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Letters to the Editor |
Department of Radiology, Charité, Universitätsmedizin Berlin. Schumannstrasse 20/21, 10117 Berlin, Germany. e-mail: thomas.kroencke@charite.de
Editor: I read with interest the article by Kawamoto et al in the March-April 2004 issue of RadioGraphics (1), which reviewed the use of multi–detector row computed tomography (CT) in the evaluation of patients undergoing laparoscopic nephrectomy for renal transplantation.
On page 463 of their article, Kawamoto and colleagues referred to "unexpected vascular anomalies that may be found at preoperative evaluation with multi–detector row CT" and mentioned abdominal aortic and splenic arterial aneurysms as examples. Although splenic arterial aneurysm might be considered a rare vascular pathologic condition, abdominal aortic aneurysms have a higher prevalence and thus should be expected in living renal donors, who, at our institution, have a mean age of 47 years (2). Surprisingly, the figure corresponding to the authors’ statement (fig 15) is a CT angiogram of a patient in whom intraoperative laceration of two prominent arterial vessels (which were nicely depicted preoperatively in figure 15) led to a serious postoperative hemorrhage. The authors stated that this complication was caused by avulsion of these prominent arteries, which arose from the superior mesenteric artery, coursed through the mesocolon, and caudally accompanied the gonadal veins in the patient.
Given the corkscrew appearance of these vessels on the CT angiogram presented, their reported course, and the fact that these arteries avulsed during surgery near the renal hilum, the diagnosis of bilaterally enlarged ovarian arteries is almost certain. Ovarian arteries arise in a pairlike fashion from the anterior circumference of the abdominal aorta, just below the level of the renal hilum or, less often, directly from accessory renal arteries. They course retroperitoneally and laterally on the psoas muscle, cross the ureters and external iliac arteries, and reach the ovaries through the suspensory ligament (3,4). If considerably large, ovarian arteries might be subject to laceration during laparoscopic surgery in this area. Ovarian arteries might also be enlarged in rare cases of absent or hypoplastic uterine arteries and thus provide the main vascular supply to the uterus. More frequently, secondary enlargement of ovarian arteries may develop because of pathologic conditions of the ovaries or uterus. Recently, ovarian arteries were recognized as a collateral pathway in the perfusion of uterine fibroids, and they accounted for clinical failures after uterine artery embolization for symptomatic uterine fibroids (5). Abdominal flush aortography performed at the level of the renal arteries depicts the origin and course of ovarian arteries, whereas selective catheterization of the ovarian artery may be necessary to confirm a relevant vascular supply to uterine fibroids (Fig). Detailed knowledge of the abdominal vasculature and its variants is crucial for successful transplant surgery because laparoscopic surgeons rely more and more on preoperative noninvasive imaging modalities such as state-of-the-art magnetic resonance (MR) angiography (2) or multi–detector row CT angiography as nicely presented by Kawamoto and colleagues in their article.
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References
Russell H. Morgan Department of Radiology, Johns Hopkins Hospital, 601 North Caroline St, Room 3254, Baltimore, MD 21287–0801. e-mail: efishman@jhmi.edu
We greatly appreciate Dr Kroencke’s interest in our article and his comments on the images shown. We closely reviewed on a workstation the CT angiograms from the case represented by figure 15, and we agree that the corkscrew vessels most likely represented dilated, tortuous ovarian arteries. As Dr Kroencke stated, under normal circumstances, the ovarian arteries are tortuous vessels of fairly small caliber, and selective catheterization is needed to demonstrate their entire course. Although the gonadal artery may be seen as a small artery arising from the abdominal aorta on CT angiograms (particularly those obtained with a 16-section multi–detector row scanner), it is very uncommon, in our experience, to visualize this dilated, tortuous artery at CT angiography. If the corkscrew vessels depicted in figure 15 were ovarian arteries, they were unusually and abnormally dilated. They were also very fragile at surgery. This latter finding prompted us to evaluate the patient’s pelvic organs and vessels with MR imaging, which showed several small leiomyomas of the uterus. The ovaries were not clearly identified at MR imaging. The uterine venous plexus was slightly prominent, but no other vascular abnormalities were found in the pelvis.
In addition to pelvic pathologic conditions, renal arterial stenosis is known to cause enlargement of ovarian arteries as collateral circulation. In our patient, however, the renal arteries were normal. Although it is possible that these dilated arteries may have been related to uterine leiomyomas, their true cause is uncertain. Nevertheless, when such a dilated, tortuous artery is encountered at CT angiography, very close attention is needed for a safe operative procedure.
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