11 TH ANNUAL VASCULAR NONINVASIVE TESTING SYMPOSIUM NOVEMBER 10, 2018

Transcription

1 11 TH ANNUAL VASCULAR NONINVASIVE TESTING SYMPOSIUM NOVEMBER 10, 2018 RENAL ARTERY DISEASE AND RENOVASCULAR HYPERTENSION 1

2 WHAT IS RENOVASCULAR HYPERTENSION? RENAL ARTERY STENOSIS ~ RENOVASCULAR HTN 2

3 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/SEC RENAL-AORTIC RATIO (RAR) < % STENOSIS: RENAL PSV > 200 CM/SEC RAR > 3.5 > 80% STENOSIS IF EDV >150 CM/SEC OCCLUDED ABSENT FLOW SENSITIVITY 84-98%; SPECIFICITY 62-99% VARIABLE BY PUBLISHED SERIES Slide provided by Heather Gornik MD 3

4 PERFORMANCE OF RENAL DUPLEX ULTRASOUND FOR DIAGNOSIS OF RAS 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 4

5 NORMAL VS. HIGH RESISTIVE RENAL DOPPLER SIGNALS Normal Signal High Resistive Signal RI=0.54 RI=0.82 Unhealthy kidney! Slide provided by Heather Gornik MD ONE MORE PARAMETER: ACCELERATION TIME Slide provided by Heather Gornik MD 5

6 DUPLEX EVALUATION FOR RENAL ARTERY STENOSIS Slide provided by Heather Gornik, MD USE CAUTION WITH RAR WHEN AORTIC VELOCITY IS NOT NORMAL 6

7 RENAL ARTERY STENOSIS Slide provided by Esther Soo Hyun Kim MD 7

8 LRA STENT Instent stenosis > 80% EDV > 150 RAR 6.2 Normal Renal Aortic Ratio is < 3.5 8

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10 Patent Bilateral Stent INTERPRETATION FOR STENTED RENAL ARTERY OUR LAB CURRENTLY FOLLOWS THE CRITERIA DISCUSSED EARLIER WHEN EVALUATING STENTING IN AN ISOLATED RENAL ARTERY. PSV < 200 CM/SEC (RAR) < % STENOSIS PSV >200 CM/SEC (RAR) > % STENOSIS > 80% STENOSIS IF EDV >150 CM/SEC STENTS, VELOCITIES MAY BE ELEVATED WITHIN A WIDELY PATENT STENT. IF NO POST-STENOTIC TURBULENCE IS NOTED. REPORT: PATENT. ELEVATED VELOCITIES NOTED WITHIN THE STENT, BUT NO TURBULENCE SEEN. 10

11 RENAL DISEASE IN THE VASCULAR LAB FIBROMUSCULAR DYSPLASIA FMD WHAT IS FMD? PATHOLOGICAL CLASSIFICATIONS 11

12 CRITERIA FOR DIAGNOSIS OF RENAL ARTERY FMD TURBULENT FLOW AND ELEVATED VELOCITIES AT MID OR DISTAL VESSEL ARE EVIDENCE OF FIBROMUSCULAR DYSPLASIA Beading String of beads appearance 12

13 ANGIOGRAPHY Slide provided by 13

14 WHO IS OUR FMD PATIENT? Slide provided by Heather Gornik MD SAME DAY ADD-ON 14

15 INITIAL SCAN INTERPRETATION 15

16 VASCULAR SURGERY CONSULT Decubitus LRA Repeat study Fasting 16

17 TWO RRAS?? Decubitus Position CT W/CONTRAST 17

18 DUS & CT RESULTS CO2 ANGIOGRAPHY LRA PTA 18

19 RRA BALLOON X2 MID NARROWING / POST DILATATION PATENT POST BALLOONING TWO MONTH POST PTA LRA 19

20 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/u NO REAL CHANGE Right renal artery: 60-99% stenosis; EDV may suggest greater than 80% stenosis. Vessel bifurcates at mid. Recommended repeat PTA of the RRA 20

21 CO2 ANGIOGRAPHY W/PTA BASED 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 21

22 SUCCESS!!!! RENAL ARTERY ANEURYSM RAA Rare Asymptomatic Usually found incidentally on other imaging Common in women age Can be associated with atherosclerosis, hypertension, and Fibromuscular Dysplasia (FMD) Rupture can be fatal Can experience abdominal pain 98% occur outside of the kidney 22

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24 TREATMENT STENTING & COIL EMBOLIZATION 24

25 ARTERIOVENOUS FISTULA VS ARTERIOVENOUS MALFORMATION OF THE KIDNEY WHO IS OUR PATIENT 25

26 NORMAL AORTIC VELOCITY COLOR DOPPLER ALIASING 26

27 POWER ANGIO BEADING??? DILATED LRV W/ TURBULENCE 27

28 Fistula Signal VAS LAB INTERPRETATION 28

29 CT SCAN RECONSTRUCTED CTA AP VIEW PA VIEW 29

30 CT RESULTS OF LEFT KIDNEY TREATMENT 30

31 CO2 ANGIOGRAPHY W/ COIL EMBOLIZATION Successful Post coil embolization 31

32 RENAL AVM AND AVF BOTTOM LINE 32

33 DUPLEX ULTRASOUND REFERENCES

34 1931 THANK YOU JEAN STARR MD, RPVI DENNIS KISER BS, RVT HEATHER GORNIK MD, RPVI 34