RENAL ARTERY DOPPLER

Objectives
Upon completion of the presentation the viewer should be able to:

Identify a normal renal artery signal. Describe Tardus-Parvus, RAR and Acceleration index. List causes for hypertension Outline a normal Renal Doppler exam

Table of Contents

Indications for a Renal Doppler Exam Renal Artery Stenosis Hypertension Anatomy & Variants Diagnostic Criteria Doppler waveform Exam Protocol Case Examples

Clinical Indications for Doppler

Evaluate a hypertensive patient for renal artery stenosis (RAS). Hypertensive patients not controlled with medical treatment. Patients with abdominal aortic dissection. Evaluation of renal transplant. Audible Bruit Patients with AAA

Renal Artery Stenosis:Causes

Atherosclerosis: Plaque deposits cause narrowing/blockage. Affects men > women Typically effects age >40 years Involves proximal aspect renal artery

Fibromuscular: Fibrous tissue growth in arterial walls.

Affects women > men ( approx.. 4: 1). Typically affects ages < 50 years

Involves mid to distal aspects of renal artery

Acute: Traumatic injury causing obstruction.

Hypertension and RAS

Relationship:

Renal Artery Stenosis causes hypertension.

Hypertension is the symptom that indicates RAS Doppler needed

Hypertension and RAS

Adrenal Gland

Kidney

Hypertension and RAS

RAS
Increased PR Decrease renal blood flow Production of rennin

Hypertension and RAS

Rennin converts angiotensinogen to angiotensin.

Angiotensin is a potent vasonstrictor.

Hypertension and RAS

Angiotensin also acts on the adrenal cortex to produce aldosterone. Aldosterone causes the kidney to absorbed more sodium and water.

Hypertension and RAS

This leads to increased in blood volume and also the BP.

Renal Artery Stenosis

Anatomy & Variants

Diagnostic Criteria

Doppler waveform
Exam Protocol

Case Examples

Renal Anatomy

Kidneys
Vessels

Accessory Vessels
Doppler Waveform

Normal Anatomy of the Kidneys

Size: 9-11cm Difference between Lt. & Rt. Renal Length < 2 cm

Normal Anatomy of the Kidneys

Normal Anatomy of the Kidneys

Celiac Axis
Rt Renal Artery Lt Renal Artery

Superior Mesenteric Artery Aorta

Segmental arteries Main Renal artery Interlobar arteries

Arcuate arteries

Normal Right and Left Renal Artery

Coronal View

Transverse

Normal Right Renal Artery

Transverse

Normal Left Renal Artery

Transverse

Renal Artery Stenosis

Normal Variants & Accessory Vessels

Normal Variants of Renal Arteries

Most common anatomy is single right and left renal artery (approx. 55% population)

Normal Variants of Renal Arteries

Second most common an is accessory renal artery branching off a main renal artery (14%)

Accessory Renal Arteries

Branch off a main renal artery or aorta.

Supply small portions of the renal parenchyma. Can be:

1) single or multiple 2) unilateral or bilateral

Accessory Renal Arteries

Accessory Renal Arteries

Can extend to upper, mid,or lower poles of kidney. Stenosis in an accessory can result in hypertension. Best evaluated in coronal plane with color Doppler.

Accessory Renal Arteries

Two Left Renal Arteries

The Normal Renal Waveform

Low resistant waveform.

Rapid and steep upstroke during systole. Dicrotic notch. Low resistant runoff during diastole.

The Normal Renal Waveform

RAS Exam

Diagnostic Criteria Protocol Example of normal Exam

Diagnostic Criteria

Color Doppler non-visualization Peak Systolic Velocity RAR Acceleration time Acceleration Index End Diastolic Ratios Tardus Parvus

Diagnostic Criteria

Peak Systolic Velocity

Normal >1.8 m/sec

Low grade(1-59%)>1.8 m/sec

No post-stenotic disturbance Post-stenotic turbulence

High grade(60-99%)>1.8 m/sec

Total occlusion - no flow

Peak Systolic Velocity

Peak Systolic Velocity

Remember all angles MUST be 60 degrees or less!

Renal-Aortic Ratio

RAR = PSV renal artery

PSV aorta

Renal-Aortic Ratio

PSV alone may be inaccurate due to difficulty with Doppler angle insonation

RAR angle independent

Obtain aortic signal 2cm distal to SMA Use highest main renal artery signal

Renal-Aortic Ratio

Normal

< 3.5

Low grade (1-59%)

< 3.5

High grade (60-99%)

> 3.5

Total occlusion renal length

< 9cm

End Diastolic Ratio

Assess both parenchymal vascular resistance and disease. Sufficient perfusion: > 0.23 Severe parenchymal vascular disease: < 0.23

Acceleration Index
V

AT

AI = V/ T

Acceleration Index

Acceleration time: time for peak systolic velocity Acceleration index: acceleration slope divided change in time < 3.78 kHz/sec/MHz indicates greater than 50% stenosis.

Acceleration Index
To calculate : Place the first cursor at the beginning of systole. Place the second cursor at the peak of systole.

Acceleration Index

Acceleration Time

Acceleration time: > 0.1 sec indicates greater than 50% stenosis. Measure with sweep speed of 100 mm/sec.

Normal waveforms have steep systolic upstrokes, whereas waveforms distal to a stenosis have a more gradual upstroke and dampened systolic peak.

Abnormal Doppler Findings

Peak systolic velocity ( PSV) in renal artery ( proximal, mid, or distal ) > 180 cm/sec. Renal Artery / Aorta Ratio ( RAR), > 3.5. Tardus-Parvus.

What is Tardus-Parvus?

Tardus: delayed early systolic acceleration or upstroke

Parvus: diminished amplitude and rounding systolic peak.

What is Tardus-Parvus?

Delayed upstroke

What is Tardus-Parvus?

Rounded

Tardus-Parvus

Seen in distal & segmental arteries, indicating high grade stenosis proximally. Measured using either :

Acceleration time (normal is less than 70ms) Acceleration Index ( normal is greater than 3/m/s square)

When present, 100% indicative of RAS, but not ALWAYS present in RAS patients

Tardus-Parvus
Normal

Tardus-Parvus

Abnormal

Tardus-Parvus

Normal renal artery: notice the steep upstroke & normal acceleration index in this waveform.

Tardus-Parvus

Notice the rounded waveform and the blunted upstroke with tardus-parvus.

Renal Artery Protocol

Exam Protocol
Normal RAS Exam

Renal Artery Doppler Scanning

Test usually takes 60-90 minutes.With experience the time can be reduced. Patient should be fasting (at least 8 hours). Patient should be well hydrated, encourage water intake.

4 to 2 MHz transducer

Protocol
Grey Scale:

Measure and document kidney size, and any abnormalities. (Normal size 9-13 cm.) Rule out mass, stones, hydronephrosis, etc. Start with the abdominal aorta midline and obtain and measure Doppler signal. Remember to look for plaque (arteriosclerosis).

Protocol / Kidneys
Abnormalities:

Hydronephrosis

Stones
Renal Failure

Polycystic Disease

Protocol / Kidneys

Protocol / Kidneys

Protocol / Kidneys

Protocol / Kidneys

Protocol / Aorta
Doppler Midline Beware of Plaque

Protocol / Aorta

Protocol / Aorta

Protocol / Aorta

Protocol
Doppler and Measure:

Rt. and Lt. renal arteries, Prox , mid, and distal aspects of each and any accessory arteries. ALL Doppler angles are 60 degrees or LESS. Segmental arteries (upper, mid, and lower poles) of each kidney.

Acceleration index of segmental arteries. Look for tardus-parvus.

A Normal Renal Artery Examination

Proximal Right Renal Artery

Mid Right Renal Artery

Mid Right Renal Artery

Transverse view

Mid Right Renal Artery

Transverse view

Distal Right Renal Artery

Segmental Renal Artery

Segmental with Acceleration Index

Angle < 60

= 60

Angle < 60

= 78

Overview of Renal Artery Study

Routine US exam of the Kidneys evaluate size and echotexture, r/o pathology Doppler Aorta Measure PSV, for RAR calculation Doppler renal arteries Measure PSV, for RAR calculation

Overview of Renal Artery Study

Doppler segmental arteries obtain acceleration index look for Tardus-Parvus Calculate RAR RAR=PSV Renal artery/ PSV Aorta

Renal Artery Stenosis: Treatment

Medically with ACE inhibitors

Balloon angioplasty Arterial stent Surgically.