Renal artery stenosis diagnostic criteria: Difference between revisions

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__NOTOC__
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{{Renal artery stenosis}}
{{Renal artery stenosis}}
{{CMG}}; {{AE}} [[User:YazanDaaboul|Yazan Daaboul]],[[User:Sergekorjian|Serge Korjian]]
{{CMG}}; '''Associate Editor-In-Chief:''' {{Shivam Singla}}


==Overview==
==Overview==
Several clinical clues aid in the suspicion of ARAS and warrant further investigation. To date, imaging is considered the optimal modality to diagnose ARAS. According to the ACC/AHA guidelines in 2011, Doppler ultrasonography, CT angiography, and MR angiography are all non-invasive techniques to diagnose ARAS. Renal angiography remains the gold standard for diagnosis of ARAS. Nonethetheless, it is an invasive procedure that should be reserved to patients who are planning to perform a catheterization procedure and concede to renal angiography or to patients whose non-invasive imaging was equivocal.
There are numerous tests and procedures involved in the detection of [[renal artery stenosis]]. [[Renal artery stenosis]] is best diagnosed with [[MRA]](Magnetic resonance Imaging), [[Doppler ultrasound]], [[Computed tomography]], [[renal scintigraphy]], peripheral renin levels, and [[renal vein sampling]]. Though these all modalities are used for making the diagnosis but still [[renal vein sampling]], [[renal scintigraphy]] is not the first choice for making the diagnosis of [[renal artery stenosis]] because of their low [[sensitivity]] and [[specificity]] which is around 38-40.


==Diagnosis==
==Diagnosis==
===Indications for Work-Up===
According to the 2011 ACC/AHA Guidelines for the Management of PAD<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>, diagnostic work-up for renal artery stenosis is indicated in the following conditions:


====Class I Recommendations<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>====
There are numerous tests and procedures involved in the detection of [[renal artery stenosis]]. [[Renal artery stenosis]] is best diagnosed with [[MRA]](Magnetic resonance Imaging), [[Doppler ultrasound]], [[Computed tomography]], [[renal scintigraphy]], peripheral [[renin levels]], and [[renal vein]] sampling. Though these all modalities are used for making the diagnosis but still [[renal vein]] sampling, [[renal scintigraphy]] are not the first choice for making the diagnosis of [[renal artery stenosis]] because of their low [[sensitivity]] and [[specificity]]<ref name="pmid11960229">{{cite journal |vauthors=Napoli V, Pinto S, Bargellini I, Vignali C, Cioni R, Petruzzi P, Salvetti A, Bartolozzi C |title=Duplex ultrasonographic study of the renal arteries before and after renal artery stenting |journal=Eur Radiol |volume=12 |issue=4 |pages=796–803 |date=April 2002 |pmid=11960229 |doi=10.1007/s003300101121 |url=}}</ref><ref name="pmid8610560">{{cite journal |vauthors=Grenier N, Trillaud H, Combe C, Degrèze P, Jeandot R, Gosse P, Douws C, Palussière J |title=Diagnosis of renovascular hypertension: feasibility of captopril-sensitized dynamic MR imaging and comparison with captopril scintigraphy |journal=AJR Am J Roentgenol |volume=166 |issue=4 |pages=835–43 |date=April 1996 |pmid=8610560 |doi=10.2214/ajr.166.4.8610560 |url=}}</ref> which is around 38-40.  
*Hypertension of any stage before the age of 30
*Stage II hypertension in patients older than 55 years
*Accelerated condition of a previously controlled hypertension
*[[Resistant hypertension]]
*[[Malignant hypertension]]
*New [[azotemia]] after administration of ACE-I or ARB
*Unexplained atrophic kidney or asymmetric kidneys that differ by > 1.5 cm
*Sudden unexplained pulmonary edema


====Class IIa Recommendations<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>====
The imaging modalities may be considered diagnostic if the following objectives are met:
*Unexplained renal failure including patients starting renal replacement therapy


====Class IIb Recommendations<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>====
(1) [[Anatomic]] and or [[Hemodynamic]] abnormality
*Presence of multi vessel [[CAD]] and no clinical clues of ARAS or PAD
*Unexplained [[CHF]] or [[refractory angina]]


<br>
(2) Anatomic consequences and complications associated with [[renal artery stenosis]] (Post stenotic dilatation of [[renal artery]] can be seen with the use of [[CTA]] and [[MRA]], shrinkage of [[renal parenchyma]], with [[kidneys]] being < 8 cm.


==Diagnostic Methods<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>==
(3) [[Functional]] and [[cellular]] consequences of [[renal artery stenosis]]
The best technique to diagnose ARAS is by imaging. Assessment of both the main and the accessory renal arteries bilaterally is important for diagnostic purposes. Further evaluation should include the anatomic location of the stenosis, severity of stenosis, associated perirenal and perivascular pathologies, such as aneurysms or masses.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref> Duplex ultrasonography, computer tomographic angiography (CTA), magnetic resonance angiography (MRA), and catheter angiography are 4 techniques that are currently recommended for the diagnosis of ARAS.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref> In contrast, neither selective renal vein renin studies and [[captopril]] renal scintigraphy nor plasma renin activity and [[captopril]] test are still not recommended.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>


====Duplex Ultrasonography====
(4) [[Renal]] impairment criteria related to [[renovascular disease]] should be me<ref name="pmid16356793">{{cite journal |vauthors=Grenier N, Hauger O, Cimpean A, Pérot V |title=Update of renal imaging |journal=Semin Nucl Med |volume=36 |issue=1 |pages=3–15 |date=January 2006 |pmid=16356793 |doi=10.1053/j.semnuclmed.2005.08.001 |url=}}</ref>.
Diagnosis by Duplex ultrasonography is considered class I recommendation. It may be used as an initial screening tool for diagnosis of ARAS. Ultrasonography might not be very accurate in obese patients or those intestinal gas.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>


====Computed Tomographic Angiography====
==='''<u>Ultrasonography</u>'''===
Diagnosis by CT angiography is considered class I recommendation. It provides higher spacial resolution compared to MRA. CT angiography may be used in patients with normal renal function to avoid contrast-induced nephropathy in patients with impaired renal function. Presence of previous stents or metallic objects are considered a contraindication for the use of CTA.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>
[[Ultrasonography]] is readily available, secure, and inexpensive, and consequently is usually the first imaging study used to detect [[Renal artery stenosis]]. Usually, the results and accuracy are operator dependent and range in between 60-90%<ref name="pmid19917332">{{cite journal |vauthors=Zhang HL, Sos TA, Winchester PA, Gao J, Prince MR |title=Renal artery stenosis: imaging options, pitfalls, and concerns |journal=Prog Cardiovasc Dis |volume=52 |issue=3 |pages=209–19 |date=2009 |pmid=19917332 |doi=10.1016/j.pcad.2009.10.003 |url=}}</ref>.
This modality helps in the assessment of


====Magnetic Resonance Angiography====
*[[Renal functional reserve]]
Diagnosis by MRA is considered class I recommendation. Gadolinium-based MRA has less nephrotoxic characterstics with good visualization of the renal arteries and perirenal pathologies. Presence of previous stents or metallic objects are considered a contraindication for the use of MRA.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>
*[[Renal resistive index]]


====Catheter Angiography====
A [[renal artery]] EDV >90cm/s<ref name="pmid11172177">{{cite journal |vauthors=Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ, Galanski M, Koch KM, Haller H |title=Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis |journal=N Engl J Med |volume=344 |issue=6 |pages=410–7 |date=February 2001 |pmid=11172177 |doi=10.1056/NEJM200102083440603 |url=}}</ref> and RRI< 75-80<ref name="pmid11704015">{{cite journal |vauthors=Mukherjee D, Bhatt DL, Robbins M, Roffi M, Cho L, Reginelli J, Bajzer C, Navarro F, Yadav JS |title=Renal artery end-diastolic velocity and renal artery resistance index as predictors of outcome after renal stenting |journal=Am J Cardiol |volume=88 |issue=9 |pages=1064–6 |date=November 2001 |pmid=11704015 |doi=10.1016/s0002-9149(01)01996-8 |url=}}</ref> represents no [[microvascular disease]]. The hemodynamic significant abnormality is concluded with the presence of spectral broadening and increased velocity on [[USG]].
Catheter angiography is considered class I recommendation. It is the gold standard for the diagnosis of ARAS. Renal angiography may be used only if previous tests are equivocal and clinical suspicion is high or if the patient is already undergoing another catheterization process and concedes to renal angiography. Generally, it is associated with a low frequency of adverse events.<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>


==2011 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>==
[[Reno aortic velocity]] ratio > 3.5 corresponds with 60% [[stenosis]]<ref name="pmid7741367">{{cite journal |vauthors=Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB |title=The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis |journal=Ann Intern Med |volume=122 |issue=11 |pages=833–8 |date=June 1995 |pmid=7741367 |doi=10.7326/0003-4819-122-11-199506010-00004 |url=}}</ref> and RAPSV (Renal artery peak systolic velocity) greater than 150cm/s corresponds to 50% stenosis whereas velocity greater than 180cm/s  corresponds to 60% stenosis<ref name="pmid7741367">{{cite journal |vauthors=Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB |title=The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis |journal=Ann Intern Med |volume=122 |issue=11 |pages=833–8 |date=June 1995 |pmid=7741367 |doi=10.7326/0003-4819-122-11-199506010-00004 |url=}}</ref><ref name="pmid7569132">{{cite journal |vauthors=Hélénon O, el Rody F, Correas JM, Melki P, Chauveau D, Chrétien Y, Moreau JF |title=Color Doppler US of renovascular disease in native kidneys |journal=Radiographics |volume=15 |issue=4 |pages=833–54; discussion 854–65 |date=July 1995 |pmid=7569132 |doi=10.1148/radiographics.15.4.7569132 |url=}}</ref>. According to recent studies, the [[sensitivity]] and [[specificity]] of [[ultrasound-guided]] detection of [[renal artery stenosis]] are usually 85% and 92% respectively. Severe [[stenosis]] is diagnosed on [[USG]] with slowed [[systolic accelerations]] along with the decreased [[resistive index]]<ref name="pmid1620853">{{cite journal |vauthors=Stavros AT, Parker SH, Yakes WF, Chantelois AE, Burke BJ, Meyers PR, Schenck JJ |title=Segmental stenosis of the renal artery: pattern recognition of tardus and parvus abnormalities with duplex sonography |journal=Radiology |volume=184 |issue=2 |pages=487–92 |date=August 1992 |pmid=1620853 |doi=10.1148/radiology.184.2.1620853 |url=}}</ref>.
===Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)<ref name="pmid21963765">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK et al.| title=2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2011 | volume= 58 | issue= 19 | pages= 2020-45 | pmid=21963765 | doi=10.1016/j.jacc.2011.08.023 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21963765  }} </ref>===


{|class="wikitable"
[[Quantitative]] criteria for diagnosing distal [[stenosis]] includes early peak [[systolic]] acceleration <3m/s2, an acceleration index > 4m/s2, and or greater than 5% difference in [[RRI]] between both the [[kidneys]]. Because these waveforms are difficult to interpret these criteria are difficult to interpret<ref name="pmid12823921">{{cite journal |vauthors=Conkbayir I, Yücesoy C, Edgüer T, Yanik B, Yaşar Ayaz U, Hekimoğlu B |title=Doppler sonography in renal artery stenosis. An evaluation of intrarenal and extrarenal imaging parameters |journal=Clin Imaging |volume=27 |issue=4 |pages=256–60 |date=2003 |pmid=12823921 |doi=10.1016/s0899-7071(02)00547-8 |url=}}</ref><ref name="pmid8983584">{{cite journal |vauthors=Baxter GM, Aitchison F, Sheppard D, Moss JG, McLeod MJ, Harden PN, Love JG, Robertson M, Taylor G |title=Colour Doppler ultrasound in renal artery stenosis: intrarenal waveform analysis |journal=Br J Radiol |volume=69 |issue=825 |pages=810–5 |date=September 1996 |pmid=8983584 |doi=10.1259/0007-1285-69-825-810 |url=}}</ref>.
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]


|-
===<u>Computed Tomographic Angiography.</u>===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is indicated in patients with the onset of [[hypertension]] before the age of 30 years. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
[[CT angiography]] provides a three-dimensional assessment of the tissue as one of the important tools in the diagnosis of [[Renal artery stenosis]].  


|-
*Contraindicated in patients with [[contrast allergy]] as this procedure modality involves the [[ionizing radiations]] and [[iodinated]] [[contrast]] medium.
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is indicated in patients with the onset of severe [[hypertension]] [as defined in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC-7 report (294)] after the age of 55 years. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*In [[patients]] having underlying [[renal impairment]] the use of [[iodinated contrast]] can lead to the development of [[contrast-induced nephropathy]], but it can be prevented with the use of [[hydration]] before doing the procedure.
*The [[sensitivity]] of this procedure is extremely high with 94% and [[specificity]] varies between 60% to 90 %<ref name="pmid17050355">{{cite journal |vauthors=Eklöf H, Ahlström H, Magnusson A, Andersson LG, Andrén B, Hägg A, Bergqvist D, Nyman R |title=A prospective comparison of duplex ultrasonography, captopril renography, MRA, and CTA in assessing renal artery stenosis |journal=Acta Radiol |volume=47 |issue=8 |pages=764–74 |date=October 2006 |pmid=17050355 |doi=10.1080/02841850600849092 |url=}}</ref><ref name="pmid17497443">{{cite journal |vauthors=Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, Fezoulidis IV, Stefanidis I |title=Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography |journal=Ren Fail |volume=29 |issue=3 |pages=295–302 |date=2007 |pmid=17497443 |doi=10.1080/08860220601166305 |url=}}</ref>.
*[[CTA]] can give the detailed resolution of even small [[accessory renal arteries]].
*It is also the diagnostic modality of choice in patients having limited capacity to hold breath and also in patients having [[claustrophobia]].
*At the same time, [[CTA]] is having limited diagnostic modality as compared to [[MRA]] in detecting clinically significant [[Renal artery stenosis]] and also in patients having [[renal]] dysfunction<br />


|-
===<u>Magnetic Resonance Angiography</u>===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is indicated in patients with the following characteristics: (a) accelerated [[hypertension]] (sudden and persistent worsening of previously controlled hypertension); (b) [[resistant hypertension]] (defined as the failure to achieve goal [[blood pressure]] in patients who are adhering to full doses of an appropriate 3-drug regimen that includes a [[diuretic]]); or (c) [[malignant hypertension]] (hypertension with coexistent evidence of acute end-organ damage, i.e., [[acute renal failure]], acutely [[decompensated congestive heart failure]], new visual or [[neurological]] disturbance, and/or advanced [grade III to IV] retinopathy). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
[[MRA]] is having [[sensitivity]] and [[specificity]] of 90-100%<ref name="pmid17050355">{{cite journal |vauthors=Eklöf H, Ahlström H, Magnusson A, Andersson LG, Andrén B, Hägg A, Bergqvist D, Nyman R |title=A prospective comparison of duplex ultrasonography, captopril renography, MRA, and CTA in assessing renal artery stenosis |journal=Acta Radiol |volume=47 |issue=8 |pages=764–74 |date=October 2006 |pmid=17050355 |doi=10.1080/02841850600849092 |url=}}</ref><ref name="pmid17497443">{{cite journal |vauthors=Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, Fezoulidis IV, Stefanidis I |title=Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography |journal=Ren Fail |volume=29 |issue=3 |pages=295–302 |date=2007 |pmid=17497443 |doi=10.1080/08860220601166305 |url=}}</ref>  


|-
*This procedure does not involve the use of [[iodinated contrast]] or [[radiations]], unlike [[CTA]].
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is indicated in patients with new [[azotemia]] or worsening [[renal function]] after the administration of an [[ACE inhibitor]] or an angiotensin receptor blocking agent (see text). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*In patients with intermediate to [[end-stage renal failure]] due to the risk of [[nephrogenic]] systemic [[fibrosis]], [[gadolinium-based contrast media]] should be avoided.
*Additionally, In patients with the kind of implanted devices (i.e., [[pacemakers]], [[defibrillators]], [[cochlear implants]], and [[spinal cord stimulators]]), or in [[claustrophobic]] patients, [[MRA]] should not be used.
*[[Contrast]] reaction associated with [[MRA]] is lower as compared to [[CTA]]


|-
===<u>Angiography</u>===
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is indicated in patients with an unexplained [[atrophic]] kidney or a discrepancy in size between the 2 kidneys of greater than 1.5 cm. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
Invasive [[renal arteriography]] is an important helpful modality used these days in evaluating [[Renal artery stenosis]].


|-
*[[Angiography]] can detect intrarenal [[vascular]] abnormalities and [[anatomical]] abnormalities of the [[kidneys]], [[renal arteries]], and [[aorta]], in addition to evaluating the severity of [[RAS]].
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is indicated in patients with sudden, unexplained [[pulmonary edema]] (especially in azotemic patients). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*[[Digital angiography]] by subtraction increases contrast resolution and can minimize the amount of [[contrast]] required to as little as 15mL.
|}
*There are risks involved with [[arterial puncture]] and catheter/wire stimulation because [[renal angiography]] is invasive, which may lead to [[arterial damage]], [[spasm]], or [[thromboembolic phenomena]]<ref name="pmid7500898">{{cite journal |vauthors=Thadhani RI, Camargo CA, Xavier RJ, Fang LS, Bazari H |title=Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases |journal=Medicine (Baltimore) |volume=74 |issue=6 |pages=350–8 |date=November 1995 |pmid=7500898 |doi=10.1097/00005792-199511000-00005 |url=}}</ref>.
*[[Carbon dioxide]] should be used as a [[non-nephrotoxic]] [[contrast]] agent in patients with [[renal failure]] or [[contrast allergy]].
*To assess hemodynamic importance before conducting therapeutic procedures such as [[percutaneous transluminal renal angioplasty]] (PTRA) or stenting, translesional pressure gradients may be measured across regions of [[stenosis]].


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The performance of [[diagnostic]] studies to identify clinically significant RAS is reasonable in patients with unexplained [[renal failure]], including individuals starting [[renal replacement therapy]] ([[dialysis]] or [[renal transplantation]]). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The performance of [[arteriography]] to identify significant RAS may be reasonable in patients with [[multivessel coronary artery disease]] and none of the clinical clues (Figure 17) or PAD at the time of arteriography. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The performance of [[diagnostic]] studies to identify clinically significant RAS may be reasonable in patients with unexplained [[congestive heart failure]] or refractory [[angina]] (see Section 3.5.2.4). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
=== Diagnostic Methods (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref> ===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Duplex [[ultrasonography]] is recommended as a [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Computed tomographic [[angiography]] (in individuals with normal renal function) is recommended as a [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Magnetic resonance angiography]] is recommended as a [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, catheter angiography is recommended as a [[diagnostic]] test to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Captopril]] renal [[scintigraphy]] is not recommended as a [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Selective [[renal vein]] renin measurements are not recommended as a useful [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' [[Plasma renin activity]] is not recommended as a useful [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''4.''' The [[captopril]] test (measurement of [[plasma renin activity]] after captopril administration) is not recommended as a useful [[screening test]] to establish the diagnosis of RAS. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==References==
==References==
 
<references />
{{Reflist|2}}
 
[[Category:Kidney diseases]]
[[Category:Nephrology]]
[[Category:Cardiology]]
 
{{WH}}
{{WS}}

Latest revision as of 23:04, 13 December 2020

Renal artery stenosis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Shivam Singla, M.D.[2]

Overview

There are numerous tests and procedures involved in the detection of renal artery stenosis. Renal artery stenosis is best diagnosed with MRA(Magnetic resonance Imaging), Doppler ultrasound, Computed tomography, renal scintigraphy, peripheral renin levels, and renal vein sampling. Though these all modalities are used for making the diagnosis but still renal vein sampling, renal scintigraphy is not the first choice for making the diagnosis of renal artery stenosis because of their low sensitivity and specificity which is around 38-40.

Diagnosis

There are numerous tests and procedures involved in the detection of renal artery stenosis. Renal artery stenosis is best diagnosed with MRA(Magnetic resonance Imaging), Doppler ultrasound, Computed tomography, renal scintigraphy, peripheral renin levels, and renal vein sampling. Though these all modalities are used for making the diagnosis but still renal vein sampling, renal scintigraphy are not the first choice for making the diagnosis of renal artery stenosis because of their low sensitivity and specificity[1][2] which is around 38-40.

The imaging modalities may be considered diagnostic if the following objectives are met:

(1) Anatomic and or Hemodynamic abnormality

(2) Anatomic consequences and complications associated with renal artery stenosis (Post stenotic dilatation of renal artery can be seen with the use of CTA and MRA, shrinkage of renal parenchyma, with kidneys being < 8 cm.

(3) Functional and cellular consequences of renal artery stenosis

(4) Renal impairment criteria related to renovascular disease should be me[3].

Ultrasonography

Ultrasonography is readily available, secure, and inexpensive, and consequently is usually the first imaging study used to detect Renal artery stenosis. Usually, the results and accuracy are operator dependent and range in between 60-90%[4]. This modality helps in the assessment of

A renal artery EDV >90cm/s[5] and RRI< 75-80[6] represents no microvascular disease. The hemodynamic significant abnormality is concluded with the presence of spectral broadening and increased velocity on USG.

Reno aortic velocity ratio > 3.5 corresponds with 60% stenosis[7] and RAPSV (Renal artery peak systolic velocity) greater than 150cm/s corresponds to 50% stenosis whereas velocity greater than 180cm/s corresponds to 60% stenosis[7][8]. According to recent studies, the sensitivity and specificity of ultrasound-guided detection of renal artery stenosis are usually 85% and 92% respectively. Severe stenosis is diagnosed on USG with slowed systolic accelerations along with the decreased resistive index[9].

Quantitative criteria for diagnosing distal stenosis includes early peak systolic acceleration <3m/s2, an acceleration index > 4m/s2, and or greater than 5% difference in RRI between both the kidneys. Because these waveforms are difficult to interpret these criteria are difficult to interpret[10][11].

Computed Tomographic Angiography.

CT angiography provides a three-dimensional assessment of the tissue as one of the important tools in the diagnosis of Renal artery stenosis.

Magnetic Resonance Angiography

MRA is having sensitivity and specificity of 90-100%[12][13]

Angiography

Invasive renal arteriography is an important helpful modality used these days in evaluating Renal artery stenosis.


References

  1. Napoli V, Pinto S, Bargellini I, Vignali C, Cioni R, Petruzzi P, Salvetti A, Bartolozzi C (April 2002). "Duplex ultrasonographic study of the renal arteries before and after renal artery stenting". Eur Radiol. 12 (4): 796–803. doi:10.1007/s003300101121. PMID 11960229.
  2. Grenier N, Trillaud H, Combe C, Degrèze P, Jeandot R, Gosse P, Douws C, Palussière J (April 1996). "Diagnosis of renovascular hypertension: feasibility of captopril-sensitized dynamic MR imaging and comparison with captopril scintigraphy". AJR Am J Roentgenol. 166 (4): 835–43. doi:10.2214/ajr.166.4.8610560. PMID 8610560.
  3. Grenier N, Hauger O, Cimpean A, Pérot V (January 2006). "Update of renal imaging". Semin Nucl Med. 36 (1): 3–15. doi:10.1053/j.semnuclmed.2005.08.001. PMID 16356793.
  4. Zhang HL, Sos TA, Winchester PA, Gao J, Prince MR (2009). "Renal artery stenosis: imaging options, pitfalls, and concerns". Prog Cardiovasc Dis. 52 (3): 209–19. doi:10.1016/j.pcad.2009.10.003. PMID 19917332.
  5. Radermacher J, Chavan A, Bleck J, Vitzthum A, Stoess B, Gebel MJ, Galanski M, Koch KM, Haller H (February 2001). "Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis". N Engl J Med. 344 (6): 410–7. doi:10.1056/NEJM200102083440603. PMID 11172177.
  6. Mukherjee D, Bhatt DL, Robbins M, Roffi M, Cho L, Reginelli J, Bajzer C, Navarro F, Yadav JS (November 2001). "Renal artery end-diastolic velocity and renal artery resistance index as predictors of outcome after renal stenting". Am J Cardiol. 88 (9): 1064–6. doi:10.1016/s0002-9149(01)01996-8. PMID 11704015.
  7. 7.0 7.1 Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB (June 1995). "The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis". Ann Intern Med. 122 (11): 833–8. doi:10.7326/0003-4819-122-11-199506010-00004. PMID 7741367.
  8. Hélénon O, el Rody F, Correas JM, Melki P, Chauveau D, Chrétien Y, Moreau JF (July 1995). "Color Doppler US of renovascular disease in native kidneys". Radiographics. 15 (4): 833–54, discussion 854–65. doi:10.1148/radiographics.15.4.7569132. PMID 7569132.
  9. Stavros AT, Parker SH, Yakes WF, Chantelois AE, Burke BJ, Meyers PR, Schenck JJ (August 1992). "Segmental stenosis of the renal artery: pattern recognition of tardus and parvus abnormalities with duplex sonography". Radiology. 184 (2): 487–92. doi:10.1148/radiology.184.2.1620853. PMID 1620853.
  10. Conkbayir I, Yücesoy C, Edgüer T, Yanik B, Yaşar Ayaz U, Hekimoğlu B (2003). "Doppler sonography in renal artery stenosis. An evaluation of intrarenal and extrarenal imaging parameters". Clin Imaging. 27 (4): 256–60. doi:10.1016/s0899-7071(02)00547-8. PMID 12823921.
  11. Baxter GM, Aitchison F, Sheppard D, Moss JG, McLeod MJ, Harden PN, Love JG, Robertson M, Taylor G (September 1996). "Colour Doppler ultrasound in renal artery stenosis: intrarenal waveform analysis". Br J Radiol. 69 (825): 810–5. doi:10.1259/0007-1285-69-825-810. PMID 8983584.
  12. 12.0 12.1 Eklöf H, Ahlström H, Magnusson A, Andersson LG, Andrén B, Hägg A, Bergqvist D, Nyman R (October 2006). "A prospective comparison of duplex ultrasonography, captopril renography, MRA, and CTA in assessing renal artery stenosis". Acta Radiol. 47 (8): 764–74. doi:10.1080/02841850600849092. PMID 17050355.
  13. 13.0 13.1 Rountas C, Vlychou M, Vassiou K, Liakopoulos V, Kapsalaki E, Koukoulis G, Fezoulidis IV, Stefanidis I (2007). "Imaging modalities for renal artery stenosis in suspected renovascular hypertension: prospective intraindividual comparison of color Doppler US, CT angiography, GD-enhanced MR angiography, and digital substraction angiography". Ren Fail. 29 (3): 295–302. doi:10.1080/08860220601166305. PMID 17497443.
  14. Thadhani RI, Camargo CA, Xavier RJ, Fang LS, Bazari H (November 1995). "Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases". Medicine (Baltimore). 74 (6): 350–8. doi:10.1097/00005792-199511000-00005. PMID 7500898.