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Аномалии сосудов почки

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by admin06.10.2015
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Различные аномалии сосудов почки, среди которых встречаются чаще всего .добавочные почечные артерии, сопровождают многие другие аномалии почек, в большинстве случаев — дистопию со сращением. Именно это обстоятельство и делает операции при таких аномалиях технически трудными. Нередко отмечается сочетание гипоплазии, нефроптоза, а также других аномалий со стенозом почечной артерии.

Удвоение основной почечной артериивстречается нечасто. Примерно с одинаковой частотой (1 : 200) наблюдаются верхнеполярные артерии, идущие к верхнему концу почки от почечной артерии и аорты, и к нижнему концу от почечной артерии, аорты, подвздошной, брыжеечной или крестцовой артерии.

Ветвь артерии заднего сегмента, идущая позади лоханки, обычно веерообразно разделяется, причем ветвление ее весьма вариабельно. Почечная лоханка может перекрещиваться одним или несколькими сосудами большого калибра, а также самой почечной артерией.

Как основной ствол, так и ветви почечной артерии первого и второго порядка могут входить в почечные ворота не на передней стенке лоханки, как обычно, а на задней. Это препятствует удалению камня наиболее удобным доступом — разрезом на задней поверхности лоханки.

Разделение основного ствола почечной артерии на равные по калибру ветви — нередкое явление. Когда имеются две почечные артерии, одна из них обычно лежит позади лоханки и берет начало от аорты или основного ствола почечной артерии.

Множественные почечные вены встречаются реже, чем артерии, и обычно с правой стороны. В норме существует одна передняя почечная вена, которая может делиться на ветви равного калибра, идущие впереди или позади почечной лоханки. Добавочные вены могут быть у верхнего или нижнего конца почки.

Внутрипочечный перетягивающий сосуд

Существуют такие варианты строения внутрипочечных сосудов, при которых один из них перетягивает основание чашки (чаще верхней), препятствуя проникновению в нее контрастной жидкости или насыщенной контрастом мочи. В зарубежной литературе этот феномен в сочетании с соответствующей клинической симптоматикой носит название синдрома Fraley.

Единственным проявлением этой аномалии до наступления осложнений может быть тупая боль в области почки, усиливающаяся в положении больного стоя и иногда доходящая до интенсивности колики. Отмечены и другие симптомы, но они обусловлены последствиями уростаза (гидрокаликоз, пиелонефрит, камень).

Диагностика аномалии основывается на данных экскреторной урографии; при этом на снимках виден дефект наполнения в верхнем конце почки и расширение соответствующей чашки при удовлетворительной экскреторной функции всей почки. Почечная ангиография делает эти данные более убедительными, особенно если наложить ангиограмму на урограмму. Дефект наполнения шейки чашки может быть узким, линейным (перетягивающий сосуд — артерия) или широким, расплывчатым (вена). Подобную рентгенологическую картину могут дать отшнуровавшаяся каверна и рентгеноотрицательный камень. Клиническая симптоматика и ангиография помогают в уточнении диагноза.

В неосложненных случаях в лечении нет необходимости. При наличии гидрокаликоза, камня, упорного пиелонефрита предпринимают различные операции: уменьшение чашки с калико- пиелонеостомией, перевязку перетягивающего сосуда, перемещение шейки чашки вперед, каликоанастомоз, резекцию конца почки.

Мы наблюдали 6 больных с добавочным внутрипочечным сосудом, который вызвал сдавление шейки верхней чашки, сопровождающееся ее расширением и деформацией, а также выраженным уростазом. Двое из этих больных были сестрами (5 и 7 лет), что является в какой-то степени подтверждением мнения о наследственном характере этой аномалии.

Клинически аномалия проявлялась у наших больных тупой болью в области почки, а при присоединении пиелонефрита — признаками этого заболевания.

Для диагностики внутрипочечного перетягивающего сосуда во всех случаях достаточным оказалось проведение экскреторной урографии.

Под нашим наблюдением находилась девочка 11 лет с гидронефрозом пояснично-дистопированной правой почки. Во время операции выяснилось, что причиной гидронефротической трансформации верхних 2/3 почки является вена диаметром 4 мм, перетягивающая почку поперек; больной была произведена нефрэктомия.

Следует упомянуть также о сужении почечной артерии, вызванном в основном фибромускулярной гиперплазией участка ее стенки, хотя в процессе участвуют и другие ее слои.

Одни считают фибромускулярную гиперплазию почечной артерии врожденной аномалией, другие — приобретенным заболеванием. Надо полагать, что в детском возрасте это все же врожденная аномалия.

Важнейшим клиническим проявлением сужения почечной артерии является артериальная гипертензия. Поэтому эта аномалия, наряду c другими причинами реноваскулярной (вазоренальной) гипертензии, рассмотрена отдельно.

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