Minimally invasive diagnosis of renal artery stenosis by spiral computed tomography angiography

Renal Artery Stenosis As Etiology of Recurrent Flash Pulmonary Edema and Role of Imaging in Timely Diagnosis and Management

Renal hypoperfusion from renal artery stenosis (RAS) activates the renin-angiotensin system, which in turn causes volume overload and hypertension. Atherosclerosis and fibromuscular dysplasia are the most common causes of renal artery stenosis. Recurrent flash pulmonary edema, also known as Pickering syndrome, is commonly associated with bilateral renal artery stenosis. There should be a high index of clinical suspicion for renal artery stenosis in the setting of recurrent flash pulmonary edema and severe hypertension in patients with atherosclerotic disease. Duplex ultrasonography is commonly recommended as the best initial test for the detection of renal artery stenosis. Computed tomography (CT) angiography (CTA) or magnetic resonance (MR) angiography (MRA) are useful diagnostic imaging studies for the detection of renal artery stenosis in patients where duplex ultrasonography is difficult. If duplex ultrasound, CTA, and MRA are indeterminate or pose a risk of significant renal impairment, renal angiography is useful for a definitive diagnosis of RAS. The focus of medical management for RAS relies on controlling renovascular hypertension and aggressive lifestyle modification with control of atherosclerotic disease risk factors. The restoration of renal artery patency by revascularization in the setting of RAS due to atherosclerosis may help in the management of hypertension and minimize renal dysfunction.

Multimodality imaging of fibromuscular dysplasia

OBJECTIVE

Fibromuscular dysplasia (FMD) is an uncommon non-inflammatory and non-atherosclerotic cause of arterial disease that may result in stenosis, tortuosity, aneurysm, or dissection. The clinical presentation depends on the vascular bed involved and ranges from asymptomatic to multisystem disease and end organ ischemia. The purpose of this article is to review the role of imaging in patients with FMD with an emphasis on renal FMD. The relevant epidemiology, histopathology, imaging techniques, and interpretation of images will be discussed.

CONCLUSION

Renal artery FMD requires a high index of suspicion for accurate and prompt diagnosis and implementation of appropriate therapy. The treatment will vary based on clinical presentation and distribution of involvement. Noninvasive imaging with duplex ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are reasonable alternatives for the depiction of FMD in comparison to catheter-directed angiography (CA). Patients with FMD are often treated by multispecialty practice including the interventional radiologist.

A novel application of CT angiography to detect extracoronary vascular abnormalities in patients with spontaneous coronary artery dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is associated with extracoronary vascular abnormalities, which depending on type and location may warrant treatment or provide additional diagnostic or prognostic information about this uncommon entity. Fibromuscular dysplasia (FMD), aneurysms, and dissections have been detected in multiple vascular territories by magnetic resonance angiography, CT angiography (CTA), and catheter angiography. The optimal modality to detect extracoronary vascular abnormalities is unknown. We highlight the technique and feasibility of a novel CTA protocol to detect extracoronary vascular abnormalities in these patients, incorporating patient safety and convenience.

METHODS

The complete CTA protocol consisting of a single CTA of the neck, chest, abdomen, and pelvis was performed on 39 SCAD outpatients. All examinations were performed with 200 mL of low-osmolar contrast agent and used radiation dose modulation techniques. Average volume CT dose index was 9 mGy for the chest, abdomen, and pelvis portions and 21 mGy for the neck portion. Studies were independently reviewed by 2 senior vascular radiologists.

RESULTS

Two patients had nondiagnostic CTA neck evaluation because of technical acquisition errors. Extracoronary vascular abnormalities were detected in 27 of 39 patients (69%). Catheter angiography detected brachial artery FMD in 1 patient, a vascular bed not included in the SCAD CTA protocol. Extracoronary vascular abnormalities were common, including FMD, aneurysms, dissection, and aortic tortuosity, and were seen in the iliac (36%), carotid and/or vertebral (31%), splanchnic (10%), and renal (26%) arteries and in the thoracic and/or abdominal aorta (10%).

CONCLUSIONS

The frequency of extracoronary vascular abnormalities and extent of territories identified the CTA protocol in our cohort are high. A tailored CTA may be the optimal imaging technique for detecting extracoronary vascular abnormalities in patients with suspected underlying vasculopathy. Although the clinical significance of extracoronary vascular abnormalities remains unclear, detection of these abnormalities has identified patients in whom cerebral imaging and serial monitoring have been recommended.

Non-contrast enhanced MR angiography: established techniques

Until recently, time-of-flight (TOF) and phase contrast (PC) were the only non-contrast MR angiography (NC-MRA) techniques practically used in clinical. In the decade, NC-MRA have been gained a revival of an interest among the MR researchers and scientists, in part because of safety concerns related to the possible link between gadolinium-based contrast agents and nephrogenic systemic fibrosis (NSF). This article introduces other established NC-MRA techniques, such as ECG-gated partial Fourier fast spin echo (FSE) and balanced steady-state free precession (bSSFP), both with and without arterial spin labeling. Then, the article focuses on two main applications: peripheral run-off and renal MRA. Recently, both applications have achieved remarkable advancements and have become a viable clinical option as an alternative to contrast-enhanced (CE)-MRA. In addition, developments on the horizon including whole body MRA applications and further advancement at 3 Tesla are discussed.

Management of heart failure with renal artery ischemia

With improved treatment, patients are surviving longer with impaired ventricular function. Hypertension results in ventricular remodeling in many patients. More than 5 million people have heart failure and are likely to have one or more co-existent diseases associated with aging, one of which is chronic kidney disease (CKD). Renal artery stenosis is fraught with varying opinions. Nephrologists, cardiologists, and interventional radiologists all manage these diseases with different strategies. This article outlines renovascular disease as it relates to CKD, the pathophysiology of development of renovascular disease and effects leading to congestive heart failure, treatment modalities, and outcomes of treatment regimens.

Renal artery stenosis: imaging options, pitfalls, and concerns

Renal artery stenosis can be diagnosed with multiple imaging modalities, each one having different risk vs accuracy tradeoffs. Catheter angiography with pressure gradient measurements is the definitive gold standard but also the most invasive and thus reserved primarily for imaging at the time of renal revascularization. Ultrasonography is the safest and least expensive but also the least accurate and most operator-dependent. Contrast-enhanced computed tomographic angiography and magnetic resonance angiography are intermediate (between ultrasound and catheter angiography) with respect to accuracy and expense. Exciting new advances in magnetic resonance that include new contrast agents, which eliminate nephrogenic systemic fibrosis risk, and techniques to characterize the hemodynamic significance of renal artery stenoses are now becoming available. In addition, magnetic resonance angiography without any contrast has become more accurate and rivals contrast-enhanced techniques in some patients. This review explores these techniques for renal artery stenosis imaging.

Evaluation and approach to treatment of renal artery stenosis in patients with diabetic nephropathy

Patients with diabetes mellitus are at increased risk for developing peripheral vascular disease and renal artery stenosis (RAS). Furthermore, in diabetic patients the progression of renal atherosclerotic disease toward critical stenosis or occlusion occurs more frequently than in their nondiabetic counterparts. Consequently, clinicians must carry a high level of suspicion for detecting RAS in diabetic patients, particularly those with established coronary and/or peripheral atherosclerotic disease and compromised renal function. In this group of patients early detection of this condition, preferably with a noninvasive diagnostic test, is very important to plan revascularization therapy. In nondiabetic patients, several studies have demonstrated that catheter-based revascularization therapy may arrest or revert renal dysfunction in patients with RAS. Although still the subject of debate, a recent study has shown that in diabetic patients with RAS and impaired renal function, revascularization therapy with endovascular stents has a positive impact in the progression of renal dysfunction.

Clinical Use of Laboratory Tests for the Identification of Secondary Forms of Arterial Hypertension

The prevalence of secondary hypertension can be underestimated if appropriate tests are not performed. The importance of selecting patients with a high pre-test probability of secondary forms of hypertension is first discussed. The laboratory tests currently used for seeking a cause of hypertension are critically reviewed, with emphasis on their operative features and limitations. Strategies to identify primary aldosteronism, the most frequent form of secondary hypertension, and to determine its unilateral or bilateral causes are described. Treatment entails adrenalectomy in unilateral forms, and mineralocorticoid receptor blockade in bilateral forms. Renovascular hypertension is also a common, curable form of hypertension, that should be identified as early as possible to avoid the onset of cardiovascular target organ damage. The tests for its confirmation or exclusion are discussed. The various tests available for the diagnosis of pheochromocytoma, which is much rarer than the above but extremely important to identify, are also described, with emphasis on recent developments in genetic testing. Finally, the tests for diagnosing some rarer monogenic forms and other renal and endocrine causes of arterial hypertension are explored.

Management of heart failure with renal artery ischemia

With improved treatment, patients are surviving longer with impaired ventricular function. Hypertension results in ventricular remodeling in many patients. More than 5 million people have heart failure and are likely to have one or more co-existent diseases associated with aging, one of which is chronic kidney disease (CKD). Renal artery stenosis is fraught with varying opinions. Nephrologists, cardiologists, and interventional radiologists all manage these diseases with different strategies. This article outlines renovascular disease as it relates to CKD, the pathophysiology of development of renovascular disease and effects leading to congestive heart failure, treatment modalities, and outcomes of treatment regimens.

Techniques in interventional radiology: renal CT angiography

Multidetector row CT angiography has become an important tool in the evaluation of patients with suspected renovascular hypertension. The following article presents a review of the published data on accuracy of this method of evaluation as well as a comparison to other diagnostic strategies, in particular, renal MR angiography.

Multidetector spiral CT renal angiography in the diagnosis of renal artery fibromuscular dysplasia

OBJECTIVE

The aim of this study was to evaluate the role and detection rate of multidetector spiral CT renal angiography (CTA) as compared with conventional angiography (CA), the commonly accepted gold standard, in the diagnosis of renal artery fibromuscular dysplasia (FMD). In addition, the role of CTA reconstructions (multiplanar reformatted images (MPR), maximum intensity projections (MIP) and shaded-surface display (SSD)) in the detection of FMD was also evaluated.

MATERIALS AND METHODS

CTA results were retrospectively reviewed in 21 hypertensive patients with CA-proven FMD. Clinical indications for referral included resistant hypertension (requiring greater than three antihypertensive medications), labile hypertension, hypertension in combination with renal impairment and the presence of abdominal bruits in the context of systemic hypertension. In some cases, these clinical indications were supplemented by positive results in other tests, including plasma renin assay, captopril scintigraphy and/or Doppler ultrasound. The findings of CA in these 21 patients were compared to CTA.

RESULTS

Mean patient age was 62.33+14.32 years (range 24-85 years). CTA identified all 42 main renal arteries (100%) and all 10 accessory renal arteries (100%) visualized on CA. In the diagnosis of FMD, CTA detected all 40 (100%) lesions detected by CA. No single CTA reconstruction technique was able to detect all lesions noted on corresponding CA, however, upon review of all CTA reconstructions (MPR, MIP and SSD) in each case, every lesion was correctly identified by CTA.

CONCLUSION

Our experience suggests that CTA is a non-invasive, reliable and accurate method for the diagnosis of renal artery fibromuscular dysplasia. Moreover, in our experience CTA has many advantages as a diagnostic screening tool over CA, including accessibility, speed, lower complication profile, versatility and cost-effectiveness. CTA shows great potential as a guiding tool for directing subsequent procedures such as CA+balloon angioplasty.

Screening tests for renal artery stenosis: A case-series from an Australian tertiary referral centre

BACKGROUND

Renal artery stenosis is a common, correctable cause of hypertension and renal impairment, with multiple screening tests available to aid diagnosis. Data assessing the accuracy of screening tests are mostly derived from tight 'experimental' protocols and the application of these tests to large-scale clinical practice is not clear. Our aim was to investigate physician preferences and diagnostic accuracy of screening tests for renal artery stenosis when applied to clinical practice in a large, Australian tertiary referral centre.

METHODS

We investigated all renal angiograms performed at our institution between September 2002 and September 2004, as referred by renal physicians. We accessed hospital and physician records of all patients to document demographics, clinical history, screening investigations, source of screening and angiogram results. The series involved 75 consecutive patients who had 79 screening investigations (four patients had two screening tests).

RESULTS

The case series showed that 19 (24%) patients did not have any screening investigations prior to angiography. Duplex ultrasonography was the most utilised screening test, being used in 20 (33%) of the remaining 60 screening tests. Computed tomographic angiography (CTA) was used in 19 (32%), magnetic resonance imaging in 13 (22%) and renal scintigraphy was used in four (7%) screening procedures. Magnetic resonance angiography was the most accurate screening test with a positive predictive value of 92%, followed by duplex ultrasonography with 88% and CTA was relatively inaccurate, with a positive predictive value (PPV) of 58% (P = 0.036). Clinical suspicion alone was inaccurate with a PPV of 40%, except in previously treated renal artery stenosis (PPV 89%).

CONCLUSION

Duplex ultrasonography was the most utilised screening investigation amongst the physicians of our referral base. Magnetic resonance angiography and duplex ultrasonography had good positive predictive values, while CTA may not be as reliable as previously reported when applied to a large, non-selective clinical practice.

Challenges in the diagnosis and management of renal artery stenosis

Renal artery stenosis (RAS) is a common cause of secondary hypertension, with the activation of the renin-angiotensin-aldosterone system being the pathophysiologic hallmark of the disease. Renovascular hypertension, ischemic nephropathy, proteinuria, and flash pulmonary edema are the main clinical syndromes associated with RAS. The prevalence of RAS is on the rise, owing to an increasing prevalence of diabetes and atherosclerotic disease among our aging population. This rise in RAS prevalence poses major challenges for clinicians making diagnostic and treatment decisions. Although renal angioplasty is of proven benefit in fibromuscular dysplasia, randomized trials in atherosclerotic RAS have not shown any advantage for revascularization over medical therapy in terms of blood pressure control or renal function preservation. Angioplasty and surgical interventions should be reserved for patients with preserved kidney size and hemodynamically significant stenosis.

Contemporary imaging techniques for the diagnosis of renal artery stenosis

Renal artery stenosis (RAS) is a potentially curable cause of renovascular hypertension (RVH) and is caused by either atherosclerosis or fibromuscular dysplasia (FMD) in the vast majority of patients. Although intra-arterial digital subtraction angiography (IA-DSA) is still considered the standard of reference test for the anatomical diagnosis of RAS, noninvasive techniques such as MR angiography, CT angiography, and color-aided duplex ultrasonography are promising alternatives that also allow functional characterization of RAS. We provide an overview of these techniques and discuss their relative merits and shortcomings. Analysis of high-quality studies shows that both MR and CT angiography are significantly more accurate for the diagnosis of at least 50% atherosclerotic RAS than ultrasonographic techniques. The primary strength of ultrasonography at present is its suggested ability to predict functional recovery based on preinterventional resistance index measurements. A still unresolved issue is the detection of FMD. Because missing RVH may have serious consequences the most important requirement for a screening test is that it has high sensitivity.

Incorporating patient-centered outcomes in the analysis of cost-effectiveness: imaging strategies for renovascular hypertension

OBJECTIVE

Our aim was to assess the contribution of patient-centered short-term disutilities and quality-of-life measures in the cost-effectiveness analysis of CT angiography, MR angiography, and conventional angiography in patients with medication-resistant hypertension.

MATERIALS AND METHODS

A decision analytic model compared the life expectancy and incremental cost per life year using three initial diagnostic tests in a cohort of hypothetical individuals with medication-resistant hypertension over a range of renal artery stenosis probabilities: CT angiography (sensitivity, 96%; specificity, 96%; cost, $865); MR angiography (98%, 94%, $850); and conventional angiography (99%, 99%, $2,627). All imaging strategies were compared with a base case scenario mimicking the natural history of medication-resistant hypertension and with a scenario immediate enhanced medical therapy without prior imaging. Individuals without evidence of renal artery stenosis on initial testing underwent conventional angiography if enhanced medical therapy failed to control hypertension. Individuals diagnosed with renal artery stenosis on MR angiography required conventional angiography for definitive stent treatment ($11,1223). Blood pressure response to renal artery stenting or enhanced medical therapy varied according to blood pressure, as did the incidence of myocardial infarction and stroke resulting from hypertension. Patients who progressed to end-stage renal disease received dialysis ($60,000 per year). Quality-of-life adjustments were made for patients with hypertension, end-stage renal disease, myocardial infarction, and stroke. Short-term disutilities from undergoing an imaging test were included. The analysis accounted for direct costs derived from Medicare reimbursements and total costs derived from the literature.

RESULTS

All imaging strategies were cost-effective compared with enhanced medical therapy alone or with natural history. When only direct costs were considered, MR angiography was the preferred strategy, with conventional angiography as a cost-effective alternative to MR angiography. When total costs were considered, conventional angiography dominated all other strategies. Adjusting for quality of life decreased the incremental cost-effectiveness ratios, making an already competitive strategy a more favorable alternative to the base case. Adjusting for test-related disutility did not significantly influence the cost-effectiveness of any of the imaging tests. Despite marked variation in the key clinical and cost variables, MR angiography remained the most cost-effective strategy.

CONCLUSION

In the evaluation and treatment of medication-resistant hypertension, strategies that included preliminary imaging saved more lives than did the immediate institution of enhanced medical therapy at a lesser cost.

Prevalence of atherosclerotic renal artery stenosis in patients starting dialysis

BACKGROUND

Atherosclerotic renal artery stenosis (ARAS) can lead to end-stage renal failure (ESRF). We determined the prevalence of ARAS in patients 45 years of age or older starting renal replacement therapy.

METHODS

Forty-nine of 80 consecutive patients (37 males, 12 females) starting renal replacement therapy in our centre gave informed consent and underwent spiral computed tomographic angiography of their renal arteries. A renal artery diameter reduction of 50% or more assessed by two radiologists was considered as a significant stenosis.

RESULTS

Twenty of 49 patients (41%) had an ARAS, and in eight cases (16%) this was bilateral or unilateral with a single kidney. Women were more likely to have an ARAS than men; 75 (9/12) vs 30% (11/37, P<0.01). However, relatively more women declined participation. Non-participants and participants did not differ in respect to other relevant clinical data. Nonetheless, findings in these patients would be negative, the prevalence of ARAS would still be 31% in women and 22% in men (NS). In 13 patients with ARAS the registered diagnosis of ESRF either was hypertension, renovascular disease or unknown. Assuming that in these patients atherosclerotic renovascular disease was the cause of renal failure, a total of 13 patients (13/49, 27%) entered the dialysis programme because of this problem.

CONCLUSIONS

These results suggest that ARAS is an important cause of ESRF.

The diagnosis and management of renovascular disease: a primary care perspective. Part I. Making the diagnosis

Renovascular disease is a complex disorder, the most common causes of which are fibromuscular dysplasia and atherosclerotic disease. It usually presents in one of three forms: asymptomatic renal artery stenosis, renovascular hypertension, or ischemic nephropathy. This complexity often makes diagnostic and management decisions difficult. This review will be presented in two parts. In Part I, the authors will discuss when to consider and how to go about making the diagnosis. In Part II (in a future issue of The JCH), the authors discuss the management of renovascular disease. The clinical index of suspicion remains paramount in setting the diagnostic strategy. Although it is subject to certain limitations, conventional contrast angiography is usually considered the gold standard in confirming the diagnosis. In addition, there are a number of available noninvasive tests that can aid in decision making. These tests can be divided into those that detect the anatomic presence of a stenosis and those that identify the functional consequences of the renal artery obstruction. No one study is appropriate for every patient. A diagnostic algorithm is proposed at the conclusion of this review.

How to diagnose, how to treat: renal artery stenosis-diagnosis and management

Renal artery stenosis is considered to be one of the more frequent causes of secondary arterial hypertension. Through its progression renal artery stenosis can cause renal insufficiency, uncontrolled hypertension, and increased cardiovascular morbidity. A thorough clinical examination and the presence of a typical abdominal bruit may provide helpful hints to identify hypertensive patients with possible renal artery stenosis. Testing for renovascular hypertension includes renal artery imaging, assessment of its functional significance, and evaluation for possible revascularization. Renal artery stenosis secondary to fibromuscular dysplasia should be mechanically corrected. For atherosclerotic renal artery stenosis, medical management can be attempted so long as it does not cause a decline of kidney function. In patients who are candidates for renovascular revascularization, surgical intervention can be helpful in improving blood pressure control and possibly halting the progression of renal failure. Randomized controlled trials comparing direct stenting with other surgical methods are necessary to define the best revascularization strategy in patients with renovascular hypertension. A careful follow-up study after renal artery revascularization should evaluate possible benefits in halting the deterioration of chronic renal insufficiency.

Contrast media nephropathy: intravenous CT angiography versus intraarterial digital subtraction angiography in renal artery stenosis: a prospective randomized trial

BACKGROUND

Spiral computed tomographic angiography (CTA) is a noninvasive method to diagnose renal artery stenosis (RAS). In digital subtraction angiography (DSA), contrast media (CM) is injected directly into the renal artery; in CTA, a greater amount of CM is injected intravenously, potentially leading to an increased incidence of CM nephropathy.

METHODS

We investigated 80 patients with suspected RAS randomized to either CTA or DSA prospectively. The following parameters were determined: serum creatinine level and single-shot inulin clearance for evaluation of renal function and urine alpha1-microglobulin and beta-N-acetyl-glucoseaminidase (beta-NAG) as markers for tubular toxicity. Data from 16 patients undergoing angioplasty in the same session were excluded.

RESULTS

In the CTA and DSA groups, 163 +/- 13 and 104 +/- 56 mL of CM (mean +/- SD; P < 0.0001) were administered, respectively. Mean serum creatinine levels increased from 1.78 +/- 1.61 to 1.92 +/-1.73 mg/dL (157 +/- 142 to 170 +/- 153 micromol/L; P = 0.00001) in the CTA group and from 1.52 +/- 1.23 to 1.60 +/- 1.28 mg/dL (134 +/- 109 to 141 +/- 113 micromol/L; P = 0.01) in the DSA group. Mean inulin clearance decreased from 63 +/- 28 to 58 +/- 23 mL/min (P = 0.01) and 65 +/- 26 to 62 +/- 26 mL/min (P < 0.01), median beta-NAG levels increased from 4.6 to 6.0 U/g creatinine (P = not significant) and 2.5 to 8.0 U/g creatinine (P < 0.001), and median alpha1-microglobulin levels increased from 13 to 17 microg/g creatinine (P < 0.025) and 11 to 21 microg/g creatinine (P = not significant) in the CTA and DSA groups, respectively. CM nephropathy occurred in 3 of 33 patients in the CTA group and 2 of 31 patients in the DSA group. The increase in creatinine level was reversible in all patients within 7 days.

CONCLUSION

On this study, CTA performed for the detection of RAS is not associated with an increased risk for CM nephropathy compared with intraarterial DSA despite a greater dose of CM.

An evidence-based approach to diagnosing renovascular hypertension

Making the diagnosis of potentially reversible renovascular hypertension can be problematic. Although there are a number of noninvasive screening tests available, no one study is appropriate for every patient. In general, the available tests can be divided into those that identify the functional consequences of a renal artery obstruction (angiotensin-converting enzyme inhibitor-augmented renography) and those that identify the anatomic presence of stenosis (duplex ultrasonography, magnetic resonance angiography, and contrast tomography angiography). The most appropriate diagnostic approach is based largely on the clinical index of suspicion, the potential etiology of the renal artery lesion (fibromuscular dysplasia or atherosclerosis), and the individual patient's physiology and presentation. A potential treatment algorithm is presented.

Noninvasive investigation for renal artery stenosis: contrast-enhanced magnetic resonance angiography and color Doppler sonography as compared to digital subtraction angiography

INTRODUCTION

The question about the most appropriate non-invasive method for detecting a renal artery stenosis (RAS) when comparing contrast enhanced magnetic resonance angiography (MRA) and color Doppler sonography (CDS) is still under discussion. Therefore we conducted a prospective study in order to evaluate both methods as compared to digital subtraction angiography (DSA).

PATIENTS/METHODS

Thirtysix consecutive patients (53,9 +/- 13,7 years) with suspected RAS were investigated. MRA was performed using gadolinium for contrast enhancement. CDS was performed using a 2.5 and 3,5 MHz transducer. A peak systolic velocity (Vmax) >200 cm/sec within renal arteries and/or a side to side difference of the resistive index (RI) of >0,05 were used to discriminate stenosis. A diameter reduction of > or = 60% by DSA was considered a stenosis relevant to the patient.

RESULTS

Sixty-eight main renal arteries and 9 accessory vessels were detected by DSA. Twenty main and 3 accessory arteries were found to be stenosed > or = 60%, while 4 main and 1 accessory artery presented with occlusion. MRA detected 70 renal vessels (65 main and 5 accessory arteries). Twenty-one stenosed arteries and 4 occluded vessels were correctly diagnosed by MRA. With CDS 68 renal vessels (62 main and 6 accessory arteries) could be visual- ized out of which 21 stenoses were diagnosed because of increased Vmax and 6 stenoses were detected because of a side to side difference of RI. For main renal arteries sensitivities and specificities were 96% and 86% for MRA and 96% and 89% for CDS.

CONCLUSIONS

MRA and CDS are both comparable methods for detection of a renal artery stenosis > or = 60%. Despite several limitations, CDS can at the moment still be favored as a screening method.

Non-surgical treatment of patients with peripheral vascular disease

Dotter first described percutaneous revascularization of peripheral vascular disease (PVD) in 1964. In 1974, Gruentzig developed a balloon catheter for dilation of vascular lesions. Currently, percutaneous transluminal angioplasty (PTA) employs a variety of devices ranging from implantable stents to endovascular radiation devices for re-stenosis and is recognized as a safe and effective alternative to surgery for selected patients. In addition to the general efficacy of peripheral angioplasty, which is comparable to that of bypass surgery for selected lesions, angioplasty offers several distinct advantages over surgery. It is performed under local anaesthesia, making it feasible to treat patients who are at high risk for general anaesthesia. When compared to surgical revascularization, the morbidity from angioplasty is low, generally related to problems at the vascular access site, and mortality is extremely rare. Unlike vascular surgery, there is no recovery period after angioplasty, and most patients can return to normal activity within 24-48 h of an uncomplicated procedure. Finally, angioplasty can be repeated if necessary usually without increased difficulty or increased patient risk compared to the first procedure, and does not preclude surgery as adjunctive or definitive therapy.

CT evaluation of renovascular disease

Computed tomography (CT) plays an important role in evaluation and management of primary renovascular disease. Nonenhanced CT is useful for demonstrating renal hemorrhage, renal parenchymal or vascular calcifications, and masses. Contrast material-enhanced CT is essential to identify global or regional nephrographic abnormalities resulting from the vascular process (eg, renal infarcts, ischemia secondary to renal artery stenosis, arteriovenous communications). In addition, renal manifestations of a systemic disease (eg, vasculitis, thromboembolic disease) can be seen at CT. In trauma, occlusion of the main renal artery can be accurately diagnosed with contrast-enhanced CT. In cases of spontaneous renal hemorrhage without an apparent cause (eg, vasculitis, coagulopathy), a careful CT study should be performed to exclude renal cell carcinoma. The presence of fat in a hemorrhagic renal mass larger than 4 cm in diameter is characteristic of angiomyolipoma complicated by hemorrhage. Acute renal vein thrombosis appears as a clot in a distended renal vein, whereas renal vein retraction with collateral vessels is highly indicative of chronic thrombosis. Helical CT, especially with multiplanar two-dimensional and three-dimensional reconstruction following an intravenous injection of iodinated contrast material, has greatly improved our ability to directly image the proximal renal arteries and detect vascular lesions.

Renal arteries in patients at risk of renal arterial stenosis: multicenter evaluation of the echo-enhancer SH U 508A at color and spectral Doppler US. Levovist Renal Artery Stenosis Study Group

PURPOSE

To assess SH U 508A in the diagnosis of suspected renal arterial stenosis by means of ultrasonography (US) and to confirm the safety of SH U 508A in a clinical setting.

MATERIALS AND METHODS

A randomized crossover study was performed in 198 patients from 14 European centers who were referred for renal arterial angiography because they were suspected of having renal arterial stenosis. All patients underwent nonenhanced and SH U 508A-enhanced Doppler US of the renal arteries. Doppler criteria included measurement of renal arterial peak systolic velocity (threshold, 1.4-2.0 m/sec) in all centers and renoaortic ratio (threshold, 3.0-3.5) in nine.

RESULTS

The number of examinations with successful results increased following enhanced Doppler US examination--160 (83.8%) compared with 122 (63.9%) with nonenhanced Doppler US (P = .001), including patients with obesity or renal dysfunction. Renal arterial stenosis (> or =50%) was detected at angiography in 72 patients. Results at enhanced Doppler US were in agreement with results at angiography more often than with results at nonenhanced Doppler US in the diagnosis or exclusion of renal arterial stenosis (P = .001). For patients examined with nonenhanced and enhanced Doppler US, sensitivity (80.0% and 83.7%, respectively) and specificity (80.8% and 83.6%, respectively) remained unchanged. There were no clinically important adverse events following use of SH U 508A.

CONCLUSION

In patients suspected of having renal arterial stenosis, SH U 508A increased the number of diagnostic renal arterial Doppler studies.

Renovascular disease

The gold standard for the diagnosis of renal artery stenosis is angiography, with response to treatment the proof of its significance. Non-invasive methods of investigation are required and are now available including functional imaging, ultrasound, CT and MR angiography and the merits and limitations of these tests are discussed.

Renal angioplasty: better for treating hypertension or for rescuing renal function?

Angioplasty of renal artery stenosis has been used extensively in the last two decades for treating renovascular hypertension, and, more recently, for preserving the jeopardized renal function. A large body of evidence has accumulated indicating that this approach is by far the most convenient for patients with fibromuscular stenosis in whom the technical success of the procedure is followed by a high cure rate (50%) or at least by some improvement of blood pressure (40%). In contrast, in patients with atheromatous stenosis, the rate of cure is very low (8-10% at best) and the rate of improvement is between 40 and 50% irrespective of whether the stenosis is treated with angioplasty or with stent implantation. Thus, before undergoing procedures which are not devoid of potentially serious side-effects, these patients should be thoroughly investigated to select those in whom the benefit actually outweighs the risks. Studies investigating the effects of angioplasty on renal function are less numerous than those addressing the effects on blood pressure, and, in most cases, suffer the limitation of using the levels of serum creatinine as the sole marker of the changes in glomerular filtration rate induced by the procedure. These investigations have shown that some amelioration can be achieved in one-third of patients, with another third having unmodified levels of creatinine at follow-up. Radioisotopic techniques, which allow a more precise and separate evaluation of the function of the two kidneys, appear to be a promising alternative for the investigation of the effects of angioplasty; indeed, preliminary studies which took advantage of these methodologies have shown that the function of the stenotic kidney can possibly be rescued by slowly reversing the multiple mechanisms by which chronic ischaemia damages the kidney.

Breath-hold 3D gadolinium-enhanced subtraction MRA in the detection of transplant renal artery stenosis

AIMS

The purpose of this study was to assess the value of breath-hold 3D gadolinium-enhanced subtraction magnetic resonance angiography (GD-MRA) in the detection of transplant renal artery stenosis (TRAS).

PATIENTS AND METHODS

Seven patients with suspected post-transplant renal artery stenosis were studied. GD-MRA was performed at 1.5T with a 3D fast spoiled gradient recalled echo (FSPGR) pulse sequence. Before injection of contrast medium, the 3D pulse sequence was performed to obtain a set of non-contrast images for subtraction purposes. Dynamic 3D imaging was performed simultaneously with the bolus injection of 40 ml of gadopentetate dimeglumine. Angiographic images were reconstructed using the Advantage Window workstation (version 2.0 GE Medical Systems) and subtraction was made with the pre-contrast image data. Any signal intensity cut-off or narrowing of more than 50% was regarded as significant stenosis. Ultrasound Doppler (USD) study was performed with both colour and spectral studies. Peak systolic velocity (PSV) of greater than 2.0 m/s and acceleration time (AT) greater than 120ms was regarded as positive for TRAS. These were then compared with the digital subtraction angiography (DSA) as the gold standard.

RESULTS

A total of nine examinations performed in seven patients were included in the analysis. MRA correlated with the DSA findings in eight examinations, with one false negative. USG correlated with DSA in six examinations, with two false negative and one false positive case.

CONCLUSION

In our opinion, GD-MRA is a promising and non-invasive technique in the detection of TRAS.

Carotid bifurcation CT angiography: assessment of interactive volume rendering

PURPOSE

The purpose of this study was to compare the accuracy of CT angiography (CTA) for the assessment of carotid bifurcation stenosis, using interactive volume rendering (VR), maximum intensity projection (MIP), and 2D transverse CT technique (t-CT).

METHOD

Nineteen consecutive patients were prospectively studied with CTA and selective digital subtraction angiography (DSA). There were 13 men and 6 women from 51 to 84 years old (mean 70 years). Results of DSA were compared with those of interactive VR, MIP, and conventional t-CT results, using North American Symptomatic Carotid Endarterectomy Trial criteria for stenosis grading.

RESULTS

There were a total of 38 carotid bifurcations studied, with 9 mild, 10 moderate, and 15 severe stenoses and 4 occlusions. Overall agreement with DSA for VR was achieved in 76%. Eighty percent of the severe stenoses were correctly predicted by VR. The overall agreement between t-CT and DSA was 89%. MIP images, when analyzed independently, showed an overall agreement with angiography of only 71%. VR was not significantly different from MIP (p = 0.60). The difference between VR and t-CT had borderline significance (p = 0.09). MIP had significantly poorer agreement with angiography than t-CT (p = 0.02).

CONCLUSION

CTA has a high degree of accuracy for the assessment of carotid artery disease compared with catheter angiography. Interactive VR increases the accuracy of diagnosing carotid stenosis and decreases the number of unsatisfactory studies as compared with MIP. Further advances in computation speeds and improvements in software may dramatically alter the future use of VR for the communication of results to clinicians; however, careful analysis of transverse sections is essential to accurate CT interpretation.

Influence of helical CT parameters on spatial resolution in CT angiography performed with a subsecond scanner

RATIONALE AND OBJECTIVES

In helical CT, the beam collimation, table feed (TF) per tube rotation, voltage, current, reconstruction increment, kernel, linear interpolation algorithm (LIA), and contrast are variable parameters. The purpose of this study was to determine which of these parameters are most important to minimize partial volume effects for improving spatial resolution in CT angiography.

METHODS

Phantom vessel stenoses of different lengths (2, 8 mm) and diameters (0.5, 1, 2, 3, 4 mm) were scanned with helical CT using a constant tube rotation time of 0.75 sec and 42 selected combinations of the above-mentioned parameters. Orthogonal targeted maximum intensity projections of the stenoses were ordered according to the increase in blurring and noise in a consensus reading by two radiologists blinded to the parameters used.

RESULTS

Three millimeters of collimation and TF in conjunction with a 180 degrees LIA and > 250 Hounsfield unit contrast density was considered the optimal parameter combination and enabled a continuous visualization of the stenoses down to 0.5 mm in diameter. A collimation of 1 or 2 mm and 5 mm was considered inferior to a collimation of 3 mm because of, respectively, noise and blurring. With 3 mm collimation, significant blurring occurred when a pitch larger than 1.5 was used. A 3 mm collimation with a pitch of 2 (6 mm TF) was found to be superior to a collimation of 5 mm in conjunction with a pitch of 1 (5 mm TF). With 5 mm collimation, the short stenoses could be visualized only when using a 180 degrees LIA and a TF per tube rotation smaller than 7 mm. Eight and 10 mm collimations failed to depict the short stenoses.

CONCLUSIONS

Collimation had the most influence on image quality in CT angiography, followed by LIA, pitch, and contrast density. Decreasing the reconstruction increment to less than one third of the TF or increasing the voltage or current beyond standard values did not improve the delineation of the stenoses. For screening examinations, the authors recommend the use of 3 mm collimation, 180 degrees LIA, and a pitch of 2.

Preoperative evaluation of living renal donors with gadolinium-enhanced magnetic resonance angiography

BACKGROUND

Preoperative evaluation of living renal donors includes an intra-arterial digital subtraction angiography (DSA). Inasmuch as this technique is invasive, uses radiation and an iodine-containing contrast medium, an alternative technique would be preferable. The purpose of this study was to determine the accuracy of gadolinium-enhanced magnetic resonance (MR) angiography in the visualization of renovascular anatomy for the preoperative evaluation of renal donors.

METHODS

Twenty-four consecutive potential renal donors underwent gadolinium-enhanced MR angiography before the standard of reference, intra-arterial DSA. Both modalities were evaluated in a blinded manner. The results were correlated with the surgical findings.

RESULTS

Three MR angiograms were technically unacceptable because of inadequate breath-hold. The remaining 21 donors had 47 renal arteries, including 5 accessory renal arteries, which were all visualized by MR angiography. MR angiography failed to visualize one case of subtle fibromuscular dysplasia in the distal part of a renal artery. In one donor, a small accessory renal artery, which had not been visualized on DSA, was encountered during nephrectomy.

CONCLUSION

Gadolinium-enhanced MR angiography is an accurate minimally invasive method for the detection of accessory renal arteries in the preoperative evaluation of potential renal donors. The accuracy for excluding stenosis in general is high; however, the depiction of stenosis that are located far distally, or in the branch vessels, is less accurate. Advantages of gadolinium-enhanced MR angiography over the currently used method, intra-arterial DSA, are the minimal invasive nature, lower costs, and superiority in detecting venous anomalies, renal cysts, and tumors.

Helical computed tomography angiography in the evaluation of Chinese living renal donors

OBJECTIVE

To determine the suitability of helical computed tomography angiography (CTA), recently used in the anatomical evaluation of potential living renal donors (LRDs) in the Caucasian population, for Chinese LRDs.

SUBJECTS AND METHODS

Eighteen consecutive potential LRD candidates underwent both CTA and conventional renal angiography (CRA). Results from each were interpreted while unaware of the results from the other. Renal function was monitored after each radiological procedure.

RESULTS

Both procedures were able to identify all four accessory renal arteries present. One prehilar branch of < 1 mm in diameter was not recognized on CTA. Renal artery ostial stenosis in one subject with normal blood pressure was identified on CTA, but not on CRA. CTA better delineated the renal venous and parenchymal anatomy and cost 60% less than CRA. There was no change in renal function after either procedure.

CONCLUSION

Despite there being few subjects. CTA has potential value as an alternative to CRA for the anatomical assessment of potential LRDs in Hong Kong. Advantages include a short examination time, non-invasiveness and lower cost. CTA may provide an opportunity to living-related and unrelated renal donor transplantation in this conservative Chinese culture.

Spiral CT: vascular applications

Recent technical advances in CT have renewed interest in the development of CT angiography (CTA). CT angiography is a minimally invasive method of visualising the vascular system and is becoming an alternative to conventional arteriography in some situations. Spiral technology allows a volume of data to be obtained on a single breath-hold with no respiratory misregistration. Fast machines with second or subsecond acquisition times mean the images are obtained while there are high circulating levels of contrast medium giving peak vascular opacification from a peripheral intravenous injection. Accurate timing will ensure either the arterial or venous phase is imaged. Multiple overlapping axial images can be obtained from the data set with no increase in radiation dose to the patient and from these scans computer generated multiplanar and 3D images are obtained which can be viewed from numerous angles. CT angiography can be performed more quickly, less invasively and at reduced cost compared to conventional angiography.

Assessment of renal artery stenosis with CT angiography: usefulness of multiplanar reformation, quantitative stenosis measurements, and densitometric analysis of renal parenchymal enhancement as adjuncts to MIP film reading

PURPOSE

Our goal was to evaluate CT angiography (CTA) in diagnosing renal artery stenosis (RAS).

METHOD

Thirty-seven patients underwent digital subtraction angiography (DSA) and CTA. Visual interpretation and stenosis measurements were made from maximum intensity projection (MIP) and multiplanar reformation (MPR) laser film prints of 78 renal arteries.

RESULTS

Visual reading of MIP films showed good diagnostic performance by receiver operating characteristic curve analysis, with 100% sensitivity in the assessment of > or = 50% RAS but only 42-54% specificity (overall accuracy 60-75%). The false-positive rate decreased when MIP and MPR films were read together, but the excess of false negatives among the calcified lesions disabled this diagnostic algorithm. Combining visual interpretation of MIP films with quantitative measurements yielded the best diagnostic performance: 92% sensitivity, 80% specificity, and 84% overall accuracy. Renal cortical enhancement measurements (26 patients) had 81% overall accuracy.

CONCLUSION

The overall accuracy of CTA with MIP film reading can be enhanced by quantitative measurement of stenosis or reviewing MPRs.