Diagnostic angiography for renovascular hypertension

Presentation Pimsiree Thalangsri

Computed Tomographic Angiography

The advent of spiral (helical) CT scanning made CT angiography (CTA) feasible. Continuous scanning through the area of interest during a single breath-hold provides data of sufficient fidelity to reconstruct three-dimensional (3D). A variety of scanning protocols have been used and may be tailored to the length of the part being studied.

Computed Tomographic Angiography

Accessory renal arteries are almost always detected with CTA.

Renal artery stenoses, in either the main or an accessory renal artery, are also detected with a high degree of accuracy.

The sensitivity and specificity of CTA in detecting renal artery stenoses of 50% or more are approximately 90% and 97%, respectively.
When only stenoses of 75% or greater are considered; the sensitivity is even higher.

Since many of the false-positive and falsenegative results are from accessory arteries, the accuracy of detecting stenoses in the main renal arteries is nearly as good as arteriography.

Magnetic Resonance Angiography

Magnetic resonance angiography (MRA) has been used to detect renal artery stenosis using time-of-flight and phasecontrast techniques. These studies have been limited by turbulent blood flow, which results in signal dropout, and by image degradation from respiratory motion.

Three-dimensional gadolinium (3D-Gd) MRA eliminates these problems by acquiring a complete data set in a single breathhold

Magnetic rensonance angiography

In addition to being a noninvasive test, MRA does not require a nephrotoxic contrast material, nor is ionizing radiation involved.

When compared to angiography, the sensitivities and specificities of MRA for the detection of renal artery stenosis are greater than 90%.
The primary limitations of the 3D-Gd MRA technique include spatial resolution, optimal bolus timing, and the need to keep the scan time short enough for breath holding.

MRA may be used to detect stenoses involving the proximal portion of the renal artery, the most common site of involvement by atherosclerosis. Evaluation of the branch or accessory renal arteries is more difficult. It is also not clear how well this technique will detect fibromuscular dysplasia. The renal parenchyma is seen on both MRA and CTA images, which helps to assess the likelihood of return of function after revascularization.

High grade renal artery stenosis

Atrophic left kidney

Arteriography
Arteriography remains the gold standard for the detection of renal artery stenosis. The hernodynamic significance may be assessed by the severity of the stenosis and by the presence or absence of collateral vessels. Lesions must occlude at least 50% of the vessel diameter to be considered significant.

However, this measurement is imprecise and does not assess the cross-sectional area or, more importantly, flow. Collateral vessels indicate that the lesion is significant because alternate pathways to provide flow have developed. Epinephrine may further restrict flow to the kidneys and may make these collaterals more apparent.

The most appropriate treatment often may be determined by the nature and location of the stenosis. A focal stenosis of the main renal artery often responds to percutaneous transluminal angioplasty (PTA), whereas a lon stenosis, orifice lesion, or bilateral disease does not do as well.

Renal artery stenosis with collateral vessels

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