Genitourinary Imaging
Radiology
Benjamin M. Yeh, MD
Fergus V. Coakley, MD
Maxwell V. Meng, MD
Richard S. Breiman, MD
Marshall L. Stoller, MD
Index terms:
Hydronephrosis, 81.84, 961.141,
961.762, 961.92
Kidney, anatomy, 81.92
Renal arteries, 961.92
Renal arteries, CT, 961.12915
Published online
10.1148/radiol.2302021030
Radiology 2004; 230:429 433
1
From the Departments of Radiology
(B.M.Y., F.V.C., R.S.B.) and Urology
(M.V.M., M.L.S.), University of Califor-
nia San Francisco, 505 Parnassus Ave,
Box 0628, C-324C, San Francisco, CA
94143-0628. From the 2002 RSNA
scientific assembly. Received August
20, 2002; revision requested October
18; final revision received June 2,
2003; accepted June 13. Address cor-
respondence to B.M.Y. (e-mail:
benyeh@itsa.ucsf.edu).
Author contributions:
Guarantor of integrity of entire study,
B.M.Y.; study concepts and design, all
authors; literature research, B.M.Y.,
M.V.M., R.S.B., M.L.S.; clinical studies,
all authors; data acquisition, B.M.Y.;
data analysis/interpretation, all au-
thors; statistical analysis, B.M.Y.; manu-
script preparation, definition of intel-
lectual content and editing, all
authors; manuscript revision/review,
B.M.Y., F.V.C., R.S.B.; manuscript fi-
nal version approval, all authors
RSNA, 2004
Precaval Right Renal Arteries:
Prevalence and Morphologic
Associations at Spiral CT1
PURPOSE: To determine the prevalence and morphologic associations of precaval
right renal arteries at spiral computed tomography (CT).
MATERIALS AND METHODS: The authors retrospectively reviewed 186 arterial
phase contrast material enhanced spiral CT scans of the abdomen (5.0-mm section
thickness in 97 scans, 2.5 mm in 89 scans) obtained during a 2-year period to
identify patients with precaval right renal arteries. During routine interpretation of
CT scans at daily readout, the authors prospectively identified 39 additional patients
with precaval right renal arteries. All cases were evaluated for anatomic variants and
associated clinical findings. Fisher exact analysis and 2 analysis were performed to
compare the frequency of anatomic variants between patients with and those
without precaval renal arteries.
RESULTS: Nine of 186 patients had precaval right renal arteries, for a prevalence of
5%. In the 48 patients with precaval renal arteries, 52 precaval arteries were found,
of which 48 were accessory and four were dominant. Fourteen patients had right
pelviectasis to the level of the precaval artery, and three of these had a clinical
diagnosis of right ureteropelvic junction obstruction. Eighteen (35%) of the 52
precaval renal arteries arose from the anterior aspect of the aorta (within 30 of the
midline). The lower pole of the right kidney was rotated anteriorly in two (22%) of
nine and 13 (33%) of 39 patients with precaval renal arteries in the retrospective
and prospective groups, respectively, compared with four (2%) of 177 patients
without precaval arteries (P .05 and P .001, respectively).
CONCLUSION: On the basis of these results, precaval right renal arteries appear to
be more common than previously reported. Anterior rotation of the lower pole of
the right kidney should prompt a search for precaval renal arteries.
RSNA, 2004
Spiral computed tomography (CT), especially multi detector row CT, enables accurate non-
invasive three-dimensional evaluation of the renal arteries, parenchyma, and collecting sys-
tem (1 4). Renal arterial variants, including early branching and accessory renal arteries, occur
in up to 40% of the population (5). Recognition of these arterial variants is particularly
important prior to modern minimally invasive urologic procedures, such as endopyelotomy
and laparoscopic radical and donor nephrectomy (6,7). Multiple renal arteries are common
anomalies, with a prevalence of 30% 40% (5,8). Right renal arteries are traditionally described
as passing posterior to the inferior vena cava, although dominant and accessory right renal
arteries that pass anterior to the inferior vena cava have been reported (9,10). Published
information regarding the frequency and anatomic relationships of such precaval right renal
arteries is minimal. Therefore, we undertook this study to determine the prevalence and
morphologic associations of precaval right renal arteries with spiral CT.
MATERIALS AND METHODS
Patients
This was a single-center study and was approved by our Committee on Human Research.
Written informed consent was not required for any component of our study. To determine
429
 the prevalence of precaval right renal ar-
teries, one author (B.M.Y.) used a com-
puter search to retrospectively identify
all contrast material enhanced multi
detector row CT scans obtained for eval-
Radiology
uation of hematuria (105 patients) or sus-
pected aortic dissection (99 patients)
between November 1999 and October
2001, because these scans are routinely
obtained during the arterial phase of en-
hancement with intravenous contrast
material. Images from only the first CT
examination for each patient were in-
cluded in the review. Eighteen of these
204 patients were excluded by the reader
(B.M.Y.) at the time of image interpreta-
tion for the following reasons: techni-
cally limited examination (10 patients),
abdominal aortic dissection or surgery
(seven patients), and severe native kid-
ney atrophy (one patient). Patients were
excluded for the latter two reasons be-
cause accessory renal arteries may be oc-
cluded in such patients. The final study
group for review consisted of 186 pa-
tients (retrospective group), including 94
women (mean age, 61 years; range,
18 95 years) and 92 male patients (mean
age, 57 years; range, 1391 years). There
was no statistically significant difference
between the mean ages of women and
men (P .15, Student two-sample t test).
An additional 39 patients with preca-
val renal arteries were prospectively iden-
tified during routine CT interpretation by
one of three study authors (F.V.C., R.S.B.,
B.M.Y.) between August 2001 and March
2002, during which time approximately
3,200 CT scans were interpreted by these
authors. The 39 patients (prospective
group) included 16 women (mean age, 49
years; range, 20 90 years) and 23 men
(mean age, 54 years; range, 36 84 years).
There was no statistically significant dif-
ference between the mean ages of
women and men (P .61, Student two-
sample t test). Results for one of these
patients were included in a previously
published case series on precaval renal
arteries (9). Indications for CT in the 39
patients were evaluation of malignancy
in nine, abdominal pain in seven, fever
in six, elevated liver function test results
in five, back pain or hematuria in four,
possible aortic aneurysm in three, and
miscellaneous in five. One reader (B.M.Y.)
reviewed the medical records of all pa-
tients with precaval renal arteries for
symptoms referable to the genitourinary
system, including symptoms of back or
flank pain or signs of hematuria or uri-
nary collecting system obstruction.
430 Radiology February 2004
CT Technique
All 186 patients in the retrospective
group underwent multi detector row CT
(LightSpeed; GE Medical Systems, Mil-
waukee, Wis) and received 150 mL of in-
travenous iohexol (Omnipaque 350; Ny-
comed Amersham, Princeton, NJ) at a
rate of 35 mL/sec. In the 97 patients
with hematuria, scans were obtained
through the kidneys with 5-mm section
thickness, pitch of 1, and scan delay of 45
seconds. Nonenhanced portal venous
phase and delayed images were also ob-
tained in patients with hematuria. In the
89 patients suspected of having aortic
dissection, arterial phase scans were ob-
Figure 1. Transverse CT scan in a 51-year-old
tained from the aortic arch to the inter- woman with abdominal pain. Image demon-
nal iliac arteries with 2.5-mm section strates an accessory precaval right renal artery
thickness, pitch of 2, and average scan (arrows) in the lower pole of the right kidney.
delay of 20 seconds. IVC inferior vena cava.
The 39 patients in the prospective
group had precaval right renal arteries
and underwent scanning with spiral CT
(LightSpeed QX/I for 16 patients, Light-
Speed Plus for 15, HiSpeed CT/i for five,
and HiSpeed Advantage for three; GE
Medical Systems), with section thickness
of 2.5 mm for 18 patients, 3 mm for one,
5 mm for 16, and 7 mm for four. All
patients received 150 mL of intravenous
iohexol at a rate of 25 mL/sec. Twenty-
two of the patients imaged with 2.5- or
3.0-mm section thickness and seven of
the patients imaged with 5-mm section
thickness underwent scanning during
the arterial phase of enhancement; 21 of
these patients also underwent scanning
during the portal venous phase or de-
layed phase. The remaining 17 patients
underwent scanning during the portal
venous phase of enhancement.
Figure 2. Transverse CT scan in a 56-year-old
man with pancreatitis. Image demonstrates an
Image Interpretation accessory precaval right renal artery (arrow-
heads) in the lower pole of the right kidney
One radiologist with subspecialty that originates from the anterior aspect of the
aorta (arrow). IVC inferior vena cava.
training in abdominal imaging (B.M.Y.)
independently reviewed all CT images for
both the retrospective and prospective
groups with a picture archiving and com- tended to a given kidney; all other renal
munication system, or PACS, worksta- arteries were considered accessory. The
tion (Agfa, Mortsel, Belgium). For both origin of precaval right renal arteries that
kidneys, the number, diameter, and arose from the aorta was classified as an-
course of all renal arteries and veins; the terior or lateral. Arteries that arose ven-
presence of a bifid collecting system; and trally from the aorta within 30 of the
the presence of pelviectasis were re- midline (between the 11- and 1-oclock
corded. A precaval renal artery was de- positions on an imaginary clock face su-
fined as a tubular structure with attenua- perimposed on the aorta) were consid-
tion similar to that of and arising from ered to have an anterior location (Fig 2),
the aorta or iliac artery that passes ante- while all other arteries were considered to
rior to the inferior vena cava and termi- have a lateral location. In patients with
nates in the right kidney (Fig 1). The pelviectasis, the position of the precaval
dominant renal artery was defined as the renal artery relative to the ureteropelvic
artery with the largest diameter that ex- junction was noted. The rotation of the
Yeh et al
Radiology
Figure 3. Transverse CT scans in a 31-year-old woman with right flank pain and hematuria. (a) Lower pole of the right kidney is rotated anteriorly.
Renal hilum at this level is rotated anteriorly more than 45 from the horizontal (angled lines). (b, c) More inferiorly, an accessory precaval renal
artery (arrow) arises from the right iliac artery (arrowhead).
right kidney upper pole and lower pole
was noted in all patients. The upper or
lower renal pole was considered to be
anteriorly rotated when the correspond-
ing portion of the renal hilum at that
level was rotated ventrally more than 45
from the horizontal (Fig 3); otherwise,
the lower kidney pole was considered to
not be rotated.
Statistical Analysis
Statistical analysis was performed with
a software package (Stata, version 7.0;
Stata, College Station, Tex). Comparison
of the proportions of patients with mor-
phologic variants between patients with
and those without precaval renal arteries
and between patients in the prospective
and retrospective groups was performed
with the Fisher exact test or 2 test. A P
value of less than .05 was considered to
indicate a statistically significant differ-
ence.
RESULTS
Anatomy
Nine of the 186 patients in the retro-
spective group had precaval right renal
arteries, for a precaval right renal artery
prevalence of 5% (95% CI: 2%, 9%). Of
these nine patients, five were women and
four were men. Of all 48 patients (nine
patients in the retrospective group, 39
patients in the prospective group) with
precaval right renal arteries, the precaval
artery was single and accessory in 42 pa-
tients (eight patients in the retrospective
group), single and dominant in two pa-
tients (one patient in the retrospective
Volume 230 Number 2
group), double with one dominant and
one accessory in two patients, and dou-
ble and accessory in two patients, for a
total of 52 precaval right renal arteries.
The accessory right precaval arteries
had a mean diameter of 2.9 mm (range,
1 4 mm) in the nine patients in the ret-
rospective group and a mean diameter of
3.1 mm (range, 1 4 mm) in the 39 pa-
tients in the prospective group in com-
parison to a mean diameter of 5.1 mm
(range, 27 mm) and 4.8 mm (range, 37
mm), respectively, for the dominant
right renal artery. The dominant right
precaval arteries (four patients) had a
mean diameter of 5.2 mm (range, 4 8
mm). All precaval arteries had an origin
from the aorta (nine patients in the ret-
rospective group and 40 patients in the
prospective group) or right common iliac
artery (three patients in the prospective
group) (Fig 3) that was separate from the
origins of other renal arteries, and in no
patient did branches of the same renal
artery pass both anteriorly and posteri-
orly to the inferior vena cava. Eighteen
(38%; 95% CI: 24%, 53%) of the 48 pre-
caval renal arteries that arose from the
aorta came from the anterior aspect of
the aorta (four [44%] of nine patients in
the retrospective group and 14 [36%] of
39 patients in the prospective group).
Morphologic Associations
Of the patients with precaval renal ar-
teries, one (11%; 95% CI: 0%, 48%) of
nine patients in the retrospective group
and 13 (33%; 95% CI: 19%, 50%) of 39
patients in the prospective group had
asymmetric dilatation of the right renal
Precaval Right Renal Arteries at Spiral CT
pelvis to the level of the precaval crossing
artery. Three of the latter patients had a
clinical diagnosis of right ureteropelvic
junction obstruction (Fig 4). None of the
other patients in our study had a diagno-
sis of right or left ureteropelvic junction
obstruction. In patients with a precaval
artery, no other clinical symptoms or
signs, including flank pain or hematuria,
were considered attributable to the pre-
caval artery.
The proportion of patients with preca-
val renal arteries who had multiple right
renal veins (five [55%] of nine patients in
the retrospective group and 24 [61%] of
39 patients in the prospective group) and
multiple left renal arteries (five [55%] of
nine patients in the retrospective group
and 13 [33%] of 39 patients in the pro-
spective group) was larger than that in
the patients without precaval renal arter-
ies (50 [28%] of 177 patients [P .17 and
P .001, respectively] and 34 (19%) of
177 patients [P .05 and P .05, respec-
tively]). Among patients with precaval re-
nal arteries, those in the retrospective
group had a prevalence of multiple right
renal veins (P .99) and multiple left
renal arteries (P .46) similar to that of
patients in the prospective group. Among
patients in the retrospective group, those
in the prospective group, and those with-
out precaval renal arteries, no significant
difference was seen in the prevalence of
multiple left renal veins (zero [0%] of
nine patients vs five [13%] of 39 patients
vs 15 [8%] of 177 patients), retroaortic
left renal veins (zero [0%] of nine pa-
tients vs three [4%] of 39 patients vs five
[3%] of 177 patients), or circumaortic left
431
Radiology
Figure 4. Transverse CT scans obtained at the same level in the lower pole of the right kidney in a 45-year-old woman with the clinical diagnosis
of ureteropelvic junction obstruction. (a) Right renal pelvis (arrow) is dilated. (b) Right renal pelvis narrows to normal caliber at the ureteropelvic
junction (arrow), and an accessory artery (arrowhead) crosses posterior to the ureter. (c) Accessory artery (arrowheads) is in precaval location.
renal veins (zero [0%] of nine patients vs
three [8%] of 39 patients vs 10 [6%] of
177 patients) (P .5 for all comparisons).
The proportion of patients with preca-
val right renal arteries who had an ante-
riorly rotated lower pole of the right kid-
ney (two of nine [22%] patients in the
retrospective group and 13 [33%] of 39
patients in the prospective group) was
larger than that in patients without pre-
caval renal arteries (four [2%] of 177 pa-
tients; P .05 and P .001, respec-
tively). One patient with a precaval right
renal artery had a horseshoe kidney.
DISCUSSION
Familiarity with anatomic variants and
their associations contributes to the
safety and success of both open and min-
imally invasive renal surgery. For exam-
ple, accessory renal arteries may be a con-
traindication to laparoscopic donor
nephrectomy, and injury of a crossing
vessel during endopyelotomy for uretero-
pelvic junction obstruction may result in
severe hemorrhage (11). A right renal ar-
tery that passes anterior to the inferior
vena cava is of particular importance for
presurgical planning, because it may be
injured inadvertently, especially during
the retroperitoneal approach when only
the right gonadal vein is expected to lie
in the precaval area. Our finding of pre-
caval right renal arteries in 5% in 186
patients suggests that these anomalies are
not uncommon. Furthermore, we found
that 37% of precaval right renal arteries
arose anteriorly from the aorta within 30
432 Radiology February 2004
of the midline in comparison to findings
in a previous report that only 2% of all
normal right renal arteries arise from this
aspect of the aorta (12). This anterior or-
igin may result in misidentification at
laparoscopy of such vessels as the inferior
or superior mesenteric or hepatic arteries.
Awareness of the possible anterior origin
of precaval arteries would also be impor-
tant during endovascular embolization
or stent placement procedures.
It has been suggested that accessory
renal arteries in the lower pole of either
kidney that cross the ureteropelvic junc-
tion contribute to ureteropelvic junction
obstruction in up to 11% of children (13)
and 52% of adults (14). Case reports
show that precaval renal arteries can
cause ureteropelvic junction obstruction
(15,16). Furthermore, identification of
crossing vessels at radiologic imaging is
important because they may be a source
of massive bleeding during endopy-
elotomy (11), and the presence of a cross-
ing vessel decreases the success rate of
endopyelotomy from 83% to 33% (15).
To our knowledge, the frequency with
which precaval right renal arteries result
in symptomatic ureteropelvic junction
obstruction has not been previously re-
ported. We found that 18 of 48 patients
with precaval right renal arteries had
asymmetric dilatation of the right renal
pelvis to the level of the crossing vessel;
three of these 18 patients had a clinical
diagnosis of right ureteropelvic junction
obstruction. This suggests that up to 6%
(three of 48) of patients with precaval
right renal arteries may develop symp-
tomatic ureteropelvic junction obstruc-
tion. Our data are limited by the absence
of long-term follow-up in our patients,
because, ideally, evaluation of symptoms
from infancy to death would help pro-
vide more accurate estimation of the fre-
quency of symptomatic ureteropelvic
junction obstruction associated with pre-
caval renal arteries.
Case reports of horseshoe kidneys and
malrotated right kidneys with associated
precaval right renal arteries have been
published (17), and findings in our study
support the hypothesis that they are re-
lated. In particular, we found that 22%
33% of patients with precaval right renal
arteries had an anteriorly rotated lower
pole of the right kidney in comparison to
only 2% of patients without precaval re-
nal arteries. Among the patients in our
retrospectively evaluated group, two
(33%) of six patients with the lower pole
of the right kidney rotated anteriorly had
a precaval renal artery. Therefore, the
finding of renal anomalies, especially an
anteriorly rotated lower pole of the right
kidney, should prompt a search for pre-
caval renal arteries.
The prevalence of precaval renal arter-
ies of 5% in patients in our study is much
higher than the previously reported prev-
alence of 0.8% (10) in a series of 380
patients evaluated with sonography and/
or contrast-enhanced CT with 6-mm-thick
sections. In that study, the authors suggest
that the majority of precaval renal arteries
were dominant and single (10). In our
study, however, the overwhelming major-
ity of precaval renal arteries were accessory
Yeh et al
 lower pole arteries. Our use of multisection
CT scanners and arterial phase imaging
likely improved accuracy in the current
study relative to that in the previous study,
which accounts for discrepancies in both
the prevalence of precaval renal arteries
Radiology
and the frequency of dominant precaval
renal arteries.
Even so, a limitation of our study is the
lack of an independent standard of refer-
ence for detection of precaval renal arter-
ies. Very small accessory renal arteries
less than 12 mm in diameter may be
missed at CT (18), particularly when
thicker sections, suboptimal vascular
enhancement, or motion artifact are
present. It is unlikely that we falsely
overcounted the presence of precaval
renal arteries, since few structures could
mimic a precaval renal artery, and the
arteries included in this study were
clearly seen to arise from the aorta, tra-
verse anteriorly to the vena cava, and
extend into the right renal parenchyma.
Therefore, the 5% prevalence of precaval
renal arteries in our study may underes-
timate the true prevalence. Likewise, se-
lection bias may be present in our study,
since the precaval arteries detected at
routine CT readout are likely to be
skewed toward larger more readily appar-
ent arteries; therefore, evaluation of asso-
ciations between smaller precaval renal
arteries is limited. The lack of a patient
denominator for the prospectively iden-
tified cases prevented the use of these
cases to evaluate prevalence.
In conclusion, on the basis of results in
Volume 230 Number 2
this study, precaval right renal arteries
appear to be more common than previ-
ously reported and may cause ureteropel-
vic junction obstruction, be injured dur-
ing endopyelotomy, or be confused with
other vessels such as mesenteric or he-
patic arteries at laparoscopy. Identifica-
tion of certain renal anomalies, particu-
larly anterior rotation of the lower pole
of the right kidney, should prompt a
search for precaval renal arteries.
References
1. Manu MA, Harza M, Manu R, et al. Com-
parative study of helical CT scan angiog-
raphy, conventional arteriography, and
intraoperative findings for the evaluation
of living renal transplant donors. Trans-
plant Proc 2001; 33:2028 2029.
2. Moritz M, Halpern E, Mitchell D, et al.
Comparison of CT and MR angiography
for evaluation of living renal donors.
Transplant Proc 2001; 33:831 832.
3. Kaatee R, Beek FJ, de Lange EE. Renal ar-
tery stenosis: detection and quantifica-
tion with spiral angiography. Radiology
1997; 205:121127.
4. Wittenberg G, Kenn W, Tschammler A,
Sandstede J, Hahn D. Spiral CT angiogra-
phy of renal arteries: comparison with an-
giography. Eur Radiol 1999; 9:546 551.
5. Kadir S. Atlas of normal and variant an-
giographic anatomy. Philadelphia, Pa:
Saunders, 1991.
6. Sampaio FJ. Renal anatomy: endourologic
considerations. Urol Clin North Am
2000; 27:585 607.
7. Shindo S, Kubota K, Kojima A, et al.
Anomalies of inferior vena cava and left
renal vein: risks in aortic surgery. Ann
Vasc Surg 2000; 14:393396.
8. Dunnick N, McCallum R, Sandler C. Text-
book of uroradiology. Baltimore, Md:
Williams & Wilkins, 1991.
Precaval Right Renal Arteries at Spiral CT
9. Meng M, Yeh B, Breiman R, Coakley F,
Schwartz B, Stoller M. Pre-caval right re-
nal artery: description and embryologic
origin. Urology 2002; 60:402 405.
10. Petit P. Precaval right renal artery: have
you seen this? AJR Am J Roentgenol 1997;
169:317318.
11. Kim F, Herrell S, Jahoda A, Albala D.
Complications of Acucise endopyelot-
omy. J Endourol 1998; 12:433 436.
12. Beregi JP, Mauroy B, Willoteaux S, Mounier-
Vehier C, Remy-Jardin M, Francke J. Ana-
tomic variation in the origin of the main
renal arteries: spiral CTA evaluation. Eur Ra-
diol 1999; 9:13301334.
13. Hoffer FA, Lebowitz RL. Intermittent hy-
dronephrosis: a unique feature of uretero-
pelvic junction obstruction caused by a
crossing renal vessel. Radiology 1985;
156:655 658.
14. Lowe FC, Marshall FF. Ureteropelvic junc-
tion obstruction in adults. Urology 1984;
23:331335.
15. Mitsumori A, Yasui K, Akaki S, et al. Eval-
uation of crossing vessels in patients with
ureteropelvic junction obstruction by
means of helical CT. RadioGraphics 2000;
20:13831395.
16. Lee JY, Chung JW, Kim SH, Cho SW, Park
JH. Proximal ureter obstruction caused by
a lower polar renal artery: demonstration
with spiral CT angiography. J Comput
Assist Tomogr 1997; 21:641 642.
17. Cocheteux B, Mounier-Vehier C, Gaxotte
V, McFadden EP, Francke JP, Beregi JP.
Rare variations in renal anatomy and
blood supply: CT appearances and em-
bryological backgrounda pictorial es-
say. Eur Radiol 2001; 11:779 786.
18. Platt J, Ellis J, Korobkin M, Reige K. Heli-
cal CT evaluation of potential kidney do-
nors: findings in 154 subjects. AJR Am J
Roentgenol 1997; 169:13251330.
433