply of the ligated vessel (PATCH 1029 WILDBOLY 1931 DEMING 1949 O COVOR 1955 and others) On the basis of corrosion preparations Grives (1954 195C) found that the supplementary arteries were segmental arteries of relatively proximal origin He thus found that the sentral and dorsal middle segments of the kidney and the apical and lower polar segments were supplied solely by the supplementary arteries He considered that supplementary arteries ran more frequently to the lower pole because the lower polar artery is the first to leave the renal artery in 63. of normals ·The supplementary arteries ma> rus together with the main It has been stressed that the lower polar artery might be fairly wide and therefore supply a relatively large portion of the lower half of the kidney and that the sessel should therefore not be ligated in cases in which it causes obstriction at the uretero peluc junction (II ILDBOLZ 1931, Deung 1919, O COVOR 1955 and others) VcDOVALD & KEYVELLS (1959) showed that a supplementary artery usually supplied m50, of the pirenchyma Clinical angiographır sfulles -- A thorough search of the literature failed to reveal any roentgen anatomic studies of the fields of surrly and relative frequency of supplementary arteries It has only been stated that relectore catheterization of a kidney with multiple arteries 18 insufficient from a w genologic point of view because not all of the renal parenchyma will te with contrast medinm (COSTA 1957) and thus the unfuled region tark, mistaken as a possible sign of tumour (EDHOLY & SELDINGER 195, The caliber of the renal artery varieg in proportion with the app functioning parenchyma (Doss 1947 IDBOURV 1951 1936 and towany) Text also holds for the Rupplementary artery Edsaan (1997) found the money of kidneys with multiple arteries the supplementary artery was 6 width as the main renal artery ORIGIN AND COURSE OF SUPPLEMENTARY ARTERIES Autopsy studies As a rule the supplementary arteris omakorda the aorta at a les el close to that of the main renal artery but somet. caudal to the latter SELDON 17-CN (1909) found that the pupila sam artery never originated more than 105 mm distal to the main sa comme HELLSTRON (1928) mersured the maximum distance as 70 mm Hg RICHARDSON & VIVEAR (1930) found the minimum distance is arteries to bc 7 nim and the maximum 80 mm They found that these mentary artery left the aorta within 19 min of the m'un renal anam yos and within 40 mm in ro', wluch agreed with the findings of ** VFLKOVIAS (1954) judged the lescl of ongin of the arteries origin of the superior mesenterte artery as well 19 to the clustaseme by owners multiplo nrteries The maximuni distance between the origin ** renal artery anıl a supplementary artery arising cramally to it up, to the funt or separately to the fulum or directly to the parenchy tra tu arte, on the distance isetween the origin of the main renal arter ansztéértem Hupplementary arter (GRATES 1976) Clinienlongiograpu er studies -- EDWA (19.37) found that the su, a mopeenery arteries aruan buth cramalls and caulalli tu the origin of the sprint ·58 artery, but more often caudal When both the ipsilateral renal arteries were equally wide, he considered the upper one as being the main artery, because it originated at the same level as a normal (single) renal artery SUMMARY Several investigators have studied multiple renal arteries from an anatomical as well as surgical point of view Differences in the frequencies of multiple arteries given by many authors are due to some extent to differences in nomen clature Anatomic investigations have shown the occurrence of multiple arteries in 25–30 % of all kidneys Graves showed that the supplementary arteries were segmental The relative frequency of these vessels has been classed according to their hilar or extra hılar course to the pole, but no previous attempts have been made to determine if the hilar vessels had a polar field of supply No systematic ana tomical examinations have been made of the fields of supply of the supplo mentary arteries Although clinical angiographic investigations have been made of the frequency of multiple arteries no endeavours have been made to chart the topography and field of supply of supplementary arteries In view of relatively recent advances in clinical angiography, especially selective renul angiography, detailed knowledge of the vascular pattern and fields of supply of multiple arteries is more necessary now than formerly ·AUTHOR'S INVESTIGATIONS MATERIAL AND METHODS ) N. mical 5 turies The present material consisted of 369 patients examen? angiography Of these, 73 were examined by unilateral spa tron, whule in 8 patients both kidneys were studied sort renal angiography of the 89 kidneys studied by the morning were found to have multiple arteries, and for this reasy afterwards studied by aortic renal angiography In the evaluation of the topography and frequency of protein those kidneys were excluded which showed signs of fusil In addition, tlose hidneys were rejected in which the Tbe studied completely This left a total of 638 kıdneti The origin, course, and field of supply of the ey: 142 kidneys could be seen in detail In the analy819 2* Buch vessels could not be classified as hilar or grizz IIELLSTROV (1928) and others It was often impoxxl.j artery entered the hilum or ran directly to the parets. thereforo named according to the pyramids they say thus guies information not only of the field of sup!? of the veseel which is directly proportional to the r It supplies As a rule the caliber of the supplementary artants. the main renal artery When both arteries were ofte that supplied inter alia the 3 5 entral pyrami 2 artery, because in the investigation of kidneve - the vessel to pyr 3-4(-5) | was the direct conte. which was in turn a continuntion of the renal arts In addition to the clinical material, montant 31 kidneys (17 pairs) removed at autopes (for to rited nally the D ral els and artery V wag ible 11) diameter the hillues 11 19 ܬܟ ·60 Table 9 Frequency of multiple arteries in 638 kidneys in the clinical ang ngrupho material I artery 2 arteries 3 arteries 4 arteries Total 941 Rght Left 4 0 65 7) حم وت 310 328 Total 486 7 1 638 Per cent 76 2 996 11 01 RESULTS FREQUENCY OF MULTIPLE ARTERIES Of 638 kidneys 162 (23 8 %) had multiple arteries [310 right kidneys and 328 left of which 69(223 %) and 83 253 %) respectively had multiple arteries) (Table 1) Obstructive changes in the vretero pelvic junction cusing hydronephirosts were seen in 64 lidness of these 33 had multiple arteries (51 6 %) If these 61 kidneys are excluded from the series it will leave a total of 574 hidneys of which 119 (20 7 %) have multiple arteries In the present autopsy material (34 kidneys without hy dronephross) 10 (29 4 %) were found to have supplementary arteries FIELDS OF SUPPLY, TOPOGRAPHY AND RELATIVE FREQUENCY OF SUPPLEMENTARY ARTERIES The origin course and field of supply of supplementary arteries to 142 Tidneys wero traced (clinical renal angiography) I ight of theso haneye had more than one supplementary artery of the 142 kidneys 32 were ly drone phrotic Of 134 hidneys in which one supı lementary artery was oliseried the latter supplied pyrimids in the pars inferior in 95 (709 %) In 18 kidneys (13 4 °.) at supplied pyrimids in the pyr 1 21 segment and in 14 (10 5°.) pyramida within the field of supply of the dorsal artery In the remaining 7 kidneys (52°) the supplementary artery supplied primis in the sentral mid portion of the kidney (pyt 3 4 51) (Table 10) In the & hidneys with more than one supplenientary artery all of the ressels were ordinary segmental arteries In the autopsy series of 10 kidneye with multiple arterte. 6 had 1 surple ·01 Tolle 10 number and types of supplementary arteries in the clinical and autor) serien Segments Uppler Sumber of pupilementary arteries Living kuljects Cadavers 3 Total 1 3 1 Total 1 0 5 18 7 05 1 0 1 PyT 1 PID Pyr 3-51 Pir 6-7 ID Pyt 3 5D Total number of hwney 90 8 103 20 3 0 2 2 2 1 4 1 0 7 5 6 2 0 13+ 7 1+2 6 # 0 10 Table 11 Varying fiell of supply fourri mentary arteries to pyr 121D in the chncal and automy series Material (12D 131 1ID 131D Tatat 5 Cluteal Autorey 11 3 20 5 5 2 DJ mentary artery and hadThere too the segmental supply of the arteries was apparent (Table 10) Pyr 1-21D - Supplementary arteries to this segment were demonstrated 112 -0 out of 142 krneys (141%. The supplementary artery was usualls narrow and supplied one or tuo pyramids The artery usualls ran to the upper part of the para superior and supplied pyr (12) or rarely (12D (Fig 24) Only m i case did the supplementary artery supply pur 1 31D (Table 11) In ő antopsy speciniens supplementary arteries were found supplying central Pyramus in Pr 1 ?ID segment (Table 1) In 2 hdness thesc 160ls origmated together with the capsular artene (tig 25) from the aorta and supplied only part of a smile pyramid Pur 3-51 - In & (50 g) of the 142 hidness the supplementary artery ran to pyr 351 In adılıtion there were 3 hidneys in which pur 31 was supplied by a branch of the supplementary arters to pr 11 (Table 11) in all of these kidneys the supplementary arters was smaller in diameter than the main renal arteri In one case not included in this group the hidner *19 supried by multiple arterie, Tho arteri to pir 351 in the case was ·62 Fig4 Aort e renal angiogram Observe supplementary artery to pyr 121 of left ki Iney R sur pyr 12V arises early from the renal artery to right kidney of the game calıber as the other 3 80 that this was taken as the man renal artery because it originated at the same level as the contralateral main renal artery In 2 kidneys the supplementary artery supplied only nyr 3-4(-5) 1 (Fig 20) while in 4 it supplied also the pyr 1-2 V Pyr 6V was supplied alternatis ely by the artery running to pr 341 as well as by that extending to pars inferior, ercept in 2 kidneys in wluch pir 51 was supplied separately by a supplementary artery arising from the norta In one of the kidneys the vessel also supplied pyr OV (Fig 27) Only in 1 of the autopay specimens did a supplementary artery run to the pyr 3 5 1 segment In this case it supplied only pir 5 Pyr 3-5 D – In 20 (141 %) of the 142 kidneys the dorsal artery way supplementary Its field of supply varied in the rime way as in kidney supplied us a single artery As a rule the supplementary arters thus represented the entire dorsal artery so that its field of supply extended from the pars inter media in both cranial and caudal direction In 17 kidneys the dorsal supple ·63 Fig 5 Autora specimen Both ha neys are * inplied by a suz i lamentary artery to pr 11 The artery of vlee int, two branches of equal cal tur ne 8 plying the renai parenchyma ani one the fatty cashule mentary artery supplied not only Pyr 45 D but also pyr 3D anci in 12 the entire clorsal portion of pars superior In 5 of theco 1 hrneys pit 121 was also supplied by this sessel (Fug 28) Caudally the field of supply often extended to include pyr 6 D (7 kidneys) less commonly poor 6 7 1) (3 kidneys) Occasionally there was more than one dorsal Artery one from the main renal artery and one suj plementary which then supplied one or more dorsal pyrimids The supplementary cloral arters supphed only JuvT 5D in ? kulness and pur 4 53) in onc (Fig 2') A further 5 bune a hnd 2 dorni arteries each one arising from the main renal artery with an ordinary field of sunil and a second with a suplementart dorsal arters nourishing only the dorsal pyramics of the pors inferior (tig 30) These 5 kidnels are in cludel in the group of rufiplenientary arteries to l'yr (710 The autopay material included two specimens in which the dorsal artery represented the suplementary arteri and in both cases it surpbed mir 15D I'yr 671D - Of 134 hidne 8 with only one supplementan arter the ·62 1 Aort c renal ang ogram Observe 8 ipplementary artery to pyr 121 of 1 ft hilney R sur pyr 121 arises early from ti e renal artery to r glt k dney of the same cahber is the other 3 so that this was taken as the main renal artery because it originated at the same level as the contralateral main renal artery In 2 kidneys the supplementary artery supplied only for 3 445) (Fig ') while in 4 it supplied also the pyr 1-21 Pyr 51 was supplied alternatively by the artery running to fyr 3+1 as well as by that extending to pars inferior ercept in 2 hi ineys in which i yt 51 was supplied separately by a supplementary artery arising from the aorta In one of the kidneys the vessel also supplied pir 6 (Ig 27) Only in 1 of the autope specimens did a supplementary artery run to the PyT 3 5 1 segment In this case it supplied onls pyr 51 Pyr 3-5 D - In 90 (141 %) of the 142 kidneys the dorsal artery war supplementary Its field of supply saried in the same way as in hidney 8 sur plied by a single artery As a rule the supplementary artery thus represented the entire dorsal artery so that its field of supply extended from the pars inter media in both crinal and caudal direction In 17 hidneys the dorsal supile ·05 3. 6 Fig 27 Sortie renal ang grom Lurmal topograp! yuf I ft kilney Arterial y hasr Luft 11 Iney supplied by multiple arterien (1) A reruntu pyr 1 41 IOD (2) A ventr pyt 5-81 (---) an! (3) & in pr 710 (---) Thr Artery to the louer Juleoriginates 110 mm caudal + the main artery an ! has a steelly Ancen ling at caught extralul ur course h Nephrogtaj lue phasr Tip of the catheter 14 close to the origin of the a venir ryt 6-01 there 14 th of spo heavy leyn uit of contraat melum in the cortes en 1 spasm in the artery with remonstration of pyt 56 AM A nuquence Pyramids of the pars inferior sero supplied in 9; In the 8 kidneys with more than one supplementary artery one of these constantis supplied the pyramids in the lower renal pole (Figs 27 29) In 89 huneys the field of supply of the supplementary artery could be seen adequately for studs The vessel had essentially the same field of supply as the artery to prre inferior in kidneys with a single renal artery Differences $ A# #

·-
7
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·68 a Ia Aort o renal ang ogram T)e ma n artery and two suplementary arter er upıly the malrotated r ght k dney A renal 9 gurp ng pyr 13 D 151 a lon T 4 5 D and a nf pyr 6-7 VD THATROs pplementary arter 9 Arise 60 an 1 117 mm au tal to or gn of na n artery Both arter en la e a steeply ascen i ng co ro and anem bo stra ghtened puus bly as a sgn that they lave prevented the normal mtat on of the h dney The lower polar a tery stems from the lac artery 6-c Urogram and agrammat cs per mpos t on of arter ogram al on ng rotat en and the relat on between the pel 4 an 1 tl o vasc lar suj ply ·69 were orcasionallt obsers ed i single kidner's because the supplı mentor artery rometines supplier onts dursal putamuds (Fig 30) and perasionally onls one pyramid (tug 31) The fiell of sulphi (f the supplementary artery karied with the origin from the aorta in the gruap (70 kuneve) in ukxh the reser! originated within 0 mm of the main real arters it supplied the entire pars meror (pyr (71D) in 1" (47 *0) and in 9 of these kidness also the Piramuk in pers mtermedia upalı pir » The number of pirimids supplied in the group tried between 1 and usually * putramids (psr 6-7 In the fronp (i krness) m shah the sus plenientary artery amar more than 10 mm dostal to the main renal arleri the same number of pyramids were supplied ag m the preskue group The entire ?urs of pyramids (pir 710 (-71D 571 )) xere supplied in *3" (15 hidne: a) Bs against si ·70 6 ·} Fug 30 Valor tate I right kiin y Mulietne ang ogram arterulph Frentals els in Iral part fl werpa! an meng tortic renal ang gram art rial plane Inntal sex Isten to lwer pol musline Ir 7 Dan larvu 90 mm from the then the main artery Tetine at gram nepłrograpk haw Of liqu ve Irregularly att nel dirt corresp nligt i yt 5D ! Tort crnal ang pamire grap! plas trintal view elropram el wing related intrarent pel (40/70 kidneys) of the lirker group in which the artery orinated within 70 mm of the main renal artery In hilneswhere not pairs of primals were supplied in the larger group it usually supplied ventril piramids in the other group mainly donat pyramıls (in ? cases por viD mpyr,"DO71) The autores ferien include chutneje nuth a suplementary arters to iv (-71D) In all of them the suplementary arteri originated within 70 ·F, 31 ·mm of the main renal arter and its field of supply was equal to that four in corresponding anglograms of lnuing subjects Four hidneys had 2 supple mentary arteries one of these can to pyramids in the lower pole while the other supplied pyramids within the pyr 1-21D 351 or 3-5 D segment (Table 10) ORIGIN AND COURSE OF SUPPLEMENTARY ARTERIES Pyr 1 21D - The artery to this fegment originated either at the level of the main renal artery or sathn 17 mm cranial to it It then ran a slightly ascending course to the upper pole of the kidney usurlly directly into the parenchyma without passing through the hilum The upper polar artery in the contra lateral kidney often also departed early from the renal artery (Fig 21) Pyr 3-31 - In 2 kidneys the artery to this segment arose caudalls to the main renal artery In both pyr 51 was supplied separately (Fig 27) In the other 6 kulney, the supplementary artery ran cranialk to the main artery within 10 min and parallel to it (Fig 26) Pyr 3-5 D - In 12 kidneys the supplementary dorsal artery arose from the aorta with a maximum of 5 mm from the main renal artery (ventral artery) In one fourth of the kidneys the supplementary dorsal artery arose cranial thereto at most 12 mm from the main renal artery and in the rest caudai to the main artery In ? kidneys the supplementary dorsal artery desiated considerably from the remainder of kidness in that the dorsal artery arose drtally from the aorta (65 and 82 mm respectively) below the ongin of the main artery and run a steeply ascending course to the hidnes (kig '9) In the remaining cases the dorsal artery ran parallel to the ventral arters and the intrirenal patterns of the two vessels could be very similar (Fan 32) As in huneys with a singlo artery the dorsal artery sometimes arose from the loner polar artery This s as observed in #instances the vessel supplying the dorsal pyramids and the pyramids in the pars inferur being supplied by the main renal artery lyr 6711 Of the 103 kidneys examined in living subjects with supple mentar arteries to pars inferior the origin of the supplementam arters could be evaluated in 101 Vost of these arteries orginated from the aorta quite clove to the main renal artery (tags 33 and 36 night) in 50 kidners within 18 mm of the trnal arters In 7 of these kidness it arose cranial to the main F. 31 Aorti anatangt rum A nam * snypl m man arteri si min ig ft m tir Ara a fow mullnetets Irlox ripin I thannal artery '11 sofs de mentary artery mine parallel to t}e mala Arters are al terram 1 T SD) ·انهدام سعیده ·mm of the main renal artery and its field of supply was equal to that found in corresponding angiograms of living subjects Four kidneys had 2 supple mentary arteries one of these ran to pyramids in the lower pole while the other supplied pyramids within the pjr 1-2 VD 3-5 V or 3-5 D segment (Table 10) 73 ORIGIN AND COURSE OF SUPPLEMENTARY ARTERIES Pyr 1-21D - The artery to this segment orginated erther at the level of the main renal artery or within 17 mm cranial to it It then ran a slightly ascending course to the upper pole of the kidney usually directly into the parenchyma fıthout passing through the hilum The upper polar artery in the contra lateral kidney often also departed early from the renal artery (Fig 21) Pyr 3-51' --- In 2 hidneys the artery to this segment arose caudilly to the main renal artery In both për 51 was supplied separately (Fig 27) In the other 6 kidneys the supplementary artery ran cranially to the main artery within 10 mm and parallel to it (Fig 26) Pyr 3-5 D - In 12 kidneys the supplementary dorsal artery arose from the aorta with a maximum of 5 mm from the main renal artery (ventral arterv) In one fourth of the kidneys the supplementary dorsal artery arose cranial thereto at most 12 mm from the main renal artery and in the rest caudal to the main artery In 2 kidneys the supplementary dorsal artery deviated considerably from the remainder of kidneys in that the dorsal artery arose distally from the aorta (65 and 82 mm respectuely) below the origin of the main artery and ran a steeply ascending course to the hidney (Fig 29) In the remaining cases the dorsal artery ran parallel to the ventral artery and the intrarenal patterns of the two vessels could be very similar (Fig 32) As in kidneys with a single artery the dorsal artery sometimes arose from the loner polar artery This was observed in 4 instances the ressel supplying the dorsal pyramids and the pyramids in the pors inferior being supplied by the main renal artery Pyr 671D -- Of the 103 kidneys exammed in living subjects with supple mentary arteries to pars nferior the origin of the supplementary artery could be evaluated in 101 Most of these arteries originated from the aorti quite close to the main renal artery (Figs 33 and 36 night) in 50 kidneys within 19 mm of the renal artery In 7 of these kidneys it arose cranial to the main Fig 31 Aortic renal ang ogram A narrow supplementary artery stemming from the aorta a few mill meters below origin of mam renal artery The supplementary artery runparallel to the main artery and supplies only one pyramid (pyr 6 D} ·74 Aort e renal ang ogram Course an l ranfcat on of supplementary forsal artery resemble that of ventral artery (1) a lore pyr 11 I 6D (a ventr ry 371 67D renal artery at most 7 mm (Fig 34) In 19 kidneys the distance was "1-39 mm in 10 40—59 mm and in 4 60–79 mm The number of supplementary arteries thus decreased with increasing distance from the origin of the main artery Caudally over 80 mm howerer the number again increased so that in 18 hidneys the origin of supplementary arteries to the lower pole was distal to this lerel (80—99 mm from origin of renal artery in 12 case4 100—119 mm in 4 and greater than 1'0 mm in 2 kidneys) The greatest distance between the main artery and the supplementary artery was 135 mm The course of the supplementary artery to the kidnej varied with its origin from the aorta the position of the kidney and tle size of the kidney Like ·nr normal kidneys malrotated kidneys +10 L -10 20 30 40 50 60 70 80 90 100 110 120 130 140 mm 43 Variations in ditance between origin of supplementary artery to pyr 8-71D and main renal artery LO Level of origin of the main artery nii -- denote origin of the supplementary artery cranially and caudally respectisely, to the main artery main renal artery, the supplementary artery sometimes ran a descending ire, sometimes horizontal, and sometimes ascending f the supplementary artery (lower polar artery) arose above the origin of maia artery or witlus 40 cum distal thereto, it almost always ran a des ding course The vessel often ran a horizontal course in the beginning, allel to the main artery especially if the two vessels originated at roughly Rame level (Fig 31) If the supplementary artery arose at a more caudal ·76 Fig 31 Aortie renal angiogram Supplernentary lower polar artery () originates from the porta 7 mm cranial to the main artery and has a descending course level it first ran cranially and then folloned the main artery to the neigh bourhood of the hilum Within or just before the hilum the vessel would course to the lower pole as an ordinary segmental artery (Fig 35) The course of the supplementary lower polar artery in the bitum and sinus was latero caudally but oning to its more proximal origin it was less steep than r ventr pyr 6-7 VD when the latter arose from the entral artery The course of the segmental artery to the kidnes was sometimes horizontal when it originated 40—70 mm from the main renal artery, but usually it was ascending of the latter course two variants were found the sessol running either in a wide arc up to the lower part of the hilum (Fig 30, left) or running a straight cranio lateral course (Fig 37) All of the supplementary arteries stemming from the aorta above the origin ·77 F g 35 Aort c renal ang ogram Supplementary louer p lar artery ar sea 12 mm caudal to the or gin of the man artery tur us cran ally and nine parallel to the latter an i ti en o ts le the 1 lum runs cau lo laterally I ke an oru nary segmental artery of the renal artery or within "0 mm caudal to it entered the kidney at the level of the hilum and the origin was never below the middle of L III In a total of 19 kidneys the supplementary segmental artery departed from the aorta more than 70 mm distal to the main renal artery In 3 of these kidneys the artery arose from the lac artery (Fig 19) and in one from the middle sacral artery (Fig 38) In 4 the supplementary artery ran a horizontal or almost horizontal course (Figs 30 38 39) In 3 of these the kidney was mal rotated while the fourth showed a double kidney pelvis the lower portion being Intrarenal (Fig 30) In these 4 kidneys there was no true caudal dystopia although the lower pole of the kidney was low The remaining 15 kidneys were situated at an ordinary level and the supple mentary artery ran an ascending course to the lower pole of the kidney The ·76 7 1 1 F. 31 Aort c renal ang ogram Supplementary lo rer polar artery (-) or g nates from the porta 7 mm cran al to the man artery and has a descend ng coure level at first ran cranially and then follored the main artery to the neigh bourhood of the hilum lithin or just before the hilum the vessel would course to the lower pole as an ordinary segmental artery (Fig 35) The course of the supplementary lower polar artery in the hilum and sinis was latero caudally but owing to its more proximal origin it was less steep thanr ventr pyr 671D when the latter arose from the ventral artery The course of the segmental artery to the kidney was sometimes horizontal when it originated 40-70 mm from the main renal artery but usually it was ascending Of the latter course two varıınts were found the vessel running either in a wide are up to the louer part of the hilum (Fig 37 left) of running a straight cranio lateral course (Fig 37) All of the supplementary arteries stemming from the aorta above the origin ·79 " 6 F9 370 Aortic renal angiogram Supplementary bower pulir arters riginate: 60 min cau lal to the origin of the main renal artery an! has a stra ght cran o lateral course to laer pole of the hidney Urogram The per is intrarenal DISCUSSION FREQUENCY OF MULTIPLE ARTERIES In order to facilitate comparison with investigations on record and the es aluation of the frequency of kidneys with multiple arteries kidneys with abnormalities liable to increase this frequency were excluded in clinical material dystopic hidneys fused kidney and hy dronephrosis with obstruction at the uretero pelvie junction are over represented Earber investigators have shown that the supply to dystopic and fused kidneys differs from normal (loria & THOMPSON 1903 GÉRARD 1903 AVITSCIIKOW 1912 BFLL 1900 FDS244 1937 and others) and that such kidneys are as a rule supplied by multiple arteries ·78 Fig 31 Aortic renal angtogram Supplementary lower polar Artery to lefl kt inny ori guates 40 mm from tho main ronal artery and rung in a wide arc cranially to the Ter part of the rennt Julum Supplementary right Jouer polar artery originaten () to the main renal artery and ling a tortuous couryo to the lower part of Julum vessel also appeared to be stretched or straightened (liga 27, 29, 40) In? patients the same appearance way sech on both sides (I 1g 40) Of these kidneys o were obviously mnlrotated and 6 only slightly as julged by the superimposi tion of the confluence of the pelu is over the kidney (intrarenal pelv19) Of the 19 kidneys in which the supplementary artery stemined at a distance of more than 70 nim from the main renal artery, it ran a completely or partly extralular course in 13 and branched distally to L III (Fig 27, 29, 40) In the remaining kidneys the supplementary artery say gaten off above the lower third of Lill in one hidney ·81 th 8 Fa 386-Urogram On 1.placement of k ine; n cran 1 1 ect n by al lo n nal compress on the lines w ll rotate st 11 more beca 19e f the tract on by the extral lar lower polar artery pelvic junction in these 3 series taken together was 48 % which is definitely higher than in a normal series After exclusion of the above mentioned kidneys the frequency of multiple arteries was 20 7 % a figure agreeing well with what I DSA (1997) found in an angiographic material (20 %) EPSVAN reported a good correlation betwscen his f gures and those found in earl er anatomic investigations It 18 strıking lowever that the two angiogriphic investigations gave a frequency of about 6 BHA ·80 19 38a Malrotated ptotic kidney Aortic renal anglogram Supplementary Inwer olar artery originates from middle sacral artery 75 mm distal to the level of origin of main renal artery ANDERSOV (1953) (72 operative specimens) and LDSSAN (1957) (angiograms f 71 kidneys) showed that multiple arteries are much more common in the resence of hydronephrosis with obstruction at the uretero pelvic junction hese authors found multiple arteries in 55 % of kidneys and 38 % respectively ompared with 51 % (64 kidneys) in the present material This relatively rge difference in frequency might be due to the smallnesa of the 3 series he overall frequency of multiple arteries with obstruction of the uretero ·83 F9 39 Lrogram shows the louble hiine) pa sanl the intrarea il I wer k lary Txis In the aortic angiographie series the tip of the catheter was placed at the level of origin of the renal arteries and contrast medium as injected in retrograde direction so that any arteries originating cranially to the main renal artery might not be properly iilled with contrast medium If this happened! characteristic segmental arteries would not show up but this feature 19 not observed in the present material nor was any part of the kidney missing in the nephrogram As will be apparent later arteries to pyr 1 21D and supplying less than one renculus do not show up in the film owing to the smallnees of the lumen and the relatively low density of contrast Therefore artenes to the segment ·82 a 6 web.wwwwww Fig 39a 6 Aortic renal ang ogram of a long double hidney Supplementary lower polar artery dise9 95 mm distal to origin of main renal artery and has a ) orizontal corse to h lum 20% while HOU JENSEN (1930) in a compilation of observations in autopay series consisting of a total of more than 2 500 kidneys reported 22 4 % and later investigators grve still higher frequencies The total material on record (4 118 kidneys) showed a frequency of 260°. The frequency found in the present autopsy series was also higher 29 4 % The present autopay series included no cases of hydronephrosis In earlier anatomic studies cases of hy dronephrosis were not excluded but such cases are probably so rare that they will hardls influence the results The discrepancy between clinical and post mortem studies can be explained by clinical angiography failing to demonstrate all supplementary renal arteries ·85 Fg 196 Urogram shows rotated pelvis On the r ght s le llum, I rerted ventrally on the left laterally supplementary artery rarely supplied the entire segment On the other hand a Blupplementary artery sometimes supplied more than one segment as in hidney 8 with a single renal artery It appears that the relatie frequencies of different supplementary arteries bare hitherto not been studied in angograms of living subjects or of endavers GRAJES (1956 1957) simply stated that supplementary arteries ran to the lower pole more frequently than to other segments On the other hand various erimincrs have studied the frequency of supplementary polar arteries (extra hular arteries) at autopsy in relation to that of supplementary arteries entering the kilum (Table 12)

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·87 0 This applies in particular to the findings of \ EINSTEIN COUNTISS & DERBES (1940) which deviated widely from those of other authors They found supple mentary upper polar arteries in 47%, whule other authors found about 21 The frequency found by the angiograms in kidneys of cadascrs in the present study agreed fairly well with the figures given by ll ESTEN COUNTIS, & DERBES while the incidence found in the clinical angiographic series was more than 30, lower The frequency with which supplementary upper polar arteries was found in the present clinical series was also lower than that found by other authors in the dissecting room despite inclusion in the present material of all arterres to pur 1 210 This included those cases in which the artery passed through the lulum to the segment However the supplementary arteries running through the hilum appeur to represent a sely small percentage since such vessels were never seen in the present autopsy series Pyr 31D al4o belongs to the upper pole but in no instance was any supplementary artery seen to run only to y 3 ) or D HYRTL (18-2) pointed out that the capsular artery coursing in & craniał direction from the renal artery octisionally supplied small regions of the renal parenchyma X EINSTEIN COL TIS&& DERBEN (1940) found that tho thirds of the supplementary arteries to the upper poie arose from suprarenal arteries A SON CAULDN FLL PICK & BFITON (1347 1319) studied the inferior phrenic artery and the suprarenal arteries at autopsy They found that these vessels could give off fine branches aurplying both the fatty capsule around the uprer renal pole and the renal parenchyma The reason why these vessels escaped demonstration in huing subjects was found on analysis of the autopsy series In 5 post mortem specimens the ventral pyramids in the segment under discussion were supplied by a supple mentary artery In all of them the artery gare off a capular artery and in 2 kidneys these tno vessels were of the same width after duasion (Fig 20) In aortic renal angrograms the capsular and pelvic arteries are not often seen because of their small diameter and the relaticly low density of contr1st medium Since these small supplementary arteries to the pyramids in the u per renal pole are not wider than the capsular arteries it is obvious that they do not appear in the angiogram either Tlus discrepancy in the supply of the upper pole between the clinical and the autopsy series explains the lower frequency of multiple arteries seen in olimcal angiograms Thur in the present clinical materni multiple arteries were seen in about 20 % as against 28% compilations gnen by F(FLLSTROVI (1948) and BERGENPAL (1936) for post mortem stuches se a difference of about 8% which corresponds to the difference in the supply to the upper renal role in the series (10%) I EINSTEIN COLITIS) & DFRBES (1910) ·86 Table 12 Relative frequency of different types of supplementary arteries in j rezlous anatomic investigations compared with tl o present angiographic study of the cl nical series and specimene from cadavers Number Supplementary of upper polar louer polar artery to artery to kidneys Author Artery artery 3-51 3D with Num Per Num Per Mum Per Num Per moltiple ber cent ber cent ber cent cent arteries ber 29 9 14 29 3 170 26 4 21 29 5 3 21 2 547 94 65 53 53 46 9 19 6 Thompson (1891) Sel lowitsch (1909) Hellstrom (1928) Bergendal (1936) Weinstein Count199 and Derbes (1940) Boijaen Angrograms (clinical) Bon en angiograms (post mortern) 00 469 130 677 192 20 141 103 72 5* 8 66 20 141 149 5 50 6 60 1 10 2 10 * Extral ılar arteries to pars inferior in 13 kidneya (91) Pyr 1-2 I D segment In the 20 kidneys in which the supplementary artery to pyr 1-? 1 D segment wis demonstrated by clinical angrograms it was found to supply the tuo ventral pyramıds in the majority of cases this part corresponding to the segment Graves (1954) called a pical In one fourth of the kidneys however the pyr 1 2 D segment was supplied by the supple mentary artery ind then the apical segment was represented by the dorsal pyramids Only in to kidneys was the entire për 1-21 supplied by the supplementary artery (Tables ]] and 13) Of the 142 hidneys in the clinical angiographic series with multiple arteries 141, had supplementary arteries running to pyr 1 2 1 D segment In the autopsy series the corresponding frequency was 50% (Tables 10 and 12) There was thus a considerable discrepancy between the frequency of supple mentary arteries to pur 1 ?I D segment as seen in angiograms of living subjects and eulevers This difference might, however be ascribed to the small number of kidneys (10) having multiple arteries in the autorey series A compilation of earlier autopsy studies however shows that of all hidneys with multiple arteries supplementary arteries supply the upper pole in 31 (151/413 Table 12) Table 12 shows a considerable difference between the results found by earlier investigators concerning the supply to the upper pole o

·89
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ROTE phrog and later metanephros in early embryonal but after Fezzy 1913)
to have a supplementary dorsal artery The distribution of such supplementary
wloral arteries in the parenchy na varied in the same was as of the vessel
rose from the renal artery The primary field of supply of the dorsal artery
thus included all dorsal pyramids just as the ventral artery supplied the ventral
pyramids In embryonal life there is a well des eloped rele arteriosum around
the aorta and the kidney (FELIX 1911 Brever 1915) (Fig 41) It is the dege
neration of certain vessels and the persistence of others that account for the
Variations in the field of supply of the rentra) and dor al arteries respectively
in the adult The pars mtermedi is the centre of a field of supply of the dorsal
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Since the dorsal artery usually branches from the renal artery and continues
undided into the renal sinus this might very well explain ny supplementary

·SS Table 13 Variations in field of supply of different types of supplementary Asteris (clinical material) Supplemen Total Number of pyramids tary supplied number Remarks of arterles to 1 3 4 5 6 7 8 kidney ? 1 15 ? 1 1 20 Pyr 1-2 VD Pyr 351 Ijr 3 5D 2 1 2 2 8 1. 2/6 5 2 90 3 911388 1 70 Pyr 6-7 ID Departs within 70 mm from main artery Departs more than 70 inm from inain artery 7 2 7 1 18 found multiple arteries m about 47 %, a figure much higher than that giren by other investigators but nevertheless in accord with the high frequency of supplementary arteries to the upper pole in their series Since two thirds of these supplementary arteries branched from suprarenal arterie they were very small in diameter and not demonstrable in the clinical angiograms This inability to detect narrow ressels to the upper pole in the clinical angiogranis explains the relatnely low frequency of kidneys with more than one supple mentary artery in the material Pyr 3-5 V – In 5 6 % of all kidneys with multiple arteries the angiograms showed supplementary arteries which supplied mainly renculi in that regment No separate supply to pyr 31 and 4V w28 observed, both pyramids usually being supplied by the supplementary artery (Fig 26), which sometimes extended crinally so that it supplied also pyr 1-2 V The pattern of the supplementary artery thus resembled that of the ventral artery in kidneys with a single renal artery where the vessel to the lower pole arose early from the renal artery (Figs 14 16) The supplementary arterz was also obviously A segmental artery in these cases In the kidneys with a single artery it was found that pyr 6 V sras sometimes supplied by the artery running to pur 3-4 V or to pyt 6-7 ID, but occasionally the vessel arose separately from the renal artery (Fig 1&} It was also found that për 5V was sometimes supplied separately by a supplementary renal artery or by a supplementary artery to the lower pole or to pyt 3-4 V The number of pyramids supplied by the artery running to Pyt 3-5 segment vaned between 1 and 5 (Table 13) Pyr 3-5 D – In all the kidneys with multiple arterieg 141% ucre found

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·90 dorsal branches to I or 2 pyramids only are uncommon when compared with supplementary branches from the ventral artery On the other hand since the dorsal artery leares the renal artery as the first branch more frequently than other segmental arteries it is understandable that it is frequently seen as a supplementary artery In recorrlance with the above findings the supplementary dorsal artery was found to supply 5-8 pyramids in two thirds of the kidneys and only occasionally I 2 pyramids and then there was a further dorsal artery brınching from the main renal artery (Table 13) In 5 kidneys one or more dorsal pyramids in the pars inferior were supplied by a supplementary artery These cases thus represented a variant of the dorsal artery but are ncluded in the next group Pyr 6 TID - Of the entire series with multiple arteries the supplementarı artery supphed the pars mferior in 725. This frequency 18 slightly lagher than what has been found in autopsy series by SFLDOW ITSCH (1909) an 1 EINSTEIN Couvriss & DERBES (1940) EISENDRATH (1920) found a suple mentary artery to the lower renul pole in 71 % but he had not included the supplementary arteries entering the hilum GRAVES (1956) described the louer polar artery as bemg much more common than other supplementary arteries It is difficult to judge from examination at antopsy which region is su pled by a giien artery HELLSTROV (1929) and BEROENDAL (1936) therefore content themselves with the determination of extra hilar polar arteries which they found in 94% and 65% respectively in the present clinical anglo graphic series definite extrahılar arteries to purs inferior were found in 91° (Table 12) The fairly wide variation in the autopsy studies (Table 12) is due at least in part to the fact that some authors classified only definite extralular arteries as polar arteries (HELLSTROV 1928 BEROENDAL 1936) while othere! loner polar supplenzentary arteries as art DERNES 1940) whers the lower portion piograms of autoper specimens and of li us atuaj s possible to determine the field of supily of tie supplementary vessel The higher frequency of supplementary ar teries to pars inferior found in the angiogrims of hing subjects when comjared with those of autopay specimens (725 % as against 10 ) can be explained by the fact that the former group included also kidneys with hy dronephro is with obstruction at the uretero jelic junction In such cases there was ? definitely Ingher frequency of suplementary arteries to ar inferior The field of supply of the lower polır artery varied to a certain extent with the origin of the vessel from the aorta This might be tentatrely espumed by ·93 More likely is that all supplementary arteries near the main artery represent persisting mesonephinc arteries According to BROVAN (1908) and others these vessels degenerate in a cranio caudıl direction so that the caudal most vessels will persist longest which implies that they have the greatest chances of persisting in adults This means that the lowest renal segment (pyT 6-7 1 D) 18 most likely to be supplied by supplementary arteries An observation in support of this assumption is that one of these ressels always supplied the lower renal pole in all kidneys in the clinical and autopsy series with more than one supplementary artery The supplementary arteries to different segments arose from the aorta at different distances from the main renal artery As a rule arteries to pyr 121D arose cranjal to the main renal artery and those to pur G 71D distal thereto though occasionally cranial to the main renal artery The supple mentary dorsal artery usually arose at a level close to the origin of the main renal arters In those kidneys in which only single dorsal pyramids were supplied by the dorsal artery the latter sometinies arose in a very distal segment of the aorta but there was then a wider dorsal artery from the main renal artery Arteries to pyt 3–51 usually arose cranial to the main renal artery close to its origin The course of the supplementary arteries varied with their origin from the aorta field of supply and position of the kidney The supplementary dorsal artery and the artery to pyt 3 55 most frequently ran parallel and close to the main renal artery while the artery to pyr 1 21D ran a more direct usually extra hilar course to the upper pole As to the origin and course of the supplementary artery to pars inferior the material could be divided into two groups namely vessels arising within 70 mm of the origin of the main renal artery and vessels I ranching later In those cases in which the artery arose within 70 mm of the main artery the origin was never below the middle of L III These arteries represent persistent mesonephric arteries which have taken over the supply after the finish of the ascent of the kidney This group was by far the largest and re presented 81 % of all supplementary arteries to the pars inferior In 50% of all kidneys with a supplementary artery to the lower pole the vegael ori ginated within 19 mm and in 68, within 39 mm of the main renal artery These figures are in good agreement with those found at autopsy (SELDO WITSCH 1909 Anson RICHARDSON & MINEAR 1936) No correction was made for the radiographic enlargement this being irrele: ant Within 40 mm from the main renal artery the lower polar artery often descended frequently in a common pedicle as in GRAVES (1956) material The artery did not run caudo laterally until it approached the kidney as a ·92 investigation to call the vider artery the main renal artery and the narrower the supplementary artery The artery which inter alia supplied pyr 3–41' was the main artery the artery to that segment normally being a direct continuation of the ventral and the renal artery (Part I) EDSVA s definition of the main renal artery & 9 being the one first to leave the aorta when multiple arteries were of equal width was found to hold in the present material in all kidneys ercept? In one of these kidneys 4 arteries rin to the kidney and the arteries to per 1-2 VD (the one that left the norta first) was of the same width as the others In the other bidney the dorsal artery 1598 n supplementary artery and de parted 12 mm cranial to the sentral artery (main renal artery) both of the same caliber In these two hidneys the artery supplying inter alia pur 3-41 arose at the level of the main renal artery to the contra lateral kidney Understanding of the wide variation in the course of the multiple arteries requires knowledge of the embryology of the lidney During the ascent of the kidney it is supplied by arteries from the aliac artery and the middle sncral artery (JEIDELL 1011) Later new arteries from the aorta appear, wlule the lower ones atrophy (BREMER 1915) When the hidney has renched its final site a mesonephric artery situated at the level of the 21st aortic segment gives off an artery to the hidney (FREDÉRIC 1897, BROWA 1911 and others) As a rule the artery takes over the entire supply of the kidney However the mesonephric arteries may reach down to the 23rd aortic segment (BROJAN 1908 FELIX 1911) (Fig 41) which may explain the supplementary arteries down to this segment te down to the level of the middle of the L III Renal arteries distal to this represent sessels that arose during the ascent of the kidney but for some reason were not obliterated According to ARE» (1994) the appearance of vascular anomalies is due among other things to the chorce of unusual paths in the primire vascular plexuses and the persistence of vessels normally obliterated GRAVES (1956) believed that the reason why the lower polar artery was the most common supplementary artery was because in 63% of cases it de parted from the renal artery as the first segmental resel when the renal artery was single His assumption could not be confirmed in the present material because the dorsal artery was found to leave the renal artery ag the first branch much more frequently (Part I 50% florsal asters) and 20° (louer polar artery )] In an earlier publication in 1954 GRAIES gave the same figure for the lower polar artery but then described it ag arising from the rentral artery wluch coincided with the findings of the present ins estigation The lugher frequency of the supplementary lower polar artery thus has nothing to do sith its early origin in normal cases ·95 when it was rotated ventrally According to these authors, the more abundant dorsal vascular supply contributed to the stronger grouth of the dorsal renal parenchyma, so that the kidney appeared to be malrotated The present investigations showed that the doreal 3 essels were of importance not in the way believed by Young & THOMPSON, but rather as a purely mechanical factor The supplementary lower polar arteries were stretched in malrotated kidneys In 3 kidneys the dorsal supply was predominant so that in 2 kidneys only dorsal pyramids (5-7 D Fig 30) were supplied and the third was supplied not only by the lower polar artery to por 6-7 VD, but also by a dorsal artery coming from below to pyt 4-5 D (Fig 29) In all of the other malrotated kidneys, the artery was extrahılar and supplied both the rentral and dorsal pyramids (Fig 10) The extrahular dorsal branch which was situated medral in these cases, prevented further rotation of the kidney Sometimes the kidney rotated inwardly before the supplementary artery became taut, rotation then being incomplete with a so called intrarenal pelvis, re the confluence of the pelvis was projected over the medial part of the parenchy ma (Figs 37 and 39 lower renal pelvis) These malrotated kidneys situated at normal level represent the only clear malrotations in the entire clinical angiographie material These observations thus prove that arteries persisting from the time of the ascent of the kidney prevent normal rotation This tightening up of the arteries during the ascent of the kidney can even cause outward rotation (Fig 10 left) CONCLUSIONS 1) The supplementary arteries are segmental and correspond to branches of a single renal artery The importance of the segmental arteries being end arteries should not be underestimated from a roentgenologic or surgical point of view About 20% of all kidneys were supplied by a supplementary artery large enough to be of diagnostic importance Selective angiography will show the presence of any supplementury arteries, both by the pattern of the intrare nal arteries and the distribution in the kidney and also by any defect in the nephrogram This 18 demonstrated best by examination of the kidney from more than one angle The supplementary arteries can supply a central portion of the kidney, 1 e within the region of the dorsal artery when no defect will be found in the nephrogram Detailed knowledge of roentgen anatomy, how eper, makes it possible to detect any absence of segmental arteries in the arterial phase in a single plane A defect in the angiogram due to lack of filling of a supplementary artery can be distinguished from a tumour because the defect produced by the former in the nephrogram is of characteristically irregular ·94 segmental artery which had originated in the renal artery or sentral artery Also within this range 40-70 mm from the main artery the vessel ran into the lower part of the hilum but no longer in a common pedicle with the main renal artery It often turned m a cranial are to the lower hulum Those supplementary arteries that originated more than 70 mm distal to the main renal artery had their origin in the aorta middle sueral artery or iliac artery which was always at a level distal to L III cxcept in one case These vessels represented persisting arteries which had arisen during the ascent of the kidney In 13 of these 19 hidneys the vessels ran an extrahlır course Il hether further extra hılar vessels were present could not be decided because the examinations were made in one plane only but in the remaining 6 kidneys the vessel was projected at the level of the lower part of the renal hilum In 15 kidneys the vessels had an ascendmg course and in 5 the hidneys were mulrotated In a further 3 cases the kidneys were malrotated so that the lulum fuced ventrally but in none of them were any signs of cranio caudal dystopia although the kidney was low and the supplementary arteries therefore almost horizontal In all of these kidneys the ureter was of normal length In addition to the 8 malrotated kidneys slight malrotation was also seen in 7 other kidneys as evidenced by the fact that the entire confluence of the renal pelvis was projected over the kidney in these kidneys the vessels were also definitely straightened In all of these the main renal artery originated at a normal level Also within the 70 mm limut but close to it an intrarenal pelus was occasionally seen but no true malrotation (Fig 37) During the ascent of the kidney the renal hilum turns from an originally ventral position to a medial one lever during this period does the hilum appear to face laterally or dorsally Formerly it was believed that the variation in the position of the hilum in adults was due to varying degrees of rotation of the kidney about its longitudinal axis (HAUCH 1903 GEYVILL 193 ») PRIVAN (1929) however found no true rotation of the kidney but only an apparent rotation due to different regional growth of the renal parenchyma He based his opinion on the investigations of FELN (1911) who showed that the number of entral tubular divisions was about twice as many as the dorsal BROCK VAN (1936) did not find any true rotation but believed that the josition of the renal hilum was due partly to the ureteric tree (which as an active component during embryonal life modified the renal tissue) and partis because of the surroundings of the kidney (u hich as a passie component influenced the position) LOFOREV (1919) showed that the position and above all the shape of the hilum depended upon changes in the arrangement or topography of the pyramids during embryonal life lovio & THVPSOV (1903) described the vessels as being more common on the medial (3 e dorsal) side of the kidney ·97 arteries was large they entered the renal hilum separately Only arteries to pyr 1 ?ID appeared to run an extrahılar course Supplementary arteries arising more than 70 mm distal to the origin of the mam renal artery or distal to the middle of L III represented persisting arteries arising during the ascent of the hidney Sueh arteries were seen in 19 kidnete 8 of which were clearly mulrotated while 7 had a pelvis whose confluence was projected orer the kidney suggesting a certain degree of mulrotntion te incomplete rotation of the entre clinical angiographic series these were the only malrotated kidneys situated at a normal level The ascending stretched artery to the lower pole in most of these cases ran an extrahılar course and prevented normal rotation of the kidneys This rotation 19 not due solely to 'fferences between the growth of the sentral and dorsal pyramids as w 1$ rmerly sui posed but to a true rotation of the kidney about its long studmal SUMMARY In investigation of the roentgen anatomy of multiple renal arteries was carried out in a clinical series examined by renal angiography consisting of a total of 309 patients of which 288 sere exammed bt aortic angiography 81 bg selective angiography In an autopsy series 34 kidnets were examined by a method described in Part I The findinga may be summarized as follows Frequency of multiple arteries - After exclusion of dystopie and fused kidneys there were 639 kidneys with multiple arteries in '38. After hidneys with hydronephrosis due to obstruction at the uretero pely ze junction were excluded (( 4 kidneys with multiple arteries in 16°) multiple arteries were found in 207. The figure 19 about 10, lower than that found in autopsy naternal and was due to the fact that small caliber arteries to the upper pole were not always demonstrable in the roentgenogram Fields of supply topography and relature frequency of supplementary artenes In hidneys with multiple arteries were studied with respect to field of supply and relatre frequency of supplementary arteries Aput from their early ongin and varying course to the kidney the supplementary arteries did not differ from segmental arteries to kidneys having a single renal artery (Part I) Pyr 121 D segment - Supplementary arteries to pyr 121 D segment were found 1 141% of all kidneys with multiple arteries a figure about 10°, lower than found in autopsz material The reason for this discrepancy was explained by angiograms of autopsy specimens in 2 out of 5 specimens Rith supplementary arteries to psr 121D the supplementary arteries were so narrow that they were not demonstrable in a clinical angiogram The artery 7 Butera ·96 outline (Figs 26 28 30) However the crammation should always be supple mented by aortic angiography of supplementary arteries are demonstrated or suspected in order to avoid missing any pathologic change in the part of the kidney that it is not filled Since selective angiography is superior to aortic angiography it should be used routinely in the investigation of the kidney lortic angiography is used only if there is reason to suspect that the kidney is supplied by more than one renal artery (hy dronephrosis with obstruction at the uretero pelvic junction malrotation dystopic kidneys fused kidneys double kidneys) and if selective angiography fails 2) Supplementary arteries to the upper pole are often so small that they are not demonstrable in the roentgenogram It is important for the surgeon to be aware of this and to realize that even if the roentgenologists report does not mention multiple arteries supplementary arteries to the upper pole might nevertheless be present These supplementary arteries to the upper 1 ole are of less diagnostic significance because of the smallness of their fields of supply Supplementary arteries were not so small in calber in any other seg ment of the kidney therefore this source of error is unimportant in the evalua tion of the vasculature of the kidney as a whole Since such multiple arteries to the upper pole are not always demonstrable in the angiogram the frequency of multiple arteries as shown in the cimical angiogram is somewhat lower than that found at autopsy 3) The field of supply of the supplementary arteries varies widely The variation was greatest for the supplementary dorsal artery which in one third of the cases supplied half of the hidney The most important vessel 19 the supplementary artery to jars inferior because this vessel occurs in clinical angiograms about twice as often as all other segmental arteries together and becau e of its surgical importance (lay dronephrosis resection) In about 60 of all kidneys the supplementary lower polar arteres supphed 25-50°. the parenchymi It most frequently supplied the entire pars inferior which suggests as in the series with 2 single renal artery that there are often good possibilities of performing partial resection of this portion of the kidney 4) Supplementary arteries to the kidney are of two types persisting me one phrie arteries and persisting arteries to the metaneplıros developing before or during the ascent of the kidney About 80% of supplementary arteries supplying pars inferior arose cranul to the middle of L III and represented persisting mesonephrie renal arteries The only way in which the latter vessels differed from segmental arteries of the renal artery was their abnormal origin The course of these sessels was the same as that of ordinary segmental arteries and they often ran in a common pedicle with the main artery However when the distance between the two 0 of ·99 group The malrotation was ascribed to the supplementary artery, because its extrahılar dorsal branch prevented normal rotation of the kidney In addition to clear malrotation, some cases in this group shosed an intrarenal' pelvis where the confluence was projected over the kidney, thereby indicating in complete rotation Such an intrarenal' pelvis was also occasionally seen, when the supplementary artery arose proximal but close to the 70 mm level ·98 supplied only a small portion of a pyramid in such cases When supplementary arteries to the upper pole were demonstrable in the angiogram the usually supplied two Pyramids usually pyt 1-9 V, sometimes pyr 1-2 D seldom all pyramids Pyr 3-5 segment In 56% of the kidneys supplementary arteries supplied this segment The field of supply of the vessel varied from 1 to w pyramids Pyr 3 5 D segment Supplementary arteries to this segment were observed in 14 1°The field of supply of the vessel varied In two thurds of the hulness It supplied 5 & pyramids (35 55 ° of the renal parenchyma) Pyr 67 ID segment - - Supplementary arteries were seen coursing to pars inferior in 72 5 % of the kidneys a figure somewhat higher than that found in studies in autopsies because the material contained an ouer representation of cises of hy dronephrosis In 88 kidneys the field of supply of the artery was demonstrated In about half of these the vessel supplied the entire pars inferior and in nearly tuo thirds 25-50 % of the renal parenchyma The field of supply varied to a certain extent with the origin of the vessel from the aorta Ongin and course of supplementary arteries -- Il hile the sentral and dorsal supplementary arteries to the middlo portion of the kidney origmated from the aorth at a level close to that of the main renal artery either crannlly or ciudally and ran together with the renal artery in a common pedicle it uns found that the supplementary olar arteries ran a separate course and branched at varying level from the main artery R sup ppr (1)2 V (D) regularly originated before the mun artery at mast 17 mm and usually ran directly to the segment without entering the sinus Rinf pyr (6-) 71 D varied the most Its origin varied from 7 mm cranial to 135 mm caudal to the origin of the main artery In the majority of hidneja the vessel arose at a les el sery close to that of the main renal artery with which it ran a common course in the pedicle to the hilum where it continued as a normal segmental artery The frequency of a supplementary artery to the lower pole decreased with increasing distance up to 70 mm distal to the main artery Distal to the level the frequency increased again with a maximum about 90 mm from the renal artery (Fig 33) The former group represented persistme mesonej burze Trnal arteries while the latter consisted of arteries wluch had arisen during the ascent of the hidney Ilhtle the vessels in the former group usually ran a de scending or horizontal course or in a cranial convercurre and then entered the lower part of the hilum the majority of the latter ran an extralular course direct h to the lower pole and appeared to be stretched All of the malrotated kidneys situated at normal level had a supplementary artery belonging to the latter ·99 group The malrotation was ascribed to the supplementary artery, because its extrahılar dorsal branch presented normal rotation of the kidney In addition to clear marotation, some cases in this group showed an intrarenal' pelris, where the confluence was projected orer the kidney thereby indicating in complete rotation Such an mtrarenal pelvis was also occasionally seen, 1 hen the supplementary artery arose proximal but close to the 70 mm les el ·APPENDIX VARIATION IN THE NUMBER OF RENAL ARTERIES WITH DIFFERENT TYPES OF RENAL PELVIS The present misestigation showed that the frequency of hidneys with multiple arteries was twice as high in the presence of changes at the uretero pelvic junction with hy dronephrosis as in a normal series Since aortic angiograms are preferable to selective of the kidney 19 supplied by more than one renal artery pre knowledge of any multiple arteries would reduce the number of cases first examined by selective angiography T hile it is well known that malrotated, dvstopic, and fused kidneys are almost always supplied by multiple arteries no investigation are on record of the frequency of multiple arteries in kidneys with normal variants of the renal pelvis (variation in number of calyces and outline of shapo of pelv19) Since renal angiography is practically alivays precerled by urography, it would be useful if the latter examination could decide whether or not there was any reason to suspect the presence of multiple arteries, in a given type of renal pelvis In kidneys with a double pelris HELLSTROW (1927, 1928) found multiple arteries in l out of 6 SJTU RUSI & LANS (1951) and SUITI (1953 1954) seldom found the kidney to be supplied by a single artery in the presence of a double pelvis and reported that the supplementary artery fed only a small part of the kidney The anatomic variations in the shape of the renal pelvis (LEGUEU 1891, GRAUHAN 1932, HERMA V 1936, LOFGREV 1957 and others) as well as in the number of calyces (HAUCII 1903, LOFOREN 1949 and others) have been elucr dated LOFGREN (1957) homologized and restored the different types of renal pelvis to an antomically uniform basic type In the present intestigation, honeter, use was made of the classification of the pelvis described by LEQUEU (1891) because the ampullar and ramifred peltis are widely used on roent genologic literature To these two were added an intermediary type and the double kidney pelvis The type of renal pels is in 113 kidneys with a single renal artery 189 com ·101 Table 14 Multiplo arteries in different types of renal relvis Type of renal A single artery Multiplo arteries pelvis Vumber Per cent Number Per cent Ramified Intermediary Ampullar Double pelvis 287 88 30 8 69 5 21 3 73 19 70 40 12 8 539 307 92 62 113 130 pared to that in 130 kidneys with multiple arteries The results are given in Table 14 It 19 clear that the number of supplementary multiple arteries did not vary with the shape of the renal pelvis In 16 kidneys with double kidney pelvis, half were found to have multiple arteries, a higher frequency than normal The frequency thus lay between tliat given by HELLSTROM (1928) and that of SVITI, Rusu & EVANS (1931) and SMITH (1953, 1954) As in Srth 8 (1954) series, the present material contained no cases of double pelvin in which the supplementary artery supplied the entire primordial inferior lobe (pyr +-7VD) only Pyramids in the pars inferior being supplied The intrarenal vascular pattern 18 thus incependent of the appearance of the ureteric tree This was also confirmed in the lobar division of the hidney (Part I) The two first pairs of pyramids formed one segment, and the third pair of pyramids, which also belonged to the superior primordial lobe, was included in the field of supply of the ventral and dorsal arteries together with the pars intermedia ventralis and dorsalis The frequency of multiple arteries in relation to the number of calyces was studied in 207 kidneys with a single artery and in 54 with multiple arteries (Table 15) Kidneys with a large number of calyces did not have multiple arteries more often than those with a small number A very large number of caly ces suggest, that the kidney 19 supplied by a single artery (Table 15) Thus slight difference alco coincides with that found in mammals (HiBTL 1872, CHIFSITZ 1897) in which multiple arteries are exceptionally rare and independent of whether the kidney is unipapullar (e g rabbit, horse) or has a large number of pupillae (dolphın, bear) Intestigations at the Roentgen diagnostic Department of the University Hospital Lund on kidneys of rat, dog and rabbit have also shown multiple arteries to be estremely rare This is also in agreement with the ·102 Table 15 Frequency of multiple arteries in relation to number of calyces Number of caly ces A single artery Multiple arteries Vumber rer cent Number Per cent 3- caly ces 5-6 7-8 9 10 11 or more calyces 6 35 100 52 14 0 9 29 169 48 25 1 68 29 15 1 0 167 537 978 207 18 findings of LOFAREV (1957), who showed that the different number of calyces depends on fusion of the papillae of the pyramids Multiple arteries are thus more common in man CONCLUSIONS The imi estigation showed no variation in the number of renal arteries in the different normal types of renal pelvis In these hidneys multiple arteries of diagnostic significance must be expected in about 20 % of all kidneys In Lidneys with double pelvis or uretero pelvic obstruction, multiple arteries must be expected in about 50 % In these, as in all malrotated, dystopic, and fused kidneys aortic angiography should be performed ·PART 111 EXTRARENAL ARTERIES ARISING FROM THE RENAL ARTERY INTRODUCTION The renal artery and ste branches surply not only the renal parenchyma hut also the fatty capsule renal pelvis the upper part of the ureter as well as the adrenal gland These arteries are often visible in selective renal angio graphy Occasionally suel sessels are also seen in aortic angiography but since ressels coursing to other abdominal organs are also filled and the denost; of the contr ist medium in the perirenal vasculature 18 seatsely low it is not possible to discern their pattern The purpose of this part of the eventigation was parti; to chart the topo graphy of vessels arising from the renal artery or its main branches asu suprlying the renal pelvis the upper part of the ureter and the fatty capsule And partly to elurdate changes in the pattern of these vessels in some common renal diseases EARLIER INVESTIGATIONS AUTOPSY STUDIES Suprarenal arteries The interior phrenic artery as well as the superior and ndille suprarenal arteries occasionally arise from the renal arters rule however af vessels to the adrenal only the inferior suprarenal artery comes from the renal artery and usually guype off a capsular artery which supplies the fatty capsule around the upper pole of the kidney (HYRTL 1872 SCHUFRBER 1895 1896 PICK & 4vsov 1940) LEU (1999) and Busck (1954) found tjue yessel to origmate from other vessels usually front the sorts in 25-30 per cent of their specimens Capsular arteries - The superior capsular artery usually hranubes from the inferior suprarenal artery but occasionally shrertis from the renal artery HYRTL (1872) showed that when this artery arose directly from the renal artery it sometimes supphed a small region of parenchy ma in the upper pole of the liney Aasos CAULDHELL PICK & Betton (1 147 1948) found that even when the vessels trose from the aorta small capsular arteries from the inferior ·104 phrenic artery and the superior middle and inferior suprarenal arteries supplied small regrons of parenchyma in the upper pole These findings were confirmed on angiography of kidneys removed post mortem (Part II) It was also observed that such arteries often escaped observation in aortic or selective renal angiograms because of their small caliber and minute field of supply Middle capsular arteries HURTL (1872) observed vessels given off by the renal artery or its branches which he called recurrent arteries and per forating arteries because of their course in relation to the renal parenchymi SCHNERBER (1896) and others confirmed these findings The recurrent arteries arose from the dorsal and ventral branches of the renal artery in the hulum or sinus They first rin medially towards the hilar lip and then laterally towards the dorsal and ventral aspect of the Lidney where they supplied the fatty capsule They were particularly abundant in the dorsal lag er (SCHMERBER 1895) and anastomosed with other capsular arteries Simular vessels also supplied the sinus fat (AUGIER 1923) The perforating arteries arose from interlobar or interlobular arteries pene trated the capsula propria supplied the fatty capsule and anastomosed with other capsular arteries These vessels were as a rule narrow and only scanty m adults (HYRTL 1872 SCHMERBER 1896) Other authors (DISSE 1909 AUaire 1923) have found them to be abundant The middle capsular arteries include also vessels arising from lumbar arteries mesenteric arteries and colic arteries Capsular arteries may also arise directly from the aorta though rarely Interior capsular artery — According to SCUDERBER (1805) the spermatic (ovarian) artery gres off a branch running to the fatty capsule at the level of the lower pole This capsular branch runs cranrally along the lateral border of the kidney and anastomoses with other capsular arteries This branch forms the vessel known asl arcade exorenale (SCHMERBER 1895) along the lateral border of the kidney together with the superior capsular artery This extrarenal vascular arcade is of regular occurrence (Fig 12) As a rule the internal spermatıc artery is given off by the aorta though sometimes by the renal artery (GÉRARD 1913) or by supplementary renal arteries (ANSON & KURTH 1955) Renal peltic and ureteric arteries - -Narrow arteries arising from the ventral and dorsal arteries supply the renal pely 1s (HIRTL 1872 SCHVERBER 1895) DOUVILLE & HOLLI SHEAD (1955) found a large number of small branches extending to various les els of the renal pelvis These small : essels arose from the renal ventral and the dorsal arteries and their branches in the sinus and anastomosed with one another ·103 12 11 Fig 1? Diagram of arteries arising from the renal artery or its intrarenal branches and supplying extrarınal parts i Inferior phrenie artery 2 4 Attenes to adrenal 5 Superior capsular Artery 6 R sup nyr 11 78 Vad lle rapsular arteries Recurrent (7) anil perforating (8) arteries 9 Peis e arteries 10 Ureteric arteries (ventral and dorsal) 11 Internal spermatu artery 12 Inferior rapeular artery which together with the superior capular artery forms larcade erorénale (SCHVERBHR) (ccasionally though rarely the inferior capsular artery departs from the renal artery The lower part of the confluence of the pelvis and the upper part of the ureter are supplied either by one artery which as a rule originates in the central artery, or by two arteries one arising from the rentral artery and one from the dorsal artery (11 RTL 1872 SCHMERBER 1895 Ronnnsox 1902 SADIPSOY 1904 and others) ·106 CLINICAL ANGIOGRAPHIC STUDIES In the presence of malignant tumours of the renal pelvis one would expect to find pathologic vessels originating in the pelric or ureteric artery, but no such vessels have been observed in aortic angiograms (NELSON 1912, Doss 1946, RU\STROY 1948 PALILOY 1952, \ EI DE 1952, LINDBLOM & SELDINGER 1955 EDSVAN 1957 and others) Pathologic vessels have, however, been seen in a selectae angiogram of a case of cancer of the renal pelvis (PIROYTI & TARQUINI 1958) Whether the pelvic or ureteric arteries were involved 18 not stated At a symposium held in 1957 in Turin at which a large number of selective renal angiograms were shown BIONDETTI & MARANI pointed out that the ureteric artery could be demonstrated in such angiogrims, but mentioned nothing about its appearance or diagnostic value in the investigation of renal disease SCHIATZEK (1958) described an accumulation of contrust medium in the wall of the renal pelvis as seen in an aortic renal angiography in n case of adı anced chronic pyelonephritis and hy dronephrosis, but no description was given of the pelvic or ureteric arteries SUMMARY The topography of the vessels supplying the renal fatty capsule, pelvis and ureter has been charted by autopsy and in corrosion preparations The appearance of these vessels in a few cases of selective renal angiograms has also been described, but no systematic investigations have been made of the appearance of these sessels in health and in disease ·AUTHOR'S INVESTIGATIONS MATERIAL AND METHODS Seventeen pairs of kidneys together with the perirenal fat adrenals and aorta were removed en bloc post mortem The renal artery was ligatel at its origin after which contrast medium was injected and angiograms were taken at different angles (see also Parts I and II) One of the hidneys was rejected because of lezhage of contrast medium The pattern of the arteries supplying the renal pelvis ureter and the fatty capsule was studied in 90 kidneys of living subjects examined by selectie renal angiography The amount of contrast medium injected varied between 5 and 10 ml according to the size and function of the kidney The contrast medium used way Urografın 60 per cent occasionally Hypaque 45 per cent The injection pressure ranged between ? 5 and 3 hg/cm? In all of the eramına tions the density of the contrast medium in the renal artery was optimal The demonstration of extra renal vessels was not influenced by the amount of contrast medium injected RESULTS ANATOMIC STUDIES OF KIDNEYS FROM CADAVERS of the total of 33 specimens studied the inferior phrenic artery and the superior+middle suprarenal arteries aros from the renal artery in 3 and 5 specimens respectively The superior and middle suprarenal arteries often appeared as a bundle of thin vessels with a characteristic straight craniolateral course (Figs 43 and 44) In 15 of 33 kidneys a vessel was seen to arise from the renal artery or one of its branches In 8 of these cases the vessel stemmed directly from the renn] artery in 4 from a primary branch of it and in 3 from a supplementary artery to the pyr 1 21 D segment This sessel branched and ran partly to the louer part of the adrenal as the inferior suprarenal artery and partly adjacent to the upper renal pole after which it ran a tortuous caudal course along the

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·109 ** a FGH A itnpsy specimen (r glth Iney) a True fr ital w bine, ze repro luct on of part of ang ogram illustrate 1 1 a Oberve th charact rst roure of the per or cam lar artery (-) along the lateral bord r of t! k In The artery wh ch laparte from a supplement ary artery to the upperjolei) 1. les ntn tuo brancl es oft ugly eq al cal ber Varro v prarenal arter ex aj o stem trm thes Ppirme tary artery Ureter c arter c9 (-) stein from the lower s far art na Ithe forsal artery Graceful iek ar geen $ rzli ng the puls (b these hidney, the artery divided into 'branches of equal caßber (Fig 44) one to pur Il and the other to the fatty capsule In 13 of 33 kidnos no arteries were seen to run to the adrenal or upper part of the renal fatty capsule In all of the hidneys except one narron arterial branches were scen to run dorsally and/or sentrally to the intermediate part of the kidney -- mid lle eipsi lar arteries These arteries departed either from the renal artery or ita main branches most frequently from the dorsal artery or sometime: from other capsular arteries When the vessels arose in the sinus thes fust ran ·110 Fig fu Autopgy specimen (left kidney) A recurrent Artery (--) branches from the dorsal artery in the sinus Viddle capsular arteries running caudalls and cranially are seen med al to the lulum Ureteric artery ) departs from Duer polar artery medially to the lerel of the hılar lip and then it turned in a lateral direction gning off branches extending cranially and caudally (recurrent arteries HYRTL 1872) (Fig45) Perforating arteries (Hurtl 1872) were observed in only a few hidneys (Fig 46) With the technique used it was not possible to detect the origin of these vessels In 2 kidneys a filling was obtained of the internal spermatıc artery which branched from a supplementary upper polar artery in one specimen and from a supplementary louer polar artery in the other In 7 kidneys a filling of the inferior capsular artery was obtained but only in one of them was the ressel well dereloped (Fig 47) and in that specimen the superior capsular arterz narrow and short The seasel departed from the lower polar artery in 2 kidneys from 2 supplementary upper polar arteri in 1 from the dorsal artery in 1 and from other capsular arteries in 3 In all of the kidneys except one (in which the contrast medium was 80 viscous that no filling was obtuned of the interlobular arteries) numerous narrow (about 01-02 mm caliber) arteries were seen to run from the

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·119 more Fig 17 Autopsy specimen (r ght hi Iney) Superior and interior casqular arteries stem from a supplementary artery to the upper pole and form larca le eroré ale renal artery and its primary branches (Figs 43 44, 46) These pelmc arteries formed a fine network around the renal pelvis within the region of the con fluence The vascular network could not be recognized peripherally because of the accumulation of contrast medium in the parenchyma In 30 of 33 hidneys the angiograms showed a nurrou artery that was wider than the pelvic arteries but narrower than the middle capsular arteries and coursed to the upper part of the ureter as the ureteric artery As a rule this artery arose from the lower polar artery but sometimes came from the renal ·113 artery or one of its primary branches (Figs 43 45 46) Some kidneys had a dorsal and a ventral ureteric artery (Fig 14) The non visualization of the ureteric artery in the remaining kidneys was due to the contrast medium being viscous in 1 and not being injected into a supplementary lower polar artery in ? The middle capsular arteries the pelvic arteries and the ureteric artery were thus regularly seen in about half of the specimens the inferior suprarenal artery and the superior capsular artery were demonstrable Only occayonally could the inferior phrenic artery superior+middle suprarenal arteries in ferior capsular artery and spermatic artery be identified ANATOMIC STUDIES OF SELECTIVE RENAL ANGIOGRAMS Selectic angiograms of 90 kidneys were studied for the occurrence of extrare ral arteries arising from the renal artery Arteries of one or more of the above mentioned types were found in 65 of the 90 kidneys studied It was noteworthy that the contrast medium persisted longer in these vessels than in any of the ressels in the hidney Extra renal sessels could therefore be readily distinguished from intra renal branches (Fig 18) Inferior phrenic and superior and middle suprarenal arterres were observed in only 1 kidney The arteries arose from the renal artery close to its origin from the aorta Inferior su prarenul artery and/or superior capsular urtery were demonstrated in 30 kidneys (one third of the cases) usually both When the tip of the catheter was located medial to the origin of the artery from the renal artery a filling was obtained of the capsular arteries and suprarenal arteries as well as an accumulation of contrast medrum in a part of the adrenal (Fug 49) Then the top of the catheter was situated peripherally to the origin of the suprarenal and capsular arteries a filling was obtained of these vessels though the contrast density was much lower and as a rule no filling was obtuned of the adrenal The superior capsular artery had a characteristic course running tortuously in a caudal direction along the lateral border of the kidney often far out laterally in the fatty tissue (Fig 50) In 3 cases the capsular artery departed from tho artery supplying fyr 1!1D (Fig 48) Viddle capsular arteries were observed in 36 out of 90 kidneys The vessels arose from the dorsal artery and sometimes from the ventral and renal arteries (Figs 50 and 55) Since the capsular arteries did not appear untıl in the late arterial phase their origin in the smus could not always be recognized because of commencing accumulation of the contrast medium in the parenchyma Bortex ·114 Ne Fig 18 Selective renal angiogram (left krney) Tho peripheral part of the superior capsular artery 19 still clemonstrable in the nephrogram For the same reason it was usually not possible to follow the course of the vessels on the dorsal or ventral aspects of the kidney The middle capsular arteries were therefore observed mainly medial to the renal llum as narrow vessels with twigs running cranially as well as caudally Perforaling artenes were seen in a few small kidneys with a narros renal artery Only in 2 angiograms was a filling obtained of the inferior capsular artery and in none was the internal spermatic (ozanan) artery demonstrable The fine netvorh of the pelvic arferies seen at the site of the confluence of the pelvis in angiograms of kidneys from cadavere was never v19blo in selec tre angiograms On the other hand, a faint accumulation of contrast medium was seen in the wall of the renal pelvis in 2 hidness In 27 of 90 kidneys one or more arteries were seen running to the lower part of the pelvic confluence and the upper part of the ureter (urclerc arteries) ·115 Pg 19 Select ve renal ang ograniglt k iney Title ath 17 19 placed net al I the or gn of super or caps lar artery ani nferruf rarenal artery Ac m lat n of contrast n adrenal Super ur car ilar art ry ella el by s Itury cyst n the lateral an llox rart thek in y As in the examination of the post mortem specimens the artery was usually fonn I to depart from the lower polar artery ar doccasionally from other branches of the renal artery As a rule the vessel was narrow but in 13 it was under than might be expected from the apperance of the uretenc artery in angio grams of post mortem specimens Only in a few angiograms were the capsular arteries renal pelvic arterie and tie ureteric arteries dernonstrable at the same time Suce only th superior capsular artery and the inferior suprarenal artery arose early d monstration of the oti er arteries 1 28 1 ot dependant on the position of it tip of the cati eter ·116 gara F9 50a Sol tary cyst in the central part of left k iney and chron e pyelonepi rit Selective renal arg ogram early arterial phase Proximal parts of suprarenal( -an superior capsular arter es (1) are seen as well as unusually y le ureter c artery ()--) ANGIOGRAPHIC APPEARANCE OF CAPSULAR AND RENAL PELVIC ARTERIES IN SOME PATHOLOGIC CONDITIONS In order to find out whether the appearance of the arteries in selective renal angiograms might be of any diagnostic value the appearance of these vessels was studied against the background of the clinical diagnosis or the pathologic diagnosis when available ·117 F9 500 Late arterial phase Superior capsular artery () has a winding course far out in the perire al fatty tiesne but 190 t displaced by the cyst YxJle cap-ul ar arteries f. art arun ne lral to thum Chronic prelonepl nuts --- In 21 of 27 kidneys of chronie pyelonephritis extra renal sessels were seen to extend into surrounding tissues The middle anul superior capsular arteries were of normal width and observed with the same frequency as in the entire material In hidneys a filling was obtained of the ureteric artery and m 3 of these it was wider than usual (Fig 50) The frequenes with which the ureterie artery was demonstrable in ·118 Fig 51 Select ve renal ang ogram (lefth Iney) Super or capsular artery 1) ureter C Artery (-) an intrarenal arter es are deeplace I by a large renal carci nma thus series was the same as that in the material as a wholo (about 30 per cent) Renal carcinoma - In 1 of 9 kidneys of renal careinoma the superior cap sular arter was demonstrated and found to be of normal width In renal ·119 6 Fig5) Renal carcinoma centrally in left hidney a Selective renalangi gram 6 Arterio gram of operative specimen Ureteric artery (-)18 mile and supply the tumour carcinoma the capsular artery may be displaced to a varying extent depending on the size and position of the tumour (Fig 51) In 3 kidneys the muddle capsular arteries were demonstrated all were wider than normal and all apperred to supply the tumour In 5 kaney, the ureteric artery was also outlined and in 3 it was wider than normal (Fig 59) In 2 of the cases no Sessels to surrounding tissues were observed Renal tuberculosis – Perirenal vessels were seen in all 5 kidneys of renal tuberculosis studied In 3 the middle capsular arteries and the pretene arteries were wider than usual In one an accumulation of contrast inedum was seen in the pelvic wall and the upper part of the ureter (Hg 53) Histologie examina tion in this case showed pronounced tuberculous inflammation of the nall of the renal pelvis Cancer of the renal pluis - In 2 of 3 hulneys of cancer of the renal pelus

·10
*
7
%
A.
a
***
F, 53 Tuberculoss of left h dney
Select ve renal ang ogram a Ir er al
pase / Early nephrograpt c phae
c Late nephrograp! e pl are Mille
car lar arter es (-) and le ure
ter c artery () are seen A cumula
on of contrast met m n confluence
and
pper part of u eter Te Hal
of ti e pel is of the operat e spec men
and the ureter were th ck an Iphone!
Tan I STA

·121 the tumour had caused considerable hy dronephrosis In both cases the renal artery was narrower than normally so that the supply to the hidney was considerably reduced Pathologic sessels branching from intra renal arteries were observed in the region of the tumour and in both cases a wide ureteric artery extended from the lower polar artery and also supplied the tumour with pathologic vessels (Fig 51) The diagnoses were papillary and anaplastic cancer of the renal pelvis respectively In the third kidney there was a small papıllary renal peluc cancer of the ramus to the upper calıx No pathologie vessels were seen Hydronephrosia 4 of 11 hidneys of hy dronephrosis studied showed middle capsular arteries displaced by the dilated confluence (Fig 55) Only in 3 were ureteric arteries seen and in 2 they appeared to be wider than normal In the third the ureteric artery was not dılated but there was an accumulation of contrast medium in the wall of the renal pelvis and early filling of the pelvic eins (Fig 56) In some other cases of renal diselsc capsular arteries were demonstrated but were not dilated in a further 6 kidneys ureteric arteries were also de monstrated but in none were they dilated DISCUSSION AND CONCLUSIONS It is obviously easier to demonstrate the occurrence of ressels in angiograms of autopay specimens than in selectie angiograms As a rule clinical angro graphy with ordinary contrast medium wall not outline vessels less than 03 mm in diameter (MATTSSON 1955) In an attempt to form an opinion as to how often selectie angiography will show arteries arising from the renal artery (or the main artery in the presence of multiple arteries) to surrounding tissue selective angiograms wero compared with the angiograms of kidneys from cadavers (Table 16) The inferior phrenic superior suprurenal middle suprarenal and the interior capsular arteries seldom originated and the internal spermalic artery nerer tooh origin from the renal artery Since it is usually the internal spermatic artery that gives off the inferior capsulır artery it is obrious that it was not possible to demonstrate SCHVERBER 8 (1895) arcade exorenale in the clinical Angiograms When arteries to the upper and intermediate part of the adrenal and the inferior phrenic artery arise from the renal artery they do so quite close to the aorta so that thes are rarely demonstrable in selective angiograms Aortic angiography appears to be preferable in the investigation of adrennt tumours becanse of the better prospects of obtaining a filling of the adrenals The frequency with which the superior capsular artery and the inferior

·122
Fguti
Fist szed mal gnant pap lloma of the pelv 19 (r ght k Iney) The kıl ey was
-
7
suprarenal artery were demonstrable was 6 % lower in selectie angiograms
than in angiograms of specimens remosed post mortem Thy difference may
also be explained by the origin of the
1oned arteries
to the aorta
The width of the superior caj sular
d considera
field of supply Sometimes the sessel ert
to the level
7

·Fig 16 Sephrograpl slase Tise peluxe tum ir 1 supp! by pathologic Tersely from intrarenal arter and frm tix wide ttreterie artery renul pole and was then narrow but sometimes it continued to the fatty tissue at the lower pole and was then der The course along the lateral border of the kidney was characteristically tortuous and the superior capsular arters sometimes extended far out into the perirenzl fat without necessarily being displaced in the presence of a spice occupying tumour the vessel way displaced to an ettent varying with the size and position of the tumour In none of these cases did the superior capsular arters appear to be dilated In selectne angiograme performed after this ·192 Fag 5ta Fı t sized malignant papilloma of the pelvis (right kidney) The kidney was enlarged and the parenchymna was severely reduced Selectise renal angiogram Arterial phase Intrarenal arteries are reduced in width and displaced A inddle capsular artery () is dieplaced Ureteric artery (-) is displaced and wide suprarenal artery were demonstrable was 6 % lower in selective angiogranis than in angiograms of specimens removed post mortem This difference may also be explained by the origin of the above mentioned arteries being close to the aorta The width of the superior capsular artery varied considerably with its field of supply Sometimes the vessel extended only to the level of the upper ·1 + },516 lep/rograjic phase ripe! mur I pled i uthol goc vaxaela from ntrarenal arter e4 A I fr m ti # le trc artery renal pole and was then narrow but sometimes it continuerl to the fatty tissue at the lower pole and was then wider The course along the lateral border of the kidney was characteristically tortuous and the superior capsular artery sometimes extended far out into the perirenal fat without necessarily leing disy laced in the presence of a space occupying tumour the vessel #19 distlued to an extent varying with the size and / osition of the tumour In none of these cases do the superior capular artery api er to be dilate In selective angiograms performed after thuis ·124 We al hig 55 Hy Ironepl ros - (r glth Iney) a Select ve renal ang ogram illo capo lar Arteries (-) are d sj lace I by the late i confluence b Retrogra lo psel grm erammation was finished definitely dulated superior capsular arteries supr lying renal carcinoma were seen As in the series of Aiso CAULDWELL Pich & BEITO (1948) the ca sular artery was found to run to the upper renal pole together with a supplementary polar artery (Part II) In cases with n single renal artery the superior capsular artery sometimes arose from the artery to the pur 121 segment in all of these cises and in contradistinction to that found when the vessels left the aorta together the capsular artery was narrower than the segmental artery The vessels running to the perirenal fat on the sentral and dorsıl as ects of the kidney were called mi ldle capsular arteries In the post mortem angio grims the vessels could be followed throughout their course while in the selectne angiograms tiey could as a rule be identified only medial to the hilum because the filling of the rest of their course was mashed by the earls nephrographic phase l'artls for this reason and partly because the ureteric ·1 39. 40°. 91 0 97 89 0 00 o 0 30 0 degree of displacement provided a rough measure of the degree of d lasten In almost all of the angiograms taken at auto an extrarenal fine network of pelve vessels was seen around the other of the pelvis The ressels were so delicate that they could not be ditur rata In hidneys hypers ascularity was demonstrated by a faint ant 'ation of the kidneys removed post morlem tireleric airleries were sees i etrnd 125 Table 16 Frequency of extrarenal arteries arising from renal artery and demonstrater! in angiograms of hidneys hidneys remove 1 in ltung post morten being (total 33 (total 90 kidneza) kidneys) A phrenica inf 6. A supraren sup and media 9. 1. A supraren in an 1 capsularis eup 33 Aa capsulares mediae Aa nutrientiae peli 19 A ureterica A spermatica int A capsularis inf arters was often similar in course and appearance the middle capçular artering could only be distinguished with difficulty from the ureteric artery The latter ran caudo medially and could be followed further distally than the carvular artery The ureteric artery often stemmed from the lower polar artery, while the capsular artery branched more proximally from the renal artery or one of its branches and also gare off branches running in eramal direction They often appeared to anastomose In the anglograms of the hadneys from cadavers a filling of the mut ile capsular arteries from the renal arters was nearly always demonstratie , while in the selective angiograms they were seen in only 40 % belarse of their small size and close relationship to the renal parenchyma In. 5 angiograms the vessels appeared to be wuler than usual mamals in 3 witli renal carcinom, and with tuberculosis of the pels 19 or size of the tumour Peliac arteries in selective angiograins of contrast medium in the wall of the renal pelus ·1.26 Fig sc Hydronephrosis with soverely reticel parenchy ma (right haney) The pekic wall of the operatie specimen was oedematous and showed a lancel cellular infiltra tron Selective renal angiogram a Farly arterial phase o Mid lle arterial phase Ureteric artery (-) thin an la place ! by thlited confluence A9 19 one of the mi ldle capsular arteries ()--) Accumulation of contraat melum in pehe wall from the lower polar artery or other branches of the renal artery in 82% of the kidneys but in only 30% of the selective renal angiograns This dif ference was due to the fact that the artery was often so narrow that it was doubtful whether it would normally ever be apparent m the angiogram (Fig 46) In 13 of the 27 hidneys in which the artery was observed it was definitely wider than normal because it had been involved by tumour or inflammatory process in the hidney It is considered that in the remaining cises in which the vessel was demonstrated it liad probably becn widened by such a pathologic process but it could not be classified as definitely enlarged ·1.77 # tig bc Late arterial phase Pelsac veina fl) are fille I early ureterie artery could be identifierd in only 3 of 11 kidney with hydro nephrosis (6 with co-existant infection of the kulney) The low frequency was dve possibly to diminished vascularisation of the kidney which is common m hydronephross The hy dronephronic group did not include the 2 kidness in which the dilata tlou 128 due to cancer of the renal pelvie In these the parenchy ma vac markedly reduced and therefore the nephrogrim was lees dens and did not mask the pathologie veesels in the pelvie tamour In both the ureteric artery was uzlened and supplied the tumour and pathologic sessels were seen In the third case with a small prap urz cancer of the renal pels the angrogram shoued no patholo, resuels Selectne rena) angiography has considerably increased the possibilities of diagnosing cancer of the renal pelu is because it is possible to obtain optimal ·128 filling of the arterial tree with accumulation of contrast medium in the tumour especially if the renal parenchyma is markedly reduced If the ureteric artery supplies the tumour the artery will be wider than usual and in its freld of supply there will be pathologic vessels A small intrarenal cancer of the peluis can not be detected by angiography howeler because in such a case the tumour 18 supplied only by the thin arteries in the renal sinus which are too fine to be identified The accumulation of the contrast medium in the normal renal parenchyma will mask any pathologic accumulation in such a tumour SUMMARY Angiographic studies of the topography of extrarenal arteries arising from the renal artery or its branches or from supplementary arteries were per formed in 33 hidneys removed post mortem and the results compared with selective renal angiography in 30 kidneys Owing to their early origin from the renal artery the inferior phrenic artery superior suprarenal artery middle suprarenal artery and to a certain extent the inferior suprarenal artery and the superior capsular artery will be seen in the selective angiography less frequently than might be expected from examina tions in the post mortem specimens Aortic angiography should therefore be given preference in the investigation of suspected space occupy mg tumours involving the adrenals The density of the contrast of the inferior suprarenal artery and the superior capsular artery but not the other adnexal arteries varies with the position of the tip of the catheter If the contrast density in the inferior suprarenal artery is high part of the adrenal will be outlined The field of supply and thereby the width of the superior capsular urters varies considerably The vessel runs a tortuous course along the lateral border of the hidney The artery is liable to be displaced by space occupying lesion The middle capsular arteries may be displaced by expanding tumours In hy dronephross the size of the extrarenal part of the renal peli 19 can be judged from the degree of displacement of the capsular arteries The vessels may be dılated in the presence of space occupying and inflammatory processe4 In pronounced chronic Pyelonephritis any hypers &scularity will be seen in the renai angiogram as an accumulation of contrast medım in the wall of the renal pelvis The renal pelirc arteries are so narrow that they do not show up in the angiogram The ureteric artery may be dilated under certain circumstances such as in chronic pyelonephritis renal carcinoma cancer of the renal pelvis and tuber culosis It appears that it is only visible in the angiogram in such cases ·129 The ureteric artery may supply a malignant tumour of the renal pelvis which will appear in the angiogram as pathologic vessels Because of reduced vascularisation in the kidney the nephrogram will be less dense and pathologic Tessels arising from intrarenal arteries can be demonstrated If the tumour 1s small and intrarenal, no such pathologie ressels are seen because they will be masked by the accumulation of contrast medium in the parenchyma The inrestigation showed that if the amount of contrast medrum is adjusted according to the size and function of the kidney as judged by urography arteries to the fatty capsule and to the renal pelus will appear independent of the caliber of the renal artery and the position of the tip of the catheter ·GENERAL SUMMARY Utulization of recent advances in renal angiography requires better know ledge of the normal angiogruphic pattern of the kidney Pre operative angio graphy is an important guide in contemplated resection of the kidney In such cases det uled information on the extent of the pathologic lesion and the topography of the intrarenal vasculature is indispensable This prompted the present investigation the purpose of which was to analyze the roentgen anatomy of the vasculiture of the kidney as seen in selective and aortic renal angiograms of living human beings and of post mortem specimens The investigation consists of three parts Part I deals with the angiogruphic pattern of the single renal artery The results are summarized on page 52 Part II is concerned with the frequency and angiographic pattern of mul tiple arteries The results are summarized on page 37 Part III 13 a study of extrarenal arteries arising from the renal artery The results are summarized on page 128 ACKNOWLEDGEMENTS — I wish tu express my sincere gratitude to Professor OLLE Oussov for constructive criticisin and guidance throughout the in vestigation Professor C G AALSTROM for kindly placing material at my dieposal and colleagues at the Roentgen diagnostic Departments for smooth co operation and help The investigation was supported by grants from the Faculty of Vedicine in Lund

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·13+ with Data on the Inferior Phrene Ureteral and Gonadal Arteries & Statistical Analysts Based on 185 Dissections and Revan of the Literature J Internat Coll Surg 29 (1933), 41 NARATU P 1 Renal Peli is and retur GruneStratton, eu lork 1951 ELSON O A Arteriography of Abilominal Organs by Aortie Injection A Preliminars Report Surg (ry nec Obstet 74 (1942) 653 O Covor 1 J Diagnosis and Treatment of Hydronephron J Urol 73 (1993). 431 OLSSON O Tol 9 in Ols in Strnad lieten Zuppinger Encyclopedia of Vedical Radio logy Springer Verlag Berlin (rottingen Herdelberg (in print) PALMLOU A Abdominal aortographs with special reference to renal diagnosis Icta chir scand 103 (1952) 16) PALUMBO Stundin anatomo radiologico sul comportamento dell arteria renale sulltromo in relazione specialmente alla nefro angiografia e alla chirurgia conservatrice del rene Arch stal Urol 25 (1952) 329 PATCH F S Conservative plastic surgers in the treatment of hy dronephrosis associated with aburrant vessels Brat T rol I (1929) 373 Pick J & ANSOY B Renal Vascular Pedicle An Anatomical Study of 430 Body Halses J (rol 44 (1940) +11 --- The Inferior Phrenic Artery Origin and Suprarenal Branches Anat Rec 78(1940) 413 PIROVII L & TARQUINI A Alcuni casi di tumore primitiva del rene studiati con I arteriografia renale selettua Mineria Chir 13 (1959) 1122 PRISIAN J A Consideration of Wormal and Abnormal Position of the Hilum of the hidney Anat Rec 12 (1929) 375 PRINES V G Innere Topographie de arteriellen Systeins der Viere und des Veren becken des Venschen und der Haustiere 7 urol Chir 40 (1935) I RAUBER KOPSCH Lehrbuch und Atlas der Anatomie des Menschen 16 Auft 1 of 2 p 465 G Thicme Leipzig 1941 Roin sov B Lan imarks in the treter Ann Surg 36 (1902) 830 RENSTROV 6 Aortografi (Suedirsh) Word West 39 (1918) 934 SAMPSON JA The Eficiency of the Periureteral Arterial Plexus and the Importance of its Preservation in the Vore Radical Operations for Carcinonia Cersion Ltera Bull Johns Hopk Hoeplo (1904) 39 SCHIVATZEN A Aortograpine lerhandlung ber Dtsch Ges Urol Hjen 1937 7 Urol Sonderb (1958) 257 SCHNERBER F Recl erches anatomiques etir l artère rénale Asseetation Typographique Lion 1895 --- Les artères de la Capsule graisseuse su rein Int Vonatsehr Anat Physiol 13 (1896) 269 CHTIZE BERGSG Die Anzeigen tine Crenzen der angiologischen dierencluagnostik Bruns Beitr klin Chir 194 (1977) 1 SELDOWITCH J B (ber die Vultiplicitat eler serenarterie und deren chirurgische Bedeutung Arch klin Chur 89 (1909) 1071 SEVB C The selective principit in the treatment of renal tuberculow Partul tacten of the tuberculous kidney J Ost C) Hoep 3 (1933), 45 Partial resection of the huney Operatne te si nique leta chur acand 109 (1935), 360 Tie Selective Principle in the Treatment of Urogenital Tuberculous Partial l'eve tron of the hrney and of the Creter Urol int i (1995) 339 ·13) roy Coll ITH PAR-umé of tle typer enee in the Jak ng of 1000 P nal Ang ogram J Ur 1 70 (1923) 38 Renal ing ngraj hy (Aortogrph ) + 1 Campbell Lroing To I p 18" 1 B Samlers C NI ! lelpt a ani Lan lon 1954 Ti PC RESH TI & FA AT I be Interpretat n of Translan bor Irtero gt my J Urol 66 (1931) 145 ITALIS rlle problem of re al comentat en connect on th tlenoles of ram f eat on of the ret al art ry ani ler allen Irel crner! (19 6) 7 STF VART HH Part al nejlret ny n tle treatment i renal cal | An Srg Fngl 11 (19) 3 -- Hart al nephrectomy E Rjes Vxleri 1re is trology C1 apter 9! SO Butter ort! (o Lon lo 1933 Таъсі н т в trag zr Toz ograth A te fr Ba clarta. Fla anat jap 9 (1931) 01 TOPON A Report of tle cmn ttet frllect pt pat on of the aton cal Soc ety of Crat Br ta n an! Ir Inl for the ar 189 90 Aunt Phys ! 2 (1891) 89 TENS TEIY BB (OL T144 FH & DE BE SheR alles els n 3 Ca laser Urol c tan R44 (1910) 13 WEYDE R Ablm al aort gray 13 re arreanuar reprt Brt T Raiol (19) 3 3 - Doab mnal Art praple besnt be er kalle! Rallon 3 (193) 313 ILDBOLZ HD rerf Igergan shalt he Ope at en l Hy tre ne pt rose Z urn ci r 31 (1931 63 NOA II & THO IP ON P Abn mn alt tten al arter 4 w hr nark on the r de clopment anl nor! 106 1 Inut il 3) nek V De Torx grayle der er ir Bu Irlere (1 rirge Aircl wall Berl n 1903 ANP Preita en el pa razly th NA fthearta leta ra lol 45 (1996) 1 ler gt ·134 with Data on the Inferior Phrenic Ureteral and Conadal Artertes A Statistical Analysis Based on 185 Dissections and Raves of the Literature J Internat Coll Surs 29 (1958) f1 MARATH PA Renal Pelvis and Ureter Grune & Stratton Mew York 19.1 NELSON OA Arteriography of Abdominal Organs by Aortic Injection A Preliminary Report Surg Gynec Obstet 74 (1942) 655 O CONOR I J Dagnosis an 1 Treatment of Hy dronephrosis J Urol 73 (190) 451 OLSSOV O Tol 9, in Olsson Strnad ieten Zuppiger Encycloped a of Ved cal Rilio logy Springer Verlag Berlin Gottingen Her lelberg (in print) PALLOT A Abdominal aortography with special reference to renal diagnoare Acta chir scand 103 (1952) 16 PALUBO Studio anatomo radiologico sul comportamento dell arteria renale suli yomn in relazione specialmente alla nefro angiografia e alla chirurgia conservatrce del rune Arch ital Urol 25 (1952) 339 PATCH FS Conservative plastic surgery in the treatment of hy dronephrosis 840ciate 1 with aberrant vessels Brit J Uro! I (1929) 373 Pick J & ANSOV BJ Renal Vascular l'edicle An Anatomical Study of 430 Body Halves J Urol 44 (1940) 411 The Inferior Phrenic Artery Origin and Suprarenal Branchea Anat Rec 78 (1940) 113 PIRONTI L & TARQUINI A Alcuni casi ili tumore primitivo del rene stu lati con I arteriografia renale Relettna Minerva Chir 13 (1958) 1122 PRIMAN J A Conokeratin of Vormal and Abnormal Position of the Hilum of the hidney Anat Rec 49 (1929) 355 PRIWIS NI C Innere 1opographie des arterie)en Systems der Niere un 1 dley Nieren beckens des Menschen und der Haustiere 2 urol Chir 40 (1935) 1 RAUBER KOPSCH Lehrbuch und Atlas der Anatomie des Venschen 16 Aufl Vol P 460 ( Thieme Leipzig 1941 ROBION B Landmarks in the Ureter Ann Surg 36 (1902) 850 RUNSTROY G Aortografi (Sued sh) Word Ved 38 (1948) 934 SAVPSON JA The Efficiency of the Periureteral Arterial Plexus and the Importance of its Preservation in the More Radical Operatuns for Carcinoma Ces1014 Uteri Bull Johns Hopk Hosp 15 (1904) 39 SCHIINATZEK A Aortographie Verhandlung ber Dtsch Ges Urol Wien 1917 7 Urol Sonderb (1958) 257 SCHMERBER F Recherchog anatomiques sur l artère rénale Association Typographique Lyon 1893 - Les artères de la Cap uile grandeuse du rem Int Vonat chi Anat Phy-20) 13 (1896) 269 SCHULZE BERGMANN O Die Anzeigen und Grenzen der angiologi chen Nierendugnostik Bruns Beitr klin Chir 194 (1937) 1 SELPOWITSCH I B Ut or dio Multiplicitat der dierenarterie und deren chirurgiche Be leuting Arch hlin cur 89 (1909) 1071 SFNB C The selective principle in the treatment «f renal tuberculosis Partial resection of the tuberculous kulnev J Oslo Cy Hosp 3 (1953) 45 Partial resection of the hidney Operatis o technique Arta chir seand 103 (195.) 360 The Selective Principle in the Treatment of Urogenital Tuberculosie Partul Resec tion of the hidney and of the Ureter Urol int 1 (1995) 359 ·133 SMITH P G A Resumé of the Fxperience in the Making of 1 501) Renal Angiograma J Urol 70 (1953) 328 Renal Angiography (Aortography) in 1 Campbell Urology Vol 1 p 187 11 B Saunders Co Philadelp! a ar 1 Lon lon 1994 SWTH P G Rush TV & ExAV A T The It terpretat on of Translumbar Arterio grams J Urol 66 (1971) 145 SYITHUIS T The problem of renal segmentation in connection with the modes of ramı fication of the renal artery and the renal vein Arch chir neer) 8 (1978) 227 STEWART H H Partial nephrectomy in the treatment of renal calcul Ann my Coll Surg Engl 11 (1952) 32 - Partial nephrectomy in E Riches Modern Tien is in Urology Chapter 9 p 80 Butterworth & Co London 1953 TANIGUCHI T Beitrag zur Topographie der grossen Aste der Bauchaorta Fla Anat jap 9 (1931) 201 THOMPSOV A Report of the committee of collectae investigation of the Anatomical Society of Creat Britain an 1 Irelan 1 for the year 1889–90 J Anat Physiol 25 (1891) 89 WEINSTEIN B B COUNTIS F H & DERBES I J The Renal Teeply in 203 Cadavers Urol cutan I ev 44 (1910) 137 WEIDE R Ab lominal a rtography in runal d sease & prel m nary report Brit J Rad ol 23 (190) 333 – Dio ab laminale Aortographie inal pson lere bez Varenkrankheiten Rad ol Clin 23 (1051) 313 WILDBOLZ H Danererfolge rgancrł altender plast scher Opurationen bei Hydr ne Throse z urol Chur 31 (1931) 63 Young A H & THOMPSON P Abnormalities of the renal arteriea with remarks on ther development an l morphology J Anat Physiol 18 (1903) 1 ZONDEK M. Do Topograph der Vlere un 1 ihre Bedeutung fur dio Vieren Chirurgie A H rechwall Berhn 1903 ODVAN P Fercutaneous selectiv ang ngraphy of the man branches of the aorta Acta racol 45 (1956) I

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