How to assess the hemodynamic importance of a renal artery stenosis. Felix Mahfoud, MD Saarland University Hospital Homburg/Saar, Germany
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1 How to assess the hemodynamic importance of a renal artery stenosis Felix Mahfoud, MD Saarland University Hospital Homburg/Saar, Germany
2 How to assess renal artery stenosis severity 1. Non-invasive assessments - Duplex ultrasound 2. Invasive assessments - Pressure gradient - Pd/Pa - Frame count
3 Duplex ultrasound Renal resistive indices Acceleration time Renal-aortic flow velocity ratio (RAR) Peak systolic flow velocity
4 Duplex ultrasound Renal resistive indices Acceleration time Renal-aortic flow velocity ratio (RAR) Peak systolic flow velocity
5 Renal Artery Duplex ultrasound - AT A T AT: enddiastolic peak systolic
6 Renal Artery Duplex ultrasound - AT Three measurements at the edge between pelvis and parenchyma at three different locations Radermacher J, Clin Nephrol 2000
7 Renal Artery Duplex ultrasound - AT Normal Doppler-signal AT <0.07 sec Post-stenotic Doppler-signal Three measurements at the edge between pelvis and parenchyma at three different locations Radermacher J, Clin Nephrol 2000 AT >0.07 sec
8 Renal Artery Duplex ultrasound - RRI To calculate RRI you need to measure: systolic peak velocity (A) enddiastolic velocity (B) RRI = (V max sys V max enddiast) / V max sys
9 Renal Artery Duplex ultrasound - RRI Impacted by Age Medication Heart rate Stroke volumen AV-Fistula...
10 Renal Artery Duplex ultrasound - RRI Impacted by Age Medication Heart rate Stroke volumen AV-Fistula... The side-difference of the RI >0.05 is the crucial point in the diagnosis of a significant unilateral RAS not the absolute value!
11 Renal Artery Duplex ultrasound - RRI RRI and AT determine significant RAS (>70%): δrri >0.05 AT >0.07 sec
12 Radermacher J, NEJM 2001
13 Revascularization of RAS with RRI >0.8 was not associated with improved renal function or blood pressure control Radermacher J, NEJM 2001
14 Invasive Assessment - Pressure gradient - Pd/Pa - Frame count
15
16 Percent Increase in Renin What is a significant renal 500 artery stenosis? DeBruyne B, JACC (BL1) 1 (BL 2) (End) Degree of Stenosis (P d /P a )
17 pcronline
18 Resting and hyperemic pressure gradients, FFR and renin activation Kapoor N, Cath Cardiovasc Interv 2010
19 Resting and hyperemic pressure gradients, FFR and renin activation Kapoor N, Cath Cardiovasc Interv 2010
20 Renal frame count Still frame images obtained at 30 frames/s. First frame is counted with complete transverse opacification of the renal artery. Final frame being the identification of a cortical vessel in a relatively straight line. This subject had a renal frame count of 18 (normal). Mahmud E, JACC Cardiovasc Interv 2008 Courtesy of Thomas Zeller
21 Renal frame count in controls, pre- and post-stent implantation RFC in the control group (n=17; 22 kidneys) without renal artery stenosis, and in the study group (n=24) before and after renal stenting for atherosclerotic renal artery stenosis. Mahmud E, JACC Cardiovasc Interv 2008
22 Prediction of improved blood pressure control after stenting of unilateral RAS 6 month-fu SBP: 151 ± 16 mmhg 129 ± 15 mmhg, P<0.001 DBP: 77 ± 16 mmhg 68 ± 10 mmhg, P=0.022 No change in antihypertensive drug regimen Mahmud E, JACC Cardiovasc Interv 2008
23 Prediction of improved blood pressure control after stenting of unilateral RAS 6 month-fu SBP: 151 ± 16 mmhg 129 ± 15 mmhg, P<0.001 DBP: 77 ± 16 mmhg 68 ± 10 mmhg, P=0.022 No change in antihypertensive drug regimen Drop in RFC: Blood pressure responder: 7.7 ± 4.6 vs. Non-responders: 1.7 ± 5.1; P= % of pts. with drop in RFC >4 were responders (P=0.024) Mahmud E, JACC Cardiovasc Interv 2008
24 How to determine hemodynamically relevant renal artery stenosis Summary Duplex sonography including the measurement of RRI and AT is a valid method of choice for assessment of RAS severity AT >70 ms and drri >0.05 are reliable indicators of significant unilateral RAS If drri is <RRI 0.05 but bilateral ACT >100 ms, bilateral significant RAS are present
25 How to determine hemodynamically relevant renal artery stenosis Summary Revascularization of RAS is meaningful if the pressure gradient ratio is Pd/Pa ratio <0.90 ( Δ 20 mmhg) This ratio correlates with an angiographic diameter stenosis of >70% The ratio correlates with duplex-derived RRI
26 Thank you! Felix Mahfoud, MD Cardiology, Angiology, Intensive Care Medicine Saarland University Hospital Homburg/Saar, Germany Tel Fax felix.mahfoud@uks.eu
27 The Global Education Course for Vascular Medicine and Intervention November 2-5, 2015 Wynn Las Vegas Rich Educational Content Beyond the Meeting
28 How to assess the hemodynamic importance of a renal artery stenosis Felix Mahfoud, MD Saarland University Hospital Homburg/Saar, Germany
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