Post on 26-Jun-2020
11/27/2018
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11TH ANNUAL VASCULAR NONINVASIVE TESTING
SYMPOSIUMNOVEMBER 10, 2018
RENAL ARTERY DISEASE AND RENOVASCULAR HYPERTENSION
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WHAT IS RENOVASCULAR HYPERTENSION?
https://my.clevelandclinic.org/health/diseases/16459-renovascular-hypertension
RENAL ARTERY STENOSIS ~ RENOVASCULAR HTN
https://my.clevelandclinic.org/health/diseases/16459-renovascular-hypertension
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ATHEROSCLEROSIS, OR HARDENING OF THE ARTERIES, IS THE MOST
COMMON CAUSE OF RENAL ARTERY STENOSIS
CRITERIA FOR DIAGNOSIS OF RENAL ARTERY STENOSIS
BROAD CATEGORIES BASED UPON RENAL AND AORTA PSV:
0-59% STENOSIS: RENAL PSV < 200 CM/SECRENAL-AORTIC RATIO (RAR) < 3.5
60-99% STENOSIS: RENAL PSV > 200 CM/SECRAR > 3.5> 80% STENOSIS IF EDV >150 CM/SEC
OCCLUDED ABSENT FLOW
SENSITIVITY 84-98%; SPECIFICITY 62-99% VARIABLE BYPUBLISHED SERIES
Slide provided by Heather Gornik MD
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PERFORMANCE OFRENAL DUPLEX ULTRASOUND FOR DIAGNOSIS
OF RAS
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•Olin JW, et al. Ann Intern Med 1995;122:833
Slide provided by Heather Gornik MD
RESISTIVE INDEX (RI)
RI = PSV-EDV/PSV=19-5.3/19=0.72
Slide provided by Heather Gornik MD
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NORMAL VS. HIGH RESISTIVE RENAL DOPPLER SIGNALS
RI=0.54RI=0.82
Normal Signal High Resistive Signal
Unhealthy kidney!
Slide provided by Heather Gornik MD
ONE MORE PARAMETER: ACCELERATION TIME
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•Slide provided by Heather Gornik MD
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DUPLEX EVALUATION FORRENAL ARTERY STENOSIS
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•Slide provided by Heather Gornik, MD
USE CAUTION WITH RAR WHEN AORTIC VELOCITY IS NOT NORMAL
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RENAL ARTERY STENOSIS
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•Slide provided by Esther Soo Hyun Kim MD
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LRA STENT
Instent stenosis > 80% EDV > 150
RAR 6.2
Normal Renal Aortic Ratio is < 3.5
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Patent Bilateral Stent
INTERPRETATION FOR STENTED RENAL ARTERY
OUR LAB CURRENTLY FOLLOWS THE CRITERIA DISCUSSED EARLIER WHENEVALUATING STENTING IN AN ISOLATED RENAL ARTERY.
PSV < 200 CM/SEC (RAR) < 3.5 0-59% STENOSIS
PSV >200 CM/SEC (RAR) > 3.5 60-99% STENOSIS
> 80% STENOSIS IF EDV >150 CM/SEC
STENTS, VELOCITIES MAY BE ELEVATED WITHIN A WIDELY PATENT STENT. IF NOPOST-STENOTIC TURBULENCE IS NOTED. REPORT: PATENT. ELEVATED VELOCITIES NOTED WITHIN THE STENT, BUT NOTURBULENCE SEEN.
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RENAL DISEASE IN THE VASCULAR LAB
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FIBROMUSCULAR DYSPLASIA “FMD”
WHAT IS FMD? PATHOLOGICALCLASSIFICATIONS
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CRITERIA FOR DIAGNOSIS OF RENAL ARTERY FMD
TURBULENT FLOW AND ELEVATED VELOCITIES AT
MID OR DISTAL VESSEL ARE EVIDENCE OF
FIBROMUSCULAR DYSPLASIA
BeadingString of beads appearance
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ANGIOGRAPHY
Slide provided by www.emorypulse.com
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WHO IS OUR FMD PATIENT?
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•Slide provided by Heather Gornik MD
SAME DAY ADD-ON
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INITIAL SCAN
INTERPRETATION
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VASCULAR SURGERY CONSULT
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Decubitus LRA
Repeat study Fasting
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TWO RRAS??
Decubitus Position
CT W/CONTRAST
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DUS & CT RESULTS
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CO2 ANGIOGRAPHY LRA PTA
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RRA BALLOON X2MID NARROWING /
POST DILATATIONPATENT POST BALLOONING
TWO MONTH POST PTA LRA
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2 MONTH POST PTA RRA
No change in right renal artery: 60-99% stenosis; EDV may suggest greater than 80% stenosis.Left renal artery: is now 0-59% stenosis.Patient to return for six month follow up DUS
RRA >80% stenosis
Abnormal RI
4 months later ~ 6 mo f/uNO REAL CHANGERight renal artery: 60-99% stenosis; EDV may suggest greater than 80% stenosis.Vessel bifurcates at mid.Recommended repeat PTA of the RRA
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CO2 ANGIOGRAPHY W/PTABASED ON VAS LAB FINDINGS
RIGHT RENAL ARTERY
STENOSIS OF ABOUT 80%
WITH A GOOD
RESOLUTION FOLLOWING
SERIAL BALLOON
ANGIOPLASTIES
ONE MONTH S/P 2ND RRA PTA
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SUCCESS !!!!
RENAL ARTERY ANEURYSM “RAA”
• Rare
• Asymptomatic
• Usually found incidentally on other imaging
• Common in women age 40-60
• Can be associated with atherosclerosis, hypertension, and Fibromuscular Dysplasia (FMD)
• Rupture can be fatal
• Can experience abdominal pain
• 98% occur outside of the kidney
http://health.clevelandclinic.org/2012/12/renal-aneurysm
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TREATMENT
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STENTING & COIL EMBOLIZATION
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ARTERIOVENOUS FISTULA VS ARTERIOVENOUS MALFORMATION OF THE KIDNEY
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WHO IS OUR PATIENT
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NORMAL AORTIC VELOCITY
COLOR DOPPLER ALIASING
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POWER ANGIO BEADING???
DILATED LRV W/ TURBULENCE
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Fistula Signal
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VAS LAB INTERPRETATION
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CT SCAN
RECONSTRUCTED CTA
AP VIEW PA VIEW
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CT RESULTS OFLEFT KIDNEY
TREATMENT
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CO2 ANGIOGRAPHY W/ COIL EMBOLIZATION
Successful Post coil embolization
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RENAL AVM AND AVF
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BOTTOM LINE
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DUPLEX ULTRASOUND
REFERENCES
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1931
THANK YOU
JEAN STARR MD, RPVIDENNIS KISER BS, RVT
HEATHER GORNIK MD, RPVI