Renal artery stenosis diagnostic criteria: Difference between revisions

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==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 2013, 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. Nonetheless, 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==


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 which is around 38-40.  
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.  


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


(1) Anatomic and or Hemodynamic abnormality
(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.  
(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  
(3) [[Functional]] and [[cellular]] consequences of [[renal artery stenosis]]


(4) Renal criteria associated with renal impairment related to renovascular disease must be met.
(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>.


=== '''Ultrasonography''' ===
==='''<u>Ultrasonography</u>'''===
Ultrasonography is widely available, safe, and inexpensive and consequently is typically the first imaging study used to detect ARAS. However, results are operator dependent, with accuracy ranging from 60% to 90%; the entire length of the renal artery or an accessory renal artery can be overlooked, and thus the stenotic lesion will be missed.42
[[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


Information on size of the kidneys, renal functional reserve, and renal resistive index (RRI [defined as peak systolic velocity – end-diastolic velocity/peak systolic velocity]) can be obtained with ultrasonography.43 A high renal artery end-diastolic velocity (>90 cm/s) and low RRI (<75-80) indicate no microvascular disease or increased resistance.39,44
*[[Renal functional reserve]]
*[[Renal resistive index]]


Spectral broadening and increased velocity on ultrasonography are markers of hemodynamically significant stenosis. For example, a Reno aortic velocity ratio (defined as the renal artery peak systolic velocity/aortic peak systolic velocity) greater than 3.5 has been correlated to 60% stenosis,45 whereas a renal artery peak systolic velocity greater than 150 cm/s correlates to 50% stenosis, and a velocity greater than 180 cm/s correlates to 60% stenosis.45-48 A literature review found that the sensitivity and specificity of ultrasonography were 85% and 92%, respectively, in detecting hemodynamically significant ARAS.49
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]].  


Severe stenosis can produce tardus-parvus spectral changes on Doppler ultrasonography, revealed as a slowed systolic acceleration with a decreased resistive index.50,51 Quantitative criteria proposed for the diagnosis of distal stenosis include blunting of early systolic peak acceleration (<3 m/s2), an acceleration index greater than 4 m/s2, increase in time to systolic peak (>0.07 s), or greater than 5% difference in RRI between kidneys. However, because of the difficulty in interpretation these complex waveforms, these criteria are seldom used.52-54
[[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>.  


=== Computed Tomographic Angiography ===
[[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>.
The possibility of 3-dimensional reconstructions has made CTA an important tool in the diagnosis of ARAS. Because CTA involves use of ionizing radiation and iodinated contrast medium, it is contraindicated in patients with contrast allergy. Patients with impaired renal function can develop contrast-induced nephropathy if iodinated contrast is used, but generous fluid hydration before contrast administration can effectively prevent this complication. For detection of ARAS, the sensitivity of CTA is 94%; the specificity varies between 60% and 90%.55,56


Compared to MRA, CTA can detect small accessory renal arteries because of its high spatial resolution. It is also preferred for patients who have implanted devices, for patients with limited breath-hold capacity (requiring shorter acquisition times), and for patients with claustrophobia. However, CTA has less specificity than MRA for detecting hemodynamically significant ARAS; it cannot be used safely in patients with borderline renal dysfunction because of the necessity of iodinated contrast agents; images obtained with CTA are difficult to interpret in heavily calcified arteries, and CTA requires use of ionizing radiation.57
===<u>Computed Tomographic Angiography.</u>===
[[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 ===
*Contraindicated in patients with [[contrast allergy]] as this procedure modality involves the [[ionizing radiations]] and [[iodinated]] [[contrast]] medium.
Magnetic resonance angiography has a reported sensitivity and specificity of 90% to 100%55,56 and does not require use of iodinated contrast or radiation. Gadolinium-based contrast medium should be avoided in patients with moderate to end-stage renal failure because of the risk of nephrogenic systemic fibrosis. Additionally, MRA should not be used in patients with certain implanted devices (ie, pacemakers, defibrillators, cochlear implants, and spinal cord stimulators) or in claustrophobic patients. Unlike CTA, MRA has no calcification artifact, neither iodinated contrast medium nor radiation is used, and contrast reaction rates are lower.1
*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 />


=== Angiography ===
===<u>Magnetic Resonance Angiography</u>===
Invasive renal arteriography is helpful in evaluating ARAS. In addition to assessing the severity of ARAS, angiography can detect intrarenal vascular abnormalities and anatomic abnormalities of the kidneys, renal arteries, and aorta. Digital subtraction angiography improves contrast resolution and may decrease the volume of contrast needed to as little as 15 mL. However, because renal angiography is invasive, there are risks associated with arterial puncture and manipulation of the catheter/wire, which can result in arterial trauma, spasm, or thromboembolic phenomenon.58 In patients with renal impairment or contrast allergy, carbon dioxide can be used as a non nephrotoxic contrast agent.
[[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>


The early work by White et al59 established that there is substantial intra- and interobserver variability in the visual estimation of coronary stenosis, which likely also applies to the visual estimation of ARAS. Therefore, relying solely on angiography to visually estimate the severity of ARAS is suboptimal, and adjunctive tools should be used to determine whether renal ischemia is present.
*This procedure does not involve the use of [[iodinated contrast]] or [[radiations]], unlike [[CTA]].
*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]]


Translesional pressure gradients can be measured across areas of stenosis to determine hemodynamic significance (if there is doubt) before performing therapeutic procedures such as percutaneous transluminal renal angioplasty (PTRA) or stenting. In a small case series, Mangiacapra et al60 measured translesional pressure gradients using papaverine and dopamine to induce renal hyperemia in 53 consecutive patients before PTRA. They found that patients with the most substantial improvement in hypertension were those with a translesional gradient greater than 20 mm Hg (corresponding to a distal-proximal pressure ratio of 0.79 as the optimal cutoff). De Bruyne et al61 demonstrated that stenosis with a distal to proximal renal artery pressure decrease greater than 10% were associated with increased renin production, suggesting that measurement of translesional pressure gradients might help identify hemodynamically significant ARAS.
===<u>Angiography</u>===
Invasive [[renal arteriography]] is an important helpful modality used these days in evaluating [[Renal artery stenosis]].


==Diagnosis==
*[[Angiography]] can detect intrarenal [[vascular]] abnormalities and [[anatomical]] abnormalities of the [[kidneys]], [[renal arteries]], and [[aorta]], in addition to evaluating the severity of [[RAS]].
===Indications for Work-Up===
*[[Digital angiography]] by subtraction increases contrast resolution and can minimize the amount of [[contrast]] required to as little as 15mL.
According to the 2013 ACC/AHA Guidelines for the Management of PAD<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>, diagnostic work-up for renal artery stenosis is indicated in the following conditions:
*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]].
====Class I Recommendations<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>====
*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]].
 
*Hypertension of any stage before the age of 30
*Stage II hypertension (severe hypertension systolic blood pressure > 180 mm Hg or diastolic blood pressure > 120 mm Hg) in patients older than 55 years. If only mild hypertension is present, then renal artery stenosis is the underlying cause in only 1% of patients <ref name="pmid3872106">{{cite journal| author=Lewin A, Blaufox MD, Castle H, Entwisle G, Langford H| title=Apparent prevalence of curable hypertension in the Hypertension Detection and Follow-up Program. | journal=Arch Intern Med | year= 1985 | volume= 145 | issue= 3 | pages= 424-7 | pmid=3872106 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3872106  }} </ref>, but if the blood pressure is markedly elevated, then the risk of renal artery stenosis goes up 10 to 50 fold.
*Accelerated condition of previously controlled hypertension
*[[Resistant hypertension]]
*[[Malignant hypertension]]
*New [[azotemia]] (50% rise in [[creatinine]] that is sustained) within one week after administration of an [[Angiotensin Converting Enzyme]] ([[ACE]])inhibitor or [[ARB]]
*Unexplained atrophic kidney or asymmetric kidneys that differ by > 1.5 cm. If the kidney is < 9 cm in size, there is a 75% chance that renal artery stenosis is present.
*Severe hypertension, impaired renal function, and recurrent flash [[pulmonary edema]]
 
====Class IIa Recommendations<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>====
 
*Unexplained renal failure including patients starting renal replacement therapy
 
====Class IIb Recommendations<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>====
 
*Presence of multi vessel [[CAD]] and no clinical clues of ARAS or PAD
*Unexplained [[CHF]] or [[refractory angina]]
 
====Other Indications====
 
*Severe hypertension in the presence of polyvascular disease ([[coronary artery disease]] or [[peripheral arterial disease]])
*A unilateral systolic-diastolic [[abdominal bruit]]. Although a bruit is infrequent in documented renal artery stenosis (the sensitivity is only 40% percent) if it is auscultated, it is associated with a very high specificity of 99%.<ref name="pmid7563536">{{cite journal| author=Turnbull JM| title=The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension? | journal=JAMA | year= 1995 | volume= 274 | issue= 16 | pages= 1299-301 | pmid=7563536 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7563536  }} </ref>
*The association of race with renal artery stenosis is not clear. Reports that it is observed more often in white patients may be due to reporting bias.<ref name="pmid2022411">{{cite journal| author=Svetkey LP, Kadir S, Dunnick NR, Smith SR, Dunham CB, Lambert M et al.| title=Similar prevalence of renovascular hypertension in selected blacks and whites. | journal=Hypertension | year= 1991 | volume= 17 | issue= 5 | pages= 678-83 | pmid=2022411 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2022411  }} </ref>
 
==Diagnostic Methods<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>==
The best technique to diagnose atherosclerotic renal artery stenosis (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="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </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="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref> In contrast, neither selective renal vein renin studies, [[captopril]] renal scintigraphy, plasma [[renin]] activity nor the  [[captopril]] test are recommended anymore.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
 
====Duplex Ultrasonography====
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 with intestinal gas.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
 
====Computed Tomographic Angiography====
Diagnosis by CT angiography is considered class I recommendation. It provides higher spacial resolution compared to magnetic resonanc angiography (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="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
 
====Magnetic Resonance Angiography====
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="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
 
====Catheter Angiography====
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 consents to renal angiography. Generally, it is associated with a low frequency of adverse events.<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </ref>
 
==Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines<ref name="pmid23473760">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 14 | pages= 1555-70 | pmid=23473760 | doi=10.1016/j.jacc.2013.01.004 | pmc=4492473 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473760  }} </ref>==
===Clinical Clues to the Diagnosis of RAS (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </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.'''Onset of hypertension before the age of 30 years or severe hypertension after the age of 55. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.'''Accelerated, resistant, or malignant hypertension. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.'''Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent    . ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''4.'''Unexplained atrophic kidney or size discrepancy between kidneys of greater than 1.5 cm. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''5.'''Sudden, unexplained pulmonary edema. ''([[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 IIa]]
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''1.'''Unexplained renal dysfunction, including individuals starting renal replacement therapy. ''([[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.'''Multi-vessel coronary artery disease. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''2.'''Unexplained congestive heart failure. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon" |<nowiki>"</nowiki>'''3.'''Refractory angina. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
===Diagnostic Methods (DO NOT EDIT)<ref name="pmid23457117">{{cite journal| author=Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH et al.| title=Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2013 | volume= 127 | issue= 13 | pages= 1425-43 | pmid=23457117 | doi=10.1161/CIR.0b013e31828b82aa | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23457117  }} </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.
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