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Indications of renal doppler ultrasound 3

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Rare Pathologies by Renal Doppler

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Indications of renal doppler ultrasound 3

  1. 1. Indications of renal Doppler ultrasound  Renal artery stenosis  Renal artery thrombosis & emboli  Renal vein thrombosis  Aneurysm & pseudo-aneurysm  Arterio-venous communications  Nutcracker syndrome  Renal mass  Miscellaneous indications
  2. 2. Arterio-venous communication Direct communication from artery to vein without capillary bed • Congenital A-V malformation 25% Multiple large arterial feeding vessels Numerous A-V communications • Acquired A-V fistula 75% Single communication of artery & vein 0.3 – 4 % after kidney biopsy Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288.
  3. 3. A-V malformation Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. A-V malformation with pseudo-aneurismal dilatation Low resistance arterial flow Arterialized venous flow Hydronephrosis or cyst with calcified wall Aneurismal dialatation with perivascular artifact
  4. 4. A-V fistula First described in 1962 1 • Cause Iatrogenic (percutaneous procedure) –Trauma • Clinic Asymptomatic (80%) Gross hematuria – High output cardiac failure Thrombo-embolic episodes – RF – HTN • Evolution Most regress spontaneously in 6 months Some progress to life-threatening complication • Rx Asymptomatic: follow-up by Doppler Symptomatic: embolization Routine post-biopsy Doppler US & 6 months later 1 Fernstrom I et al. J Urol 1962 ; 88 : 709. 2 J Clin Ultrasound 2008 ; 36 : 377 – 380.
  5. 5. Arterio-venous fistula Feeding artery Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. Perivascular artifact in inferior pole “confetti phenomenon” Color Doppler US / High PRF Low resistance arterial flow Arterialized venous flow Feeding artery & draining vein
  6. 6. Indications of renal Doppler ultrasound  Renal artery stenosis  Renal artery thrombosis & emboli  Renal vein thrombosis  Aneurysm & pseudo-aneurysm  Arterio-venous communications  Nutcracker syndrome  Renal mass  Miscellaneous indications
  7. 7. Doppler US in nutcracker syndrome Hilar portion & aorto-mesenteric portion Cut-off value in supine position 3.8 Cut-off value in upright position 5.5 Fitoz S et al. J Ultrasound Med 2007 ; 26 : 573. Ratio of A-P diameter of LRV Ratio of peak velocities of LRV Aorto-mesenteric portion & hilar portion Cut-off value in supine position 4.2 Cut-off value in upright position 5.1
  8. 8. Nutcracker syndrome / Ratio of A-P diameter Oblique transverse sonograms Peker A et al. J Clin Ultrasound 2011 ; 39 : 418 – 421. Hilar portion: 25 mm Aorto-mesenteric portion: 2mm Ratio: 12.5 Supine position Hilar portion: 24 mm Aorto-mesenteric portion: 2mm Ratio: 12 Upright position
  9. 9. Nutcracker syndrome / Ratio of peak velocities Cho BS et al. Nephrol Dial Transplant 2001 ; 16 : 1620 – 1625. Peak velocity ratio: 6 LRV near hilum Peak velocity: 19.9 cm/sec LRV between aorta & SMA Peak velocity: 99.7 cm/sec
  10. 10. Nutcracker syndrome / SMA angle Peker A et al. J Clin Ultrasound 2011 ; 39 : 418 – 421. Upright position 14 ° Supine position 33° Cut-off value 41° in supine position – 21° in upright position
  11. 11. Indications of renal Doppler ultrasound  Renal artery stenosis  Renal artery thrombosis & emboli  Renal vein thrombosis  Aneurysm & pseudo-aneurysm  Arterio-venous communications  Nutcracker syndrome  Renal mass  Miscellaneous indications
  12. 12. Doppler in renal Mass Limited role compared to CT • Pseudo-tumors Prominent column of Bertin Persistent fetal lobulation Dromedary hung • Renal tumors Tumoral vascularization CEUS: solid or cystic mass • Venous invasionRenal veins IVC Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412.
  13. 13. Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. Normal interlobular arteries at periphery of PCB Prominent column of Bertin (PCB) Mistaken for intra-renal tumor Prominent column of Bertin or mass
  14. 14. Vascularization of renal tumors Jinzaki’s classification Intratumoral focal vessels Penetrating vessels Peripheral vessels Penetrating & peripheral Angiomyolipoma Angiomyolipoma Carcinoma Carcinoma Pattern 1 Pattern 2 Pattern 3 Pattern 4 Jinzaki M et al. Radiology 1998 ; 209 : 543 – 550.
  15. 15. Vascularization of renal tumors Jinzaki M et al. Radiology 1998 ; 209 : 543 – 550. Pattern 3 Peripheral vessels Carcinoma Pattern 4 Penetrating & peripheral vessels Carcinoma
  16. 16. Solid renal mass / CEUS Hypervascular lesion CEUS / 34 sec MSCT / arterial phase Hypervascular lesion Gray-scale US Subtle deformation of renal contour Clear renal cell tumor at surgery Setola SV et al. Abdom Imaging 2007 ; 32 : 21 – 28.
  17. 17. Bosniak renal cyst classification Category CT features Significance I Thin wall, water density & does not enhanced No septa, calcification, or solid component Benign Israel GM & Bosniak MA. Urology 2005 ; 66 : 484 – 488. II Thin septa with “perceived” enhancement Fine or slightly thick calcification High attenuation non-enhancing cyst < 3 cm Benign IIF Thick regular septa with “perceived” enhancement Thick regular wall with “perceived” enhancement Thick, nodular, & irregular calcification High attenuation non-enhancing cyst > 3 cm Likely benign Follow-up III Thick smooth or irregular septa Thick smooth or irregular wall With measurable enhancement Some benign Some malignant IV Criteria of category III Enhancing mass independent of wall or septa Malignant Cystic carcinoma
  18. 18. Cystic renal mass / CEUS Thin-walled cyst No septa or solid component Bosniak category I CECT scan Enhancing mural nodule within cyst Bosniak category IV CEUS Park BK et al. Eur J Radiol 2007 ; 61 : 310 – 314. Renal cell carcinoma after partial nephrectomy
  19. 19. Invasion of IVC in RCC Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. Color Doppler US Localization of upper extremity of thrombus Power Doppler US Tumoral vascularization of thrombus
  20. 20. Indications of renal Doppler ultrasound  Renal artery stenosis  Renal artery thrombosis & emboli  Renal vein thrombosis  Aneurysm & pseudo-aneurysm  Arterio-venous communications  Nutcracker syndrome  Renal mass  Miscellaneous indications
  21. 21. • Nephropathies • Kidney stones • Hydronephrosis • Uretero-pelvic junction obstruction • Fraley syndrome (Upper calix syndrome) Miscellaneous indications
  22. 22. Renal Doppler in nephropathies • Acute tubular necrosis • Tubulo-interstitial nephropathy • Micro-angiopathy • Nephro-angiosclerosis • Diabetic nephropathy Glomerulo-nephritis (↑ RI in end stage disease) Elevated RI Normal RI
  23. 23. Diabetic nephropathy Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. Increased resistive index: 0.89 Renal insufficiency
  24. 24. Kidney stone / Twinkling artifact Tchelepi H et al. Am J Roentgenol 2009 ; 192 : 11 – 18. Twinkling sign from large stone Presence of small stone Large stone causing hydronephrosis Presence of posterior shadowing Useful for evaluation of small kidney stones High PRF & gain just below artifact limit
  25. 25. Hydronephrosis RI of LK: 0.45RI of RK: 0.65Hydronephrosis of right UPJ Δ RI (right – left) > 0.05 Sensibility: 10 – 40%, Specificity > 80% Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. Obstruction without dilatation Indications Dilatation without obstruction Hydronephrosis in pregnancy
  26. 26. Renal colic in pregnancy Physiological hydronephrosis or stone? Retrospective study of 262 patients (2 local hospitals) Data on clinical presentation, imaging, & interventions Clinical & laboratory features unhelpful to predict stone Left-sided colic more likely to indicate stone Improved accuracy of Doppler in predicting stone (55 – 72%): Elevated resistive index Absence of urinary jet Andreoiu M et al. Urology 2009 ; 74 : 757 – 761.
  27. 27. Urinary jet Obstructed ureter if no jet seen after 15 min of observation Presence of jet do not exclude incomplete obstruction Tuma J et al. European course book: Genitourinary ultrasound. European Foundation of Societies of Ultrasound in Medicine & Biology, 2011.
  28. 28. Uretero-pelvic junction obstruction Most common cause of UT obstruction in children Multiples proposed factors Delayed recanalization of fetal ureter Abnormal development of ureteral muscle Abnormal ureteral peristalsis Aberrant vessels or bands Sivit CJ. Ultrasound Clin 2006 ; 1 : 67 – 75. Bilateral in 25%
  29. 29. Uretero-pelvic junction obstruction Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. Sidhu R et al. Semin Ultrasound CT MRI 2009 ; 30 : 271 – 288. Hilar artery seen in 30 – 45% of patients Crossing vessel usually located anterior to UPJ obstruction
  30. 30. Fraley syndrome / Upper calyx syndrome Vascular compression of superior calyx Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. IV pyelography Superior calyx obstruction due to extrinsic compression Color Doppler US Segmental artery crossing the dilated calyx CT Angiography before tt: polar nephrectomy – reimplantation
  31. 31. References Arnold – 2004 Springer-Verlag – 2011 Hélénon O et al. EMC-Radiologie 2005 ; 2 : 367 – 412. EFSUMB – 2011

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