The document summarizes renal vascular disease topics including anatomy, causes, normal Doppler indices, renal artery stenosis, fibromuscular dysplasia, nutcracker syndrome, and renal vein thrombosis. It provides diagrams to illustrate renal anatomy and conditions. Key points covered are the segmentation of renal arteries, compression of the left renal vein between vessels potentially causing hematuria, and identification of stenosis through Doppler criteria exceeding thresholds.

1. O Allah, please bring me out of the darkness of doubt
and favor me with the light of comprehension,
O Allah open to us the doors of your mercy and unfold
for us the treasure of your knowledge by your mercy O
the most merciful of the merciful ones.

2. Renal Vascular Disease
Presented By: Syed Shoaib Muhammad
Subject:
Applied Doppler, Vascular Doppler.

3. Topics:
• Anatomy
• Causes
• Normal Renal artery Doppler indices
• Renal Artery Stenosis
• Fibromuscular dysplasia (FMD)
• Nutcracker Syndrome
• References.

4. Anatomy of the Kidney.
Renal parenchyma:
cortex & medullary pyramids
Renal sinus:
arteries, veins, lymphatics, collecting system, & fat
Renal hilum:
Concave, in continuity with renal sinus

5. Anatomy of the Kidney.
Segmental artery
Apical, upper, middle, lower, posterior
Interlobular artery
Between renal pyramids
Glomerular arteriole
Main renal artery
Arcuate artery
Between cortex & medulla
Glomerular arteriole

6. Anatomy of the Kidney.

7. Anatomy of the Kidney.
Left lobe of liver
Duodenum
Bile duct
Spinal column
Right renal artery
Aorta
Superior
mesenteric artery
The left renal vein is physiologically compressed between the aorta and the superior
mesenteric artery. It is slightly congested proximal to the compression site.

8. Anatomy of the Kidney.
Normal renal artery waveform. Arterial flow to the kidney
shows typical low-resistance features with well-maintained
diastolic flow throughout the cardiac cycle, a broad systolic
peak, and a gradual transition between systole and
diastole. Also note the sharp, well- defined early systolic
peak and the steep early systolic slope. Faint venous flow
from an adjacent vein is seen below the baseline.
3D power Doppler view of the intra
renal arteries shows multiple segmental
arteries in the renal hilum branching
into lobar and interlobular arteries.

9. Causes:
 Renal artery stenosis
 Fibromuscular dysplasia (FMD)
 Nutcracker syndrome
 Renal vein thrombosis
 Aneurysm & pseudo-aneurysm
 Arterio-venous communications
 Renal mass
 Miscellaneous indications
> 95 % of cases

10. Normal Renal artery Doppler indices
 Pulsatility Index (PI) 0.7 – 1.4
 Resistive index (RI) 0.56 – 0.70
 Peak systolic velocity (PSV) 60 –140 cm/s (< 180 cm/s)
 Systolic/Diastolic ratio (S/D) 0.26 – 0.4
 Renal Artery/Aortic Ratio (RAR) < 3.5
 ∆ RI (right – left) < 0.05
 AccelerationTime (AT) < 0.07 sec
 Acceleration Index (AI) > 3.5 m/s2

11.  Renal Artery Stenosis:
Stenosis of the renal artery is due to
atrerosclerotic disease in the vast
majority of patients, or to fibromuscular
dysplasia of the arterial wall in the
younger, generally female patient. RAS
may cause hypertension and may
eventually cause renal failure. It is
frequently bilateral, and is responsible
for up to 15% of patients who require
long-term dialysis. It is associated with
aortic aneurysm, neurofibromatosis or
can be traumatic in origin.

12. Atherosclerosis
> 90%
FMD
< 10%
Age After age of 50 Young
Gender More common in males More common in
females
Location Proximal 1 cm of main RA
Branching points
Middle of renal artery
Others (carotids)
Post-stenotic
dilatation
Rare Frequent
 Renal Artery Stenosis:

13. Color flow Doppler of the aorta in
coronal view. There is marked
atheroma of the aortic wall. The
origin of the right renal artery is
demonstrated beneath the inferior
vena cava.
 Renal Artery Stenosis:

14. Direct signs
Focal color aliasing
Color bruit
Turbulence
PSV > 180 cm/sec
Renal Aortic Ratio > 3.5
Indirect signs
AT > 0.07 sec
AI < 3 m/s2
Δ RI (right – left) > 5 %
 Pulsatility Index (PI) 0.7 – 1.4
 Resistive index (RI) 0.56 – 0.70
 Peak systolic velocity (PSV) 60 –140 cm/s (< 180 cm/s)
 Systolic/Diastolic ratio (S/D) 0.26 – 0.4
 RenalArtery/Aortic Ratio (RAR) < 3.5
 ∆ RI (right – left) < 0.05
 AccelerationTime (AT) < 0.07 sec
 Acceleration Index (AI) > 3.5 m/s2
NormalValues
 Renal Artery Stenosis:

15. Direct criteria
Plaque in anterior wall of LRA
PSV: 148 cm/sec
 Renal Artery Stenosis:

16. Indirect criteria
PSV: 85.7 cm/s
EDV: 47.2 cm/s
RI: 0.64
Left renal hilumRight renal hilum
PSV: 125 cm/sec
EDV: 58.1 cm/s
RI: 0.75
Δ RI (right – left) > 0.05 → RA stenosis in side of lower RI
 Renal Artery Stenosis:

17. Right RenalArtery
PSV : 465 cm/s
Right RenalArtery
PSV : 246 cm/s
 Renal Artery Stenosis:

18.  Renal Artery Stenosis:

19.  Renal Artery Stenosis:

20.  Fibromuscular Dysplasia (FMD):
Fibromuscular dysplasia is a condition
in which at least one of your arteries
has an abnormal cluster of cells
growing in the artery wall. This cluster
causes the artery to narrow, which can
cause damage to the organs that
receive blood through the narrowed
artery. Fibromuscular dysplasia can
cause a number of complications, such
as high blood pressure and a bulging
area of the artery .
Fibromuscular dysplasia appears most
commonly in the arteries leading to the
kidneys.

21.  Fibromuscular Dysplasia (FMD):

22.  Fibromuscular Dysplasia (FMD):

23.  Nutcracker Syndrome:
Nutcracker syndrome is a vascular
compression disorder, and refers to the
compression of the left renal vein
between the superior mesenteric artery
(SMA) and aorta. This can lead to renal
venous hypertension, resulting in
rupture of thin-walled veins into the
collecting system with resultant
hematuria.
Renal Vein
Compression

24.  Nutcracker Syndrome:
SMA
IVC
Aorta

25.  Nutcracker Syndrome:
Due to Nutcracker syndrome backward pressure caused vericocele.

26.  Renal vein thrombosis:
Bland renal vein thrombosis is a relatively rare event in
adults. It occurs in the settings of dehydration,
coagulopathy, trauma, and certain renal parenchymal
processes that cause the nephrotic syndrome such as
membranous glomerulonephritis. It may also occur
secondary to inferior vena cava thrombosis or ovarian
vein thrombosis.

27. Renal vein thrombosis. Transverse gray-scale (A) and power Doppler view (B) of
the left renal vein show an intraluminal thrombus (arrow) that only partially
occludes the vessel.The aorta (A) and the inferior vena cava (lVC) are also seen.
 Renal vein thrombosis:

28.  Renal vein thrombosis:

29. References: