Clinical Anatomy 29:660–664 (2016)

ORIGINAL COMMUNICATION

The Gross Anatomy of the Renal Sympathetic

Nerves Revisited
BLANCA MOMPEO,1* EVA MARANILLO,2 ARTURO GARCIA-TOUCHARD,3
THERESA LARKIN,4 AND JOSE SANUDO2
1
Department de Morphology, Universidad de Las Palmas de Gran Canaria. Las Palmas, Spain
2
Department of Human Anatomy and Embryology, University Complutense of Madrid, Madrid, Spain
3
Department of Cardiology, Hospital Puerta de Hierro. Autonomous University of Madrid, Madrid, Spain
4
Graduate School of Medicine, University of Wollongong, Wollongong, Australia

Catheter-based renal denervation techniques focus on reducing blood pressure

in resistant hypertension. This procedure requires exact knowledge of the ana-
tomical interrelation between the renal arteries and the targeted renal nervous
plexus. The aim of this work was to build on classical anatomical studies and
describe the gross anatomy and anatomical relationships of the renal arteries
and nerve supply to the kidneys in a sample of human cadavers. Twelve human
cadavers (six males and six females), age range 73 to 94 years, were dissected.
The nervous fibers and renal arteries were dissected using a surgical micro-
scope. The renal plexus along the hilar renal artery comprised a fiber-ganglionic
ring surrounding the proximal third of the renal artery, a neural network along
the middle and distal thirds, and smaller accessory ganglia along the course of
the nerve fibers. The fibers of the neural network were mainly located on the
superior (95.83%) and inferior (91.66%) surfaces of the renal artery and they
were sparsely interconnected by diagonal fibers. Polar arteries were present in
33.33% of cases and the renal nerve pattern for these was similar to that of the
hilar arteries. Effective renal denervation needs to target the superior and infe-
rior surfaces of the hilar and polar arteries, where the fibers of the neural net-
work are present. Clin. Anat. 29:660–664, 2016. VC 2016 Wiley Periodicals, Inc.

Key words: autonomous nervous system; aorto-renal ganglia; renal ganglia;

renal plexus

INTRODUCTION resulting in significant reductions in blood pressure in

patients with resistant hypertension (Urban et al.,
Clinical interest in the renal plexus was established 2013). However, the technique has two major limita-
early in the 20th century, when the renal sympathetic tions: the potential complication of renal arterial ste-
nerves were surgically sectioned to treat essential nosis (Kaltenbach et al., 2012) and a lack of response
hypertension (Petit-Dutaillis and Flandrin, 1923; in some patients (Vonend et al., 2012). The latter has
Mitchell, 1947). Whilst this produced the desired been explained as a consequence of the high variabili-
result in some cases, complications and inconsistent ty of the renal nerves and ganglia (Tzafriri et al.,
outcomes led to abandonment of the technique
(Mitchell, 1947). However, renal sympathetic denerva-
*Correspondence to: Dr. Blanca Mompeo  , Departamento de
tion has recently been reintroduced for patients with
Morfologıa, Universidad de Las Palmas de Gran Canaria, Facultad
resistant hypertension, but using endovascular
de Ciencias de la Salud, Blas Cabrera Felipe s/n 35016-Las Palmas
catheter-based renal denervation techniques (Mah- de Gran Canaria, Spain. E-mail: [email protected]
foud et al., 2013; Stouffer et al., 2013; Thukkani and
Bhatt, 2013; Reddy and Olin, 2014). Received 11 March 2016; Accepted 23 March 2016
Initially, this catheter-based technique was consid- Published online 19 April 2016 in Wiley Online Library
ered the perfect approach for renal denervation, (wileyonlinelibrary.com). DOI: 10.1002/ca.22720

C
V 2016 Wiley Periodicals, Inc.
 Renal Sympathetic Nerves 661

The abdominal and thoracic cavities were accessed

and eviscerated. The thoracic splanchnic nerves, the
superior hypogastric plexus, and the solar plexus gan-
glia were identified and the parietal peritoneum was
removed. The aorta, inferior vena cava, and both kid-
neys, surrounded by their perinephric fat, were
extracted in blocks. The renal nerves were dissected
under a surgical microscope.

RESULTS
Micro-dissection of the renal nerves revealed that
they could be clearly described in three sections: (1)
renal ganglia and proximal renal artery; (2) renal
Fig. 1. The renal sympathetic renal plexus of a right plexus, small ganglia, and distal renal artery; and (3)
kidney. A: Anterior view and (B) posterior view. A fibro- accessory arteries and renal nerve fibers.
ganglionic mass encircles the proximal third of the renal
artery and fibers of the renal plexus course along the
superior and inferior surfaces of the renal artery, being Renal Ganglia and Proximal Renal Arteries
interconnected along the distal two thirds of the artery. A fiber-ganglionic mass was found to encircle the
Ag (adrenal gland), Arg (aorticorenal ganglion), Coe
medial third of the main hilarrenal arteries (n 5 24).
(coeliac ganglion), CoT (coeliac trunk), Ig (renal infe-
This mass comprised the celiac ganglion (100% of
rior ganglion), LC (contribution of the lumbar chain to
cases), the aorticorenal ganglion (100%), the inferior
the renal plexus), Pg(renal posterior ganglion), RK
renal ganglion (95.83, and the posterior renal gan-
(right kidney), SMg (superior mesenteric ganglion), SP
(Thoracic splanchnic nerves), * (connection between
glion (70.83%). Short and thick nerve fiber strands
ganglia). connected the individual ganglia to form this mass. A
complete ring of nervous tissue surrounded the artery
in seven of the 24 cases (29.16%) (Figs. 2A,B).
The celiac and aorticorenal ganglia were fused as a
2014), variations in the renal arteries (Rimoldi et al., single mass in 15 of the 24 cases (62.5%). The aorti-
2014; Okada et al., 2015), or aberrant reinnervation corenal ganglion was always connected to the inferior
by sympathetic fibers post-ablation (Booth et al., renal ganglion by one to three thick neural bands that
2015). Several recent studies that support catheter- crossed over the anterior surface of the medial third
based renal denervation techniques have used immu- of the renal artery (Fig. 1A).
nohistochemical methods to describe the location and The inferior renal ganglion was located over the
density of nervous fibers around the renal artery inferior surface of the renal arteries and connected to
(Atherton et al., 2011; Tellez et al., 2013; Sakakura the posterior renal ganglion (Figs. 1A, 1B, and 2B).
et al., 2014) and its segmental branches (Lusch et al.,
2014).However, none of these studies considered this
information in the context of the classical descriptions
of the sympathetic renal innervation (Legueu and
Flandrin, 1923; Petit-Dutaillis and Flandrin, 1923;
Hovelacque, 1927; Testut, 1931; Delmas et al., 1933;
Mitchell, 1950a,b; Mitchell, 1951, 1956), nor did they
include detailed anatomical descriptions of the renal
plexus and vessels, including their anatomical rela-
tionships and variations.
Therefore, this work was undertaken with the aim
of revisiting the gross anatomy of the renal arteries
and renal nerve supply in a reliable sample of human
cadavers, and describing this in the context of clinical
application to renal sympathetic denervation.
Fig. 2. Schematic drawing of the renal sympathetic
plexus of a right kidney. A: anterior view and (B) posterior
MATERIALS AND METHODS view. Arg (aorticorenal ganglion), Coe (coeliac ganglion),
Cof (Connection Fibers), CoT (Coeliac artery), Dsf (Distal
Twelve embalmed cadavers (six males and six superior Fibers), GSP (great splanchnic nerve), Ig (infe-
females; age range: 73–94 years) were included in rior ganglion), Inf (inferior Fibers), LC (contribution of the
this investigation. A total of 24 kidneys were studied. lumbar chain to the renal plexus), LSP (lesser splanchnic
The cadavers belonged to the Department of Anatomy nerve), Pg (renal posterior ganglion), RK (right kidney),
and Embryology and were obtained following the legal Smg (superior mesenteric ganglion), Sp (lower splanch-
procedures governing the donation of bodies. nic nerve).
662 Mompeo et al.

The inferior ganglion joined with the posterior gan- iations included polar arteries (33.33%; in five males
glion to form a single ganglionic mass in three of the and three females).
24 cases (12.5%). The inferior renal ganglion received Five of the polar arteries were on the right side and
fibers from the sympathetic lumbar chain, interme- three on the left. In a single case, this was an inferior
senteric nerves, and superior mesenteric ganglion polar artery that arose directly from the aorta, while
(Figs. 1A, 1B, 2A, and 2B). the rest were all superior polar arteries. Of the seven
The posterior renal ganglion, named by the classi- superior polar arteries, two arose from the hilar renal
cal authors as Hirschfeld’s ganglion, was identified as artery, four from the renal anterior branch from the
an irregular mass on the posterior surface of the renal renal artery and one from a segmental artery.
artery in a total of 17 cases. This ganglion was located Regarding arterial variation, it was observed that if
in various anatomical relationships to the renal artery. more than one hilar artery was present, some nerves
In 9 of the 17 cases (52.94%), it was located on the crossed the faces of the main renal artery to the acces-
medial third of the renal artery (two on the right side sory arteries. The nervous fibers associated with the
and seven on the left) and in seven cases (41.17%) it accessory arteries arose from the same ganglia as
was located on the intermediate third of the renal those associated with the main renal artery. They also
artery, on the right side only. In one case (5.88%) the had the same course and the same relationship to the
ganglion covered both the medial and intermediate artery, with the main fibers running over the superior
thirds of the artery. The lesser and lowest thoracic and inferior surfaces and interconnected by thin fibers.
splanchnic nerves were connected to the posterior
renal ganglion in 11 of the 24 kidneys (45.83%).
DISCUSSION
Renal Plexus, Renal Arteries, and Small The anatomical basis of the catheter-based tech-
Ganglia nique for renal sympathetic innervation is the proxim-
ity of numerous renal sympathetic nerves to the
The renal plexus was composed of nerve fibers lumen of the renal arteries, as demonstrated by histo-
coming from the celiac ganglion, inferior and posterior logical and immunological studies (Atherton et al.,
renal ganglia, superior mesenteric ganglion and tho- 2011; Tellez et al., 2013; Tzafriri et al., 2014; Saka-
racic splanchnic nerves. kura et al., 2014). However, this conflicts with the dis-
Most of the plexus was located around the interme- section studies from the first part of the 20th century
diate and distal thirds of the renal artery. Its main (Petit-Dutaillis and Flandrin, 1923; Legueu and Flan-
fibers were located over the superior and inferior arte- drin, 1923; Hovelacque, 1927; Testut, 1931; Delmas
rial surfaces and connected by thin diagonal twigs, et al., 1933), which demonstrated only a very few
which ran along the anterior and posterior surfaces of renal nerves, not usually located in the adventitia of
the renal artery (Figs. 2A, 2B). A branch of the greater the proximal renal artery.
splanchnic nerve contributed directly to the renal It is classically accepted that the renal plexus com-
plexus in one of the 24 kidneys (4.1%), connecting to prises fibers coming from the celiac ganglion, aorti-
the intermediate and distal thirds of the artery. In corenal ganglion, lowest thoracic splanchnic nerve,
addition, some fibers arising from the superior mesen- first lumbar splanchnic nerve and aortic plexus
teric ganglia were observed on the superior proximal (Williams and Warwick, 1992). Although the contribu-
third of the artery in four of the 24 (16.66%). tion of a direct branch of the thoracic splanchnic
The renal plexus fibers ran over the superior and nerves to the renal plexus has been considered an
inferior surfaces of the renal artery toward the renal exception (Hovelacque, 1927; Mitchell, 1950b), this
hilum where they continued in the same orientation was found in one of the 24 cases studied here.
following the division of the hilar artery. All along their
course, the main superior and inferior fibers were con-
Renal Ganglia and Renal Arteries
nected by thin twigs that ran over the anterior and
posterior surfaces of the renal arteries (Figs. 1A, 2B, Our results showed that the inferior part of the celiac
2A,and 2B). ganglion is located over the superior surface of the renal
Additional small ganglia (between one and four in artery, and the renal part of the aorticorenal ganglion is
number) of different shapes and sizes were also iden- in contact with the anterior surface of the renal artery,
tified along the renal plexus in 21 (87.5%) of the 24 as previously described (Petit-Dutaillis and Flandrin,
cases. There was no clear way to classify the locations 1923; Legueu and Flandrin, 1923; Hovelacque, 1927;
of these ganglia; however, in all 21, one (n 5 17; Testut, 1931; Delmas et al., 1933; Mitchell, 1947;
70.83%) or two (n 5 4; 19.04%) were consistently Mitchell, 1950a; Norvell, 1968). Furthermore, our
found at the bifurcation of the anterior and posterior results showed that some fibers from two other, sepa-
branches of the hilar renal artery. rate renal ganglionic masses also contribute to the renal
plexus, one of them located on the inferior surface of
Accessory Renal Arteries and Renal Plexus the renal artery (Petit-Dutaillis and Flandrin, 1923) and
the other (Hirschfeld’s ganglion) posterior to that artery
There were variations in the renal arteries in 10 of (Legueu and Flandrin, 1923; Testut, 1931; Hovelacque,
the 24 cases (41.66%). These were found in five 1927; Delmas et al., 1933; Mitchell, 1947; Mitchell,
males and five females, with seven on the right side 1950a). This posterior renal ganglion is considered to
and three on the left. Interestingly, eight of these var- be where the lesser and lowest thoracic splanchnic
 Renal Sympathetic Nerves 663

nerves end, together with the uppermost lumbar (Mitchell, 1950a). We observed these small ganglia at
splanchnic nerve (Mitchell, 1950b). the bifurcation of the hilar renal artery in 70.83% of
The inferior and posterior renal ganglia have been cases, where the nerves divided to follow the anterior
reported as contributing to the aorticorenal ganglion and posterior renal artery branches. Although, we could
(Petit-Dutaillis and Flandrin, 1923; Norvell, 1968). not find small ganglia macroscopically in 12.5% of
The inconsistent presence of the posterior ganglion in cases, microscopic ganglia could have been present. It
the current study (70.83% of cases), the variability in remains unknown whether the additional ganglia were
the position of the aorticorenal ganglion in relation to sympathetic or parasympathetic.
the renal artery’s junction with the aorta (Norvell,
1968), and the fusion of both ganglia (inferior and Accessory Renal Arteries and Renal Plexus
posterior) in 12.5% of cases, make it plausible that
these three renal ganglionic masses (aorticorenal and Renal artery anatomy and its variations are impor-
inferior and posterior renal) are parts of a larger, com- tant for determining patient eligibility for the catheter-
mon aorticorenal ganglion. based denervation technique (Mitchell, 1947; Mahfoud
Interestingly, in the current study, a complete et al., 2013; Okada et al., 2015). First, the arteries
fiber-ganglionic ring encircling the entire renal artery need to be of adequate diameter and length, based on
was found in 29% of cases. This was formed by fibers the dimensions of the instrumentation. This will
from the lowest part of the celiac ganglion and the become a handicap in respect of accessing the seg-
three renal ganglionic masses being interconnected by mental arteries or smallest polar vessels (Id et al.,
thick strands of fibers around the artery. This gangli- 2013). Secondly, the number and arrangement of
onic ring could be considered a target for renal dener- renal arteries determine the success of the procedure
vation. However, it is anatomically interconnected because of their relationships with the surrounding
with the superior mesenteric ganglion, the contralat- nerves (Id et al., 2013; Mendelsohn, 2014).
eral aorticorenal ganglion, the lumbar sympathetic Renal arterial variations are reported with an inci-
chain, and the thoracic splanchnic nerves. Therefore, dence ranging from 20% to 28% of cases (Christensen
since it conveys fibers not only to the kidney but also et al., 1951; Merklin and Michels, 1958; Ozkan€ et al.,
to other abdominal organs, undesirable side-effects 2006; Kaneko et al., 2008; Id et al., 2014). The current
could occur after ablation intended purely for the renal study showed a higher incidence: 41.66%. Among the
sympathetic nerves. general variability of the renal arteries, an important
aspect to be considered is the presence of arteries that
arrive directly at the parenchyma of the renal poles
Renal Plexus, Renal Arteries, and Small (polar arteries). We report polar arteries in 33% of the
Ganglia kidneys studied, 29% being superior, and 4.1% inferior.
The renal plexus conveys both sympathetic and par- Most of them (50%) originated from the anterior
asympathetic fibers (Mitchell, 1950a; Mitchell, 1951). branch of the hilar renal artery. Of the remainder, 25%
The classical description of the renal plexus is that the originated from the hilar renal artery, 12.5% from seg-
nerves course over just the superior surface of the mental branches, and 12.5% from the aorta. Our
results showed that both accessory and polar arteries
renal artery (Petit-Dutaillis and Flandrin, 1923; Hove-
were surrounded by fibers from the renal plexus, run-
lacque, 1927; Mitchell, 1947; Mitchell, 1950a; Mitchell,
ning, as in the hilar arteries, on the superior and inferior
1951; Mitchell, 1956) or both its superior and inferior
surfaces of the arteries interconnected by thin twigs.
surfaces (Legueu and Flandrin, 1923; Testut, 1931).
In summary, the renal plexus along the hilar
Other studies have described these nerves coursing on
arteries is made up of: (a) a fiber-ganglionic ring
the anterior and posterior surfaces of the artery (Petit-
around the proximal third of the renal artery, (b) a
Dutaillis and Flandrin, 1923; Hovelacque, 1927; Del-
neural network along the middle and distal thirds of
mas et al., 1933; Mitchell, 1950a). The current results
the renal artery, and (c) small accessory ganglia.
showed that long nerves arising from the fiber-
The neural network consists of fibers mainly
ganglionic mass run lateral toward the renal hilum and
located on the superior and inferior surfaces of the
branch along the segmental arteries, mainly over the
renal arteries interconnected by diagonal fibers on the
superior and inferior surfaces of the arteries. These are
anterior and posterior arterial faces. The polar arteries
interconnected by a very few thin vertical and diagonal
also carry nerve fibers to the kidney in a similar way
fibers to make up a complex neural network surround- to the hilar arteries. Most of the superior polar arteries
ing the renal artery. In addition to the more usual pat- originate in the anterior branch of the hilar renal
tern described above, there were cases in which nerve artery. Therefore, to perform effective renal denerva-
fibers arose from other sources. Contributions were tion, it would be necessary to target the superior and
observed from thoracic splanchnic nerve branches, inferior surfaces of the hilar arteries and, where pres-
which directly joined the plexus after coursing the mid- ent, the polar arteries.
dle third of the artery (4.1%), and from the ipsilateral
and contralateral superior mesenteric ganglia, proxi-
mal to the plexus in 16.6% of cases. ACKNOWLEDGMENTS
It has previously been reported that additional small
ganglia in the renal plexus are always present in adult The authors gratefully thank all the body donors and
subjects (Hovelacque, 1927; Mitchell, 1950ab), located their families. This work was made possible by their
mostly on the branches where the nerves unite or divide selfless gifts.
664 Mompeo et al.

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