Spontaneous Rupture of an Aneurysm of the Renal Artery With Survival

Abstract

ANEURYSMS of the renal artery are well documented and it is recognised that rupture may occur. However, only 11 case reports of survival after rupture could be found in the literature (Burt et al., 1956; Harrow and Sloane, 1958, 4 cases; Schneider, 1962;Menzi, 1965;Viville et al., 1965; Poutasse, 1966, 2 cases; McKenzie, 1967). One further case of survival after rupture of a renal artery aneurysm is described and the literature is reviewed.Case Report.-A married woman of 72 was on her way by train to visit her daughter when she suddenly felt faint and had an acute pain in the right hypochondrium radiating through to her back. She managed to get to her destination and when seen by a doctor she was thought to have had a severe coronary thrombosis for she was pale and sweating with an unrecordable blood pressure. Morphine mg. 10 gave her no relief and two hours later she was sent to hospital.When seen five hours after the onset of symptoms she was still in pain and felt nauseated. She was pale but not sweating, and her blood pressure was Sol55 mm. Hg with a pulse rate of 110 per minute. Her temperature was 99.4" F. Abdominal examination revealed a large smooth tender mass in the right upper quadrant of the abdomen coming from beneath the costal margin and extending back into the loin. The abdominal muscles were relaxed. There was no evidence of any other disorder.A chest X-ray revealed some emphysematous lung changes and in the abdominal film an ill-defined mass could be seen coinciding in position with that felt on examination. Her hamoglobin was 87 per cent (12.8 g./100 ml.) and white cell count 18,800 per cmm. Liver function tests were normal. Serum bilirubin was 1.0 mg./100 ml. An initial diagnosis of abdominal neoplasm was made and subsequently changed to that of pyonephrosis. In the next 24 hours her hzmoglobin fell to 58 per cent. (8.5 g.1100 ml.) but her pain became less severe and her general condition improved.Forty-eight hours after admission the pain returned and the swelling appeared to be increasing in size. Once again she became pale and her blood pressure fell. Surgical aid was then sought. By this time a diagnosis of right renal hzmorrhage was obvious and it was thought that a tumour was the probable cause.Laparotomy was performed 60 hours after the onset of symptoms, a posterior approach to the swelling being made through the bed of the twelfth rib. Within the peri-renal fascia there was a huge mass of blood clot. This was mobilised in its entirety until the pulsating renal pediclt: could be felt and controlled with artery forceps. The mass was then delivered. After removal the specimen was found to consist of a large amount of clot, contained within the perirenal fascia, surrounding a normal-sized kidney. The suprarenal gland had been pushed upwards by the expanding blood clot and was preserved in its normal position. The peritoneum was incised and about half a litre of thick blood was sucked out of the peritoneal cavity. Clotted blood lay in the loose cellular tissues behind the ascending colon a...