RENAL ARTERY ULTRASOUND RENAL DUPLEX ULTRASONOGRAPHY RENAL ARTERY ULTRASOUND RENAL ARTERY ULTRASOUND RENAL ARTERY ULTRASOUND RENAL ARTERY ULTRASOUND

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1 RENAL DUPLEX ULTRASONOGRAPHY Phiip J Bendick, PhD RVT Vascuar Sonography Education Rena Artery Stenosis I. Direct Of a patients with hypertension, ony 2 4% have hypertension 2o rena artery stenosis Netter iustration from Esevier Inc. A rights reserved III. Parenchyma Netter iustration from Esevier Inc. A rights reserved Netter iustration from Esevier Inc. A rights reserved 1

2 Rena Artery Stenosis Direct - Proxima rena artery Patient preparation Morning examinations Light mea the night before NPO after midnight NO smoking or gum chewing the morning of the examination Patient preparation Hydrate Hydrate Hydrate!! Aortic PSV: cm/s Rena Artery Stenosis - Technique Direct - Proxima rena artery Anterior approach Rena Artery Stenosis - Technique Direct - Proxima rena artery Don t strugge and frustrate yoursef If at first you don t succeed, move on!! 2

3 Rena Artery Stenosis - Technique Direct - Proxima rena artery Rena Artery Stenosis - Technique Direct - Proxima rena artery Obique Rt RA Fank approach Aorta and RA Origins Images courtesy of Patrick Meyers Images courtesy of Patrick Meyers Rena Artery Stenosis - Technique Direct - Proxima rena artery Don t hesitate to move the patient around Optimize your contros: B-mode gain, depth of view, coor gain and scae, Dopper sampe voume and gain, foca zones,... Coor Dopper Imaging PRF high: Differentiate arteria from venous fow Less aiasing Less coor fash Increase wa fiter Minimize ROI (higher frame rate) Zoom Rena Artery Stenosis - Technique Remember You ony get A Few Good Breaths Direct approach- Proxima rena artery Breath hoding technique: Stop breathing è Optimize contros before breath hod 3

4 Anterior approach: Technique Dopper Ange Anterior approach: Technique Dopper Ange Images courtesy of Patrick Meyers Anguated probe Images courtesy of Patrick Meyers Origin Rena Artery Norma Rena Artery Origin Sharp systoic upstroke Sustained diastoic fow Rena Artery Stenosis Hemodynamicay significant Measurabe pressure drop Approximate 60% diameter reduction Rena Artery Stenosis (> 60%) Veocity Ratio RAR > 3.5 Absoute Veocity PSV > 200 cm/sec 4

5 RAR 4.1 Rena Rena Artery Stents Rena Artery Stents Artery Stenosis: Proxima rena artery Foca veocity acceeration Post-stenotic turbuence Rena Artery Stents Fibromuscuar Dyspasia Of patients with Fibromuscuar Dyspasia: 90% femae Age at onset years Typica age at diagnosis ~ 50 years 5

6 Fibromuscuar Dyspasia Fibromuscuar Dyspasia Of patients with Fibromuscuar Dyspasia: 60-75% with rena artery invovement 35% biatera 60-75% carotid artery invovement 10-20% iiac artery invovement 30-40% with invovement of mutipe vascuar beds Fibromuscuar Dyspasia Of patients with renovascuar hypertension: ~ 10% secondary to FMD Invoves dista rena artery String of beads appearance Oin, NEJM 2004 Fibromuscuar Dyspasia PRE Images courtesy of: Mike Ledwidge, RDMS RVT University of Wisconsin Fibromuscuar Dyspasia Images courtesy of: Mike Ledwidge, RDMS RVT University of Wisconsin Fibromuscuar Dyspasia MID POST Images courtesy of: Mike Ledwidge, RDMS RVT University of Wisconsin Images courtesy of: Mike Ledwidge, RDMS RVT University of Wisconsin 6

7 When the direct approach works - Netter iustration from Esevier Inc. A rights reserved Netter iustration from Esevier Inc. A rights reserved Segmenta Interobuar Arteries Arcuate Interobar Segmenta Indirect - Technique Set scae for arge spectra dispay Low PRF Lower baseine Increase Dopper gain Large sampe voume Increase sweep speed as needed No ange correction needed 7

8 Rena Artery Stenosis Segmenta artery Eary Systoic Peak absent Rena Artery Stenosis Segmenta artery Eary Systoic Peak absent Sowed Systoic Rise Time Abnorma: Systoic Rise Time (AT) > sec Damped waveform Rena Artery Stenosis: Caveats Proxima rena artery Rena artery occusion Rena artery occusion Rena Artery Stenosis: Caveats Proxima rena artery Accessory rena arteries Netter iustration from Esevier Inc. A rights reserved 8

9 Accessory rena arteries Accessory rena arteries Netter iustration from Esevier Inc. A rights reserved Netter iustration from Esevier Inc. A rights reserved III. Parenchyma Netter iustration from Esevier Inc. A rights reserved Netter iustration from Esevier Inc. A rights reserved Parenchyma - Technique Set scae for arge spectra dispay Low PRF Lower baseine Increase Dopper gain Large sampe voume No ange correction needed Arcuate arteries Renovascuar resistance?? 9

10 Renovascuar resistance = Norma < 0.7 Abnorma > 0.8 Systoic Diastoic Systoic Indirect Approach: Caveat Not reiabe if RI > 0.80 (Eary systoic peak and acceeration time exaggerated) Renovascuar resistance Dz progression (36 month f/u) < 0.80 > 0.80 Decreased rena fctn 9% 76% Diaysis dependent 5% 64% Death 1% 24% Renovascuar resistance > 0.80 Angiopasty / Stenting: No improvement in BP 97% No improvement in rena fctn 80% Do not forget the Rena Vein (Required for accreditation) 10

11 Rena Imaging: Chronic rena artery occusion Rena Imaging: Rena artery occusion N kidney ength 9 13 cm N cortex > 1 cm with uniform echogenicity Decreased kidney ength Cortica thinning Rena Imaging: Rena Imaging: Rena cysts Chronic rena artery occusion Rena cysts Simpe cyst Poycystic kidney disease Rena Imaging: Rena Imaging: Chronic rena artery occusion Rena cysts Rena stones 11

12 Rena Imaging: Soid rena masses: Chronic rena artery occusion Rena cysts Rena stones Rena mass Benign ~ 10% Rena ce carcinoma 70-75% Tumor? Assume rena ce carcinoma unti proven otherwise Rena Imaging: Rena mass Rena ce carcinoma Rena Imaging: Rena mass Rena ce carcinoma?? Rena Imaging: Rena mass Rena tumor - Transpant 12