renal artery duplex a special thanks to the : leading...
TRANSCRIPT
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Renal Artery Duplex
Leading Edge
Atlantic City 2019
Patrick Washko BSRT,RDMS,RVT,FSVU
Technical Director
Rex Hospital (UNC Healthcare)
Raleigh, NC
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A Special Thanks To The :
UNC Rex Healthcare
North Carolina Heart and Vascular Hospital
Peripheral Vascular Lab Team
• S. Wayne Smith M.D.,RVT,RDMS,FSVM,RVPI
• Patrick A Washko BSRT,RDMS,RVT,FSVU
• Robert Mendes M.D
• Elvira Castellanos RDMS,RVT
• Otis Darden RDMS,RVT
• Dorian de Frietas M.D. RVPI
• Kelly Edwards BS RDMS
• Jason Kim M.D, RVPI
• Martyn Knowles M.D. RPVI
• Lauren Lissenden BS, RVT
• Anna Moore BS , RDMS, RVS
• Liliana Nanez M.D. RPVI
• Jim Morgan MS, RVT
• Lauren Estrada RDMS, RVT
• Brandy O’hara RDMS, RVS
• Olusegun Osinbowale, M.D. RVPI
• Hillary Sawyer RVT
• Bob Scissons RVT,FSVU ( Honorary Staff Member)
• Daniel Sherrill RVT
• Daryl Smith MBA,RDMS, RVT
• Kristen Stahura BS RVT
• Brian Stull, RDMS,RVT
• Aaron Thomas, P.A.C, RVT
• Sharon Wertz RDMS, RDCS, RVS
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My Ultimate Goal Everyday
Make Duplex
The
Gold
Standard……
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Bilateral Renal Arteries Veins and Iliac Bifurcation
Renal Artery Renal Vein
Iliac Bifurcation
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What We Need In Vascular Ultrasound
•Technology with Functionality
•Precision demonstrating B-Mode
•Clinical understanding
•Secondary imaging parameters
•Fortification of pre test probability
•Utilize and Do Not Be Afraid to change transducers
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Renal
Duplex
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Critical Anatomy
•Aorta
•Common Iliac
• IVC
•Celiac
•SMA
•Right Renal Artery
•Left Renal Artery
•Bilateral Renal Veins
•Spleen
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Renal Artery Anatomy
• Located 2 cm below the Xiphoid process
• The RRA has a longer course to travel
than the left, ( LRV length > RRV )
• IVC serves as the mid aspect position on the
RRA ( RAO &- SUP )
• Arise from the lateral or posterolateral
wall of the abdominal aorta
• Right think 9-10 o’clock
• Left think 2-3 o’clock
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Right Left
Aorta
Renal Artery Anatomy
Aorta
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Normal Blueprints
* Blueprints are essential
in complex matters !
Spectral Blueprints
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Arteries Are Arteries
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High Resistance Vascular Beds
•Aorto-iliac
•Upper and lower peripheral
arteries
•Fasting SMA
•Subclavian artery
•External carotid artery
If low resistance is seen in a high resistance bed,
something is usually not right !
No Diastolic
Flow
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Low Resistance Vascular Beds
• ICA
•Vertebral
•Renal
•Celiac tributaries
•Hyperemic state in high resistance beds
If high resistance is seen in a low resistance bed,
something is usually not right !
Diastolic
Flow
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Kidneys
Spleen
Liver
Brain
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Low Resistance Vascular Beds
Think
Parenchymal
Organs!
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Renal Duplex Prep
•Mild laxative ( Milk of Magnesia)
•Nothing but fluids, Jello after 9pm
• Jello is ok for breakfast
•Please take meds !
•Coffee
•No smoking
•Patients are encouraged to bring a snack for post
duplex
•Research prior exams !!!
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The Renal Duplex Examination
•Could Be Extremely difficult
•Skinny is not always easy !
•Experience plays key role
•Equipment
•Breathing, CHF, Gas
• Multangular Interrogation Approach
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Utilization of Probes
• Standard Convex ,Curved
• Vector
• DO NOT BE AFRAID TO USE NON
STANDARD PROBES FOR INSONATION !
• Multiple angles of Interrogation
• Patients disserve excellence in image
quality and So does your reading
Physician
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Know your Tools
• Linear array
scanhead
• Curved array
scanhead
• Phased array
scanhead
USE
LOTS OF GEL!
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Use More Than One Probe !!!
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Oblique and Lateral
Probe Change for Intercostal Interrogation
Curved Micro
Convex
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Probe Changes Can Makes large Differences
Curved 6C-1Micro Convex 6MC-1
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Communication
and Projection Changes…..
Supine
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Communication
and Projection Changes…..
Supine Oblique
This is one of the reasons Why Renal Arteries
need To be Interrogated From Two
Projections…..
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Don’t Be afraid To draw …
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Tortuous Vessels
Supine
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Tortuous Vessels Cause Velocity Errors
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Settings- Settings- Settings ……
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Renal Perfusion Settings
Renal Perfusion
Directional Power Doppler
Monochrome -SMI
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Don’t Forget About Directional Power Doppler !
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Color Frequency Change
• Note lack of visualized color flow Lower color frequency
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Indirect Method
Aorta B Mode -Longitudinal and
Transverse to assess for an
abdominal aortic aneurysm.
• Kidney lengths-cortex
assessment for reduced size.
• Perfusion Kidney- color Doppler
used to assess the perfusion to
the edge of the renal cortex.
• Resistive Index- Spectral Doppler
of kidney parenchyma at the
interlobar (segmental) arteries
and interlobular
(arcuate)arteries.
• Acceleration Time
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Direct Method
Renal / Aortic ratio > 3.5
- Peak Systolic velocity of RA
Peak Systolic velocity of AO
PSV > 180-200 cm/s
Post stenotic turbulence
Aortic velocities less than
-40 -50cm/s and greater than
120 cm/s can skew RAR results
+PSV >225-240
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Why Are We
Performing Renal
Duplex
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Causes of RAS
Major causes of the renal arterial lesions are:
• Atherosclerosis —It is the cause of RAS in >2/3
rdof the cases. This primarily affects
men over the age of 45 and usually involves the aortic orifice or the proximal main renal artery. This disorder is particularly common in patients with diffuse atherosclerosis, but can occur as a relatively isolated renal lesion.
• Fibromuscular dysplasia — In comparison to atherosclerosis, fibromuscular dysplasia most often affects younger women and typically involves the distal main renal artery or the intrarenal branches.
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Causes of RAS
• Other less common causes of RAS include:
Vasculitis (Takayasu’s arteritis)
Dissection of the renal artery.
Thromboembolic disease
Renal artery aneurysm
Renal artery coarctation
Extrinsic compression
Radiation injury
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Assess The
Surrounding Area
and Don’t Ignore
The Obvious …
OMG…
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Abdominal Aorta
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Abdominal Aorta
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Atherosclerotic
Disease Progression
• Inside out
• Plaque Progresses
Abdominal aorta into
ostial renal segment
• the renal stent is to be
advanced within the
Abdominal aorta
Aorta
Renal Artery Stent
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Right Renal Artery
625/95
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Location, Location ,Location
•Think Proximal
•Any other region especially with No Plaque
PMH of underlying cardiac issues
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Ostial Stenosis
Remember Proximal!!!
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Disease Location
Color Is Doppler
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FMD vs Atherosclerosis
FMD
( Fibromuscular dysplasia )
Atherosclerotic
(ostial lesion)
Location-Location-Location
Drawn By
Laura Tastad RVT
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Renal Artery Duplex
• Renovascular Disease
- Atheroscleortic (Proximal)
- Fibromuscular dysplasia ( Mid )
- Embolic
• Ischemic nephropathy
• Renal Vein Thrombosis
- Nephrotic syndrome
Stent F/U
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Velocities Obtained
416cm/s
322cm/s
288cm/s
• European descent female and
usually under 50 years of age
• Mid to distal segment
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Velocities Obtained
416cm/s
322cm/s
288cm/s
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Fibromuscular Dysplasia
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Post Angioplasty
Pre Angioplasty
Pre and Post Angioplasty
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Renal Artery Duplex
• Renovascular Disease
- Atheroscleortic Proximal
- Fibromuscular dysplasia Mid
- Embolic
• Renal Vein Thrombosis
- Nephrotic syndrome
Proximal ( Ostial ) Lesion
Mid- Distal Lesion
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Fibromuscular Dysplasia
Fibromuscular dysplasias are
uncommon angiopathies associated
with heterogeneous histologic
changes that may affect the carotid
circulation as well as the visceral
and peripheral arteries.
String of beads is the classic
radiographic finding seen in FMD.
FMD, as a cause of RAS usually
affects young to middle-aged adults,
mostly women, but it can also affect
children.
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Fibromuscular Dysplasia
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Technical Issues and Having Two
Transducers Ready…..
•42 year old female
•Hypertension
•Anxiety
•Hyperlipidemia
•No impressive family history
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RRA Mid Aspect
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>60% Lesion ?
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What is your diagnosis ?
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Same Patient
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Contrast Projections
Sagittal Transverse
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Multiangular Approaches
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Questions?
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Thank You
Patrick A Washko BSRT,RDMS,RVT,FSVU
Technical Director
North Carolina Heart and Vascular Hospital
UNC Rex Healthcare
Peripheral Vascular Laboratory
Raleigh, NC