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

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

C
V 2016 Wiley Periodicals, Inc.

Fig. 1. The renal sympathetic renal plexus of a right
kidney. A: Anterior view and (B) posterior view. A fibro-
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
interconnected along the distal two thirds of the artery.
Ag (adrenal gland), Arg (aorticorenal ganglion), Coe
(coeliac ganglion), CoT (coeliac trunk), Ig (renal infe-
rior ganglion), LC (contribution of the lumbar chain to
the renal plexus), Pg(renal posterior ganglion), RK
(right kidney), SMg (superior mesenteric ganglion), SP
(Thoracic splanchnic nerves), * (connection between
ganglia).
2014), variations in the renal arteries (Rimoldi et al.,
2014; Okada et al., 2015), or aberrant reinnervation
by sympathetic fibers post-ablation (Booth et al.,
2015). Several recent studies that support catheter-
based renal denervation techniques have used immu-
nohistochemical methods to describe the location and
density of nervous fibers around the renal artery
(Atherton et al., 2011; Tellez et al., 2013; Sakakura
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.
MATERIALS AND METHODS
Twelve embalmed cadavers (six males and six
females; age range: 73–94 years) were included in
this investigation. A total of 24 kidneys were studied.
The cadavers belonged to the Department of Anatomy
and Embryology and were obtained following the legal
procedures governing the donation of bodies.
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
plexus, small ganglia, and distal renal artery; and (3)
accessory arteries and renal nerve fibers.
Renal Ganglia and Proximal Renal Arteries
A fiber-ganglionic mass was found to encircle the
medial third of the main hilarrenal arteries (n 5 24).
This mass comprised the celiac ganglion (100% of
cases), the aorticorenal ganglion (100%), the inferior
renal ganglion (95.83, and the posterior renal gan-
glion (70.83%). Short and thick nerve fiber strands
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
single mass in 15 of the 24 cases (62.5%). The aorti-
corenal ganglion was always connected to the inferior
renal ganglion by one to three thick neural bands that
crossed over the anterior surface of the medial third
of the renal artery (Fig. 1A).
The inferior renal ganglion was located over the
inferior surface of the renal arteries and connected to
the posterior renal ganglion (Figs. 1A, 1B, and 2B).
Fig. 2. Schematic drawing of the renal sympathetic
plexus of a right kidney. A: anterior view and (B) posterior
view. Arg (aorticorenal ganglion), Coe (coeliac ganglion),
Cof (Connection Fibers), CoT (Coeliac artery), Dsf (Distal
superior Fibers), GSP (great splanchnic nerve), Ig (infe-
rior ganglion), Inf (inferior Fibers), LC (contribution of the
lumbar chain to the renal plexus), LSP (lesser splanchnic
nerve), Pg (renal posterior ganglion), RK (right kidney),
Smg (superior mesenteric ganglion), Sp (lower splanch-
nic nerve).
662 Mompeo et al.
The inferior ganglion joined with the posterior gan-
glion to form a single ganglionic mass in three of the
24 cases (12.5%). The inferior renal ganglion received
fibers from the sympathetic lumbar chain, interme-
senteric nerves, and superior mesenteric ganglion
(Figs. 1A, 1B, 2A, and 2B).
The posterior renal ganglion, named by the classi-
cal authors as Hirschfeld’s ganglion, was identified as
an irregular mass on the posterior surface of the renal
artery in a total of 17 cases. This ganglion was located
in various anatomical relationships to the renal artery.
In 9 of the 17 cases (52.94%), it was located on the
medial third of the renal artery (two on the right side
and seven on the left) and in seven cases (41.17%) it
was located on the intermediate third of the renal
artery, on the right side only. In one case (5.88%) the
ganglion covered both the medial and intermediate
thirds of the artery. The lesser and lowest thoracic
splanchnic nerves were connected to the posterior
renal ganglion in 11 of the 24 kidneys (45.83%).
Renal Plexus, Renal Arteries, and Small
Ganglia
The renal plexus was composed of nerve fibers
coming from the celiac ganglion, inferior and posterior
renal ganglia, superior mesenteric ganglion and tho-
racic splanchnic nerves.
Most of the plexus was located around the interme-
diate and distal thirds of the renal artery. Its main
fibers were located over the superior and inferior arte-
rial surfaces and connected by thin diagonal twigs,
which ran along the anterior and posterior surfaces of
the renal artery (Figs. 2A, 2B). A branch of the greater
splanchnic nerve contributed directly to the renal
plexus in one of the 24 kidneys (4.1%), connecting to
the intermediate and distal thirds of the artery. In
addition, some fibers arising from the superior mesen-
teric ganglia were observed on the superior proximal
third of the artery in four of the 24 (16.66%).
The renal plexus fibers ran over the superior and
inferior surfaces of the renal artery toward the renal
hilum where they continued in the same orientation
following the division of the hilar artery. All along their
course, the main superior and inferior fibers were con-
nected by thin twigs that ran over the anterior and
posterior surfaces of the renal arteries (Figs. 1A, 2B,
2A,and 2B).
Additional small ganglia (between one and four in
number) of different shapes and sizes were also iden-
tified along the renal plexus in 21 (87.5%) of the 24
cases. There was no clear way to classify the locations
of these ganglia; however, in all 21, one (n 5 17;
70.83%) or two (n 5 4; 19.04%) were consistently
found at the bifurcation of the anterior and posterior
branches of the hilar renal artery.
Accessory Renal Arteries and Renal Plexus
There were variations in the renal arteries in 10 of
the 24 cases (41.66%). These were found in five
males and five females, with seven on the right side
and three on the left. Interestingly, eight of these var-
iations included polar arteries (33.33%; in five males
and three females).
Five of the polar arteries were on the right side and
three on the left. In a single case, this was an inferior
polar artery that arose directly from the aorta, while
the rest were all superior polar arteries. Of the seven
superior polar arteries, two arose from the hilar renal
artery, four from the renal anterior branch from the
renal artery and one from a segmental artery.
Regarding arterial variation, it was observed that if
more than one hilar artery was present, some nerves
crossed the faces of the main renal artery to the acces-
sory arteries. The nervous fibers associated with the
accessory arteries arose from the same ganglia as
those associated with the main renal artery. They also
had the same course and the same relationship to the
artery, with the main fibers running over the superior
and inferior surfaces and interconnected by thin fibers.
DISCUSSION
The anatomical basis of the catheter-based tech-
nique for renal sympathetic innervation is the proxim-
ity of numerous renal sympathetic nerves to the
lumen of the renal arteries, as demonstrated by histo-
logical and immunological studies (Atherton et al.,
2011; Tellez et al., 2013; Tzafriri et al., 2014; Saka-
kura et al., 2014). However, this conflicts with the dis-
section studies from the first part of the 20th century
(Petit-Dutaillis and Flandrin, 1923; Legueu and Flan-
drin, 1923; Hovelacque, 1927; Testut, 1931; Delmas
et al., 1933), which demonstrated only a very few
renal nerves, not usually located in the adventitia of
the proximal renal artery.
It is classically accepted that the renal plexus com-
prises fibers coming from the celiac ganglion, aorti-
corenal ganglion, lowest thoracic splanchnic nerve,
first lumbar splanchnic nerve and aortic plexus
(Williams and Warwick, 1992). Although the contribu-
tion of a direct branch of the thoracic splanchnic
nerves to the renal plexus has been considered an
exception (Hovelacque, 1927; Mitchell, 1950b), this
was found in one of the 24 cases studied here.
Renal Ganglia and Renal Arteries
Our results showed that the inferior part of the celiac
ganglion is located over the superior surface of the renal
artery, and the renal part of the aorticorenal ganglion is
in contact with the anterior surface of the renal artery,
as previously described (Petit-Dutaillis and Flandrin,
1923; Legueu and Flandrin, 1923; Hovelacque, 1927;
Testut, 1931; Delmas et al., 1933; Mitchell, 1947;
Mitchell, 1950a; Norvell, 1968). Furthermore, our
results showed that some fibers from two other, sepa-
rate renal ganglionic masses also contribute to the renal
plexus, one of them located on the inferior surface of
the renal artery (Petit-Dutaillis and Flandrin, 1923) and
the other (Hirschfeld’s ganglion) posterior to that artery
(Legueu and Flandrin, 1923; Testut, 1931; Hovelacque,
1927; Delmas et al., 1933; Mitchell, 1947; Mitchell,
1950a). This posterior renal ganglion is considered to
be where the lesser and lowest thoracic splanchnic

nerves end, together with the uppermost lumbar
splanchnic nerve (Mitchell, 1950b).
The inferior and posterior renal ganglia have been
reported as contributing to the aorticorenal ganglion
(Petit-Dutaillis and Flandrin, 1923; Norvell, 1968).
The inconsistent presence of the posterior ganglion in
the current study (70.83% of cases), the variability in
the position of the aorticorenal ganglion in relation to
the renal artery’s junction with the aorta (Norvell,
1968), and the fusion of both ganglia (inferior and
posterior) in 12.5% of cases, make it plausible that
these three renal ganglionic masses (aorticorenal and
inferior and posterior renal) are parts of a larger, com-
mon aorticorenal ganglion.
Interestingly, in the current study, a complete
fiber-ganglionic ring encircling the entire renal artery
was found in 29% of cases. This was formed by fibers
from the lowest part of the celiac ganglion and the
three renal ganglionic masses being interconnected by
thick strands of fibers around the artery. This gangli-
onic ring could be considered a target for renal dener-
vation. However, it is anatomically interconnected
with the superior mesenteric ganglion, the contralat-
eral aorticorenal ganglion, the lumbar sympathetic
chain, and the thoracic splanchnic nerves. Therefore,
since it conveys fibers not only to the kidney but also
to other abdominal organs, undesirable side-effects
could occur after ablation intended purely for the renal
sympathetic nerves.
Renal Plexus, Renal Arteries, and Small
Ganglia
The renal plexus conveys both sympathetic and par-
asympathetic fibers (Mitchell, 1950a; Mitchell, 1951).
The classical description of the renal plexus is that the
nerves course over just the superior surface of the
renal artery (Petit-Dutaillis and Flandrin, 1923; Hove-
lacque, 1927; Mitchell, 1947; Mitchell, 1950a; Mitchell,
1951; Mitchell, 1956) or both its superior and inferior
surfaces (Legueu and Flandrin, 1923; Testut, 1931).
Other studies have described these nerves coursing on
the anterior and posterior surfaces of the artery (Petit-
Dutaillis and Flandrin, 1923; Hovelacque, 1927; Del-
mas et al., 1933; Mitchell, 1950a). The current results
showed that long nerves arising from the fiber-
ganglionic mass run lateral toward the renal hilum and
branch along the segmental arteries, mainly over the
superior and inferior surfaces of the arteries. These are
interconnected by a very few thin vertical and diagonal
fibers to make up a complex neural network surround-
ing the renal artery. In addition to the more usual pat-
tern described above, there were cases in which nerve
fibers arose from other sources. Contributions were
observed from thoracic splanchnic nerve branches,
which directly joined the plexus after coursing the mid-
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.
It has previously been reported that additional small
ganglia in the renal plexus are always present in adult
subjects (Hovelacque, 1927; Mitchell, 1950ab), located
mostly on the branches where the nerves unite or divide
Renal Sympathetic Nerves 663
(Mitchell, 1950a). We observed these small ganglia at
the bifurcation of the hilar renal artery in 70.83% of
cases, where the nerves divided to follow the anterior
and posterior renal artery branches. Although, we could
not find small ganglia macroscopically in 12.5% of
cases, microscopic ganglia could have been present. It
remains unknown whether the additional ganglia were
sympathetic or parasympathetic.
Accessory Renal Arteries and Renal Plexus
Renal artery anatomy and its variations are impor-
tant for determining patient eligibility for the catheter-
based denervation technique (Mitchell, 1947; Mahfoud
et al., 2013; Okada et al., 2015). First, the arteries
need to be of adequate diameter and length, based on
the dimensions of the instrumentation. This will
become a handicap in respect of accessing the seg-
mental arteries or smallest polar vessels (Id et al.,
2013). Secondly, the number and arrangement of
renal arteries determine the success of the procedure
because of their relationships with the surrounding
nerves (Id et al., 2013; Mendelsohn, 2014).
Renal arterial variations are reported with an inci-
dence ranging from 20% to 28% of cases (Christensen
et al., 1951; Merklin and Michels, 1958; Ozkan€ et al.,
2006; Kaneko et al., 2008; Id et al., 2014). The current
study showed a higher incidence: 41.66%. Among the
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
(polar arteries). We report polar arteries in 33% of the
kidneys studied, 29% being superior, and 4.1% inferior.
Most of them (50%) originated from the anterior
branch of the hilar renal artery. Of the remainder, 25%
originated from the hilar renal artery, 12.5% from seg-
mental branches, and 12.5% from the aorta. Our
results showed that both accessory and polar arteries
were surrounded by fibers from the renal plexus, run-
ning, as in the hilar arteries, on the superior and inferior
surfaces of the arteries interconnected by thin twigs.
In summary, the renal plexus along the hilar
arteries is made up of: (a) a fiber-ganglionic ring
around the proximal third of the renal artery, (b) a
neural network along the middle and distal thirds of
the renal artery, and (c) small accessory ganglia.
The neural network consists of fibers mainly
located on the superior and inferior surfaces of the
renal arteries interconnected by diagonal fibers on the
anterior and posterior arterial faces. The polar arteries
also carry nerve fibers to the kidney in a similar way
to the hilar arteries. Most of the superior polar arteries
originate in the anterior branch of the hilar renal
artery. Therefore, to perform effective renal denerva-
tion, it would be necessary to target the superior and
inferior surfaces of the hilar arteries and, where pres-
ent, the polar arteries.
ACKNOWLEDGMENTS
The authors gratefully thank all the body donors and
their families. This work was made possible by their
selfless gifts.
664 Mompeo et al.
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