RENAL

DOPPLE
R

Dr Mohit Goel
6 feb, 2014
 ULTRASOUND OF THE RENAL ARTERIES - NORMAL

ANTERIOR APPROACH

The renal arteries are clearly imaged in B Mode from an anterior,

subcostal approach however as it is perpendicular to the ultrasound
beam it is not suitable for Doppler assessment.

Supernumerary (duplicate) arteries can be seen looking posterior to

the IVC in B Mode and Color in a sagittal plane.
Anterior Approach
OBLIQUE APPROACH
By moving the probe to the left of midline and angling toward the patient's
right, an acceptable Doppler angle of 60 degrees is achieved. To avoid
aliasing set the colour scale high enough so it is minimized. If the scale is
too low then it is difficult to determine which vessel is the vein and which
vessel is the artery.
 Anterior Approach Oblique Approach

Transverse B-mode view of the abdominal aorta

and right renal artery from an anterior approach. By moving the probe to the left of midline
and angling toward the patient’s right,
The ultrasound probe is oriented at midline and an acceptable Doppler angle of 60
the Doppler cursor placed in the proximal right renal degrees is achieved
artery.
The angle of incidence of the Doppler beam to the
flow is unacceptable at approximately 89 degrees.
Flank/ Coronal Approach
Roll the patient into a decubitus position to avoid bowel gas and improve
visibility of the renal artery, especially the mid to distal portion.
FLANK APPROACH
Oblique approach for right renal artery Right Decubitus for left renal artery
 Flank approach showing the abdominal aorta and origin of both renal arteries.

The Doppler sample volume is placed The Doppler reading of the abdominal
within the proximal right renal artery. In aorta is taken near the level of the renal
this view, an acceptable Doppler angle of arteries.
60 degrees or less is easily obtained. This value is applied to the RAR .
 Arterial anatomy
Upon reaching the renal hilum, the main renal arteries divide into anterior and posterior segmental
arteries. These further divide to feed the multiple segments of the kidney. The segmental arteries, in
turn, give rise to the interlobar arteries which course alongside the renal pyramids toward the
periphery of the kidney. The interlobar arteries branch into arcuate arteries at the corticomedullary
junction. The arcuate arteries travel across the top of the renal pyramids and give rise to the
interlobular arteries
 Supernumery right renal arteries.
Variant anatomy is common in the renal vascular system. Approximately 30% of
individuals have more than a single renal artery on each side. Supernumery
arteries may occur unilaterally or bilaterally.

Most accessory renal arteries arise from the abdominal aorta, but they may also
originate from the common iliac, superior or inferior mesenteric, adrenal, and right
hepatic arteries.
 Anomalous left renal vein
Anomalous anatomy affects the venous drainage as well as the arterial
inflow. The left renal vein may follow a retroaortic course passing
posterior to the aorta instead between the aorta and SMA.
 Circum Aortic Left Renal Vein

Alternatively, the renal vein may be circumaortic, dividing before reaching the aorta with
one branch coursing anteriorly and another posteriorly
Normal renal arteries demonstrate low resistance waveforms – R I <
0.7.
Increased vascular resistance with decreased diastolic flow may be
seen in hydronephrosis, renal vein thrombosis and chronic renal
disease. RI increases with decreasing diastolic flow.
• Normal intrarenal arteries
• – low resistance
• – R I is < 0.7
• – ESP (Early systolic peak)
present
• Rapid acceleration to peak
systole (< .07s)
Normal Doppler waveforms obtained from the main renal artery and segmental renal artery

A low resistance waveform with sharp systolic upstroke is expected in the normal main
renal artery (A).

The early systolic peak (ESP) (arrow) is seen as a small notch in systole in the normal
intrarenal arterial waveform. The systolic upstroke is rapid with an acceleration time of
0.07 seconds or less.
Contrast angiography (CA) is the gold standard in the diagnosis of renal
artery stenosis (RAS).

Due to its invasive nature, however, CA is not suitable for screening.

Multiple studies have shown that Doppler Ultrasound can be an effective

tool in the diagnosis of RAS.
TWO DOPPLER METHODS FOR DETECTING
RENAL ARTERY STENOSIS
• Direct Evaluation
• Direct visualization with
Doppler throughout the
Main renal artery and all
accessory renal arteries
• Indirect Evaluation
• Doppler of the
segmental/interlobar renal
arteries at the upper, mid
and lower renal poles

The most reliable approach combines the two methods.

 Direct Evaluation

The direct method involves Doppler interrogation of the entire

length of the main renal artery, including any accessory renal
arteries.

Although stenosis is usually located near the renal artery origin,

fibromuscular dysplasia is more often located in the mid to distal
segment, thus requiring a look at the entire length of each artery.

The highest velocity found in the renal artery is compared to that of

the abdominal aorta (at the level of the renal arteries). This is termed
the renal/aortic ratio or RAR.
 Criteria for Renal Artery Stenosis
Direct Evaluation
• Velocities greater than 200 cm/sec have been shown to indicate a
>60% RAS.

• Post-stenotic turbulence must be documented beyond any focal

velocity increase to confirm stenosis.

• Bruits seen in Color Doppler or in the spectral waveform can also

increase diagnostic confidence and aid in localization of a stenosis.

• The RAR is calculated by dividing the highest peak systolic velocity in

the renal artery by the normal aortic velocity. An RAR greater than 3.5
is considered abnormal.
The use of the RAR instead of the absolute PSV value is preferable since hypertension
itself can cause increased PSV velocities in all the vessels in hypertensive patients
 Patient with renal artery stenosis

Image A is a color Doppler image of a stenotic right renal artery origin.

A color bruit is seen in the tissue surrounding the area of the post stenotic turbulence.

The presence of the bruit can help to identify the location of the stenosis and increase
diagnostic confidence.
A Doppler reading(B) obtained near the renal artery origin shows velocities over 600
cm/s in systole and over 300 cm/s in diastole consistent with a high grade stenosis.

The arrows are pointing to a bruit that is evident on the spectral display.
Image C shows a spectral waveform obtained in the area of poststenotic turbulence just beyond
the maximal area of stenosis.
The velocity is lower at 317 cm/s and the waveform profile is irregular due to the turbulent flow.
 Criteria for Renal Artery Stenosis

Indirect Evaluation

• Absence of ESP (most sensitive criterion)

• Tardus Parvus shape

• Delayed acceleration time (AT > .07 sec)

• RI difference between kidneys exceeding >0.05–0.07

The Doppler waveform obtained from the segmental renal arteries within the right
kidney shows a tardus parvus shape with absence of the ESP (D).

The AT measures 0.11 sec.

Tardus–parvus waveform in a patient with RA stenosis. Note the delayed and dampened
upstroke yielding a rounded appearance to the waveform.
 Range of abnormal waveforms with increasing levels
Normal of renal artery stenosis from top to bottom.

• The ESP is detected on each waveform.

• In some cases, the ESP is the highest peak, but in Since the ESP is absent on abnormal waveforms, the AT is
others, the highest peak occurs later in systole. measured from the beginning of systole to the systolic
• The AT is always measured to the first systolic peak, peak. These waveforms are termed tardus parvus due
which is the ESP in normal waveforms. to the delayed systolic acceleration.
RENAL TRANSPLANT

• Pathologies
• Rejection.
• Infraction.
• Renal artery anastomotic stenosis
• Renal vein anastomotic stenosis
• A V fistula.
 REJECTION

In cases of severe acute rejection,

the transplanted kidney becomes
edematous and manifests as a
globular, hypoechoic mass with poor
differentiation of the central renal
sinus fat.
The edema leads to increased
vascluar resistance and elevation
of the resistive index.

However, the finding of increased

resistive index is a non-specific
finding which can also be seen in
the setting of infection, acute
tubular necrosis, perioperative
ischemia, hydronephrosis and
extrinsic compression
 Infarct of a renal graft.

Power Doppler US image demonstrates segmental loss of perfusion in the

transplanted kidney (arrows), a finding compatible with infarct.
©2005 by Radiological Society of North America
Renal artery anastomotic stenosis
 Renal vein anastomotic stenosis

Ultrasound findings of hemodynamically significant venous stenosis

include

• focal narrowing with upstream luminal dilatation,

• focal color aliasing and

• focally increased velocity with 4-fold or greater gradient across the

segment of suspected stenosis.
Venous thrombosis can occur secondary to infection, severe rejection or
technical problems with the anastomosis.

The diagnostic ultrasound findings include absence of flow on Power,

color and spectral Doppler analysis.

Venous thrombosis results in a high-resistance vascular circuit and can

result in subsequent reversal of diastolic flow in the arterial waveform;
however, reversed diastolic flow is a nonspecific finding which can be
seen in severe rejection, severe pyelonephritis, drug toxicity and extrinsic
compression.
 Arteriovenous fistula.

Color Doppler US image demonstrates a highly vascular lesion.

 Arteriovenous fistula.

Akbar S A et al. Radiographics 2005;25:1335-1356

Duplex Doppler US image of the lower pole segmental artery shows increased
velocity and decreased resistive index.
©2005 by Radiological Society of North America
 Arteriovenous fistula.

DuplexAkbar S A et al. Radiographics 2005;25:1335-1356

Doppler US image of the adjacent vein shows arterialization of flow, a finding
consistent with arteriovenous fistula.
©2005 by Radiological Society of North America
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