Techniques of Renal
Arteriography
Subhash Banerjee, MD
UT Southwestern Med. Ctr &
VA North Texas Health care;
Dallas, TX
Indications For Renal Artery Angiography &
Revascularization
• Persistent hematuria of unresolved cause
• Detection of renal tumor vacularity, venous invasion embolization
• Suspected renal artery stenosis (RAS)
• Suspected transection of the renal artery (penetrating injury)
• Detection of inflammatory conditions, aneurysm or AVM
• Evaluation of renal vascular anatomy of prospective donors
• Evaluation of postoperative renal transplantation
• Diagnosis of thrombosis revealed by renal venography
• Collection of a sample of blood from the renal vein
Prevalence of Atherosclerotic (A)RAS at
Cardiac Catheterization
Study, Year
n
ARAS > 30%
(%)
ARAS > 50%
(%)
Bilateral
(%)
Vetrovec et al,
1989
116
29%
23%
29%
Harding et al, 1992
1302
29%
15%
28%
Jean et al, 1994
196
33%
18%
-
Rihal et al, 2002
297
34%
19%
19%
Weber-Mzell et al,
2002
177
25%
11%
26%
Routine screening for RAS during coronary angiography NOT indicated
White et al. Circulation.2006; 114: 1892-1895
Objectives of Renal Arteriography
•
•
•
•
•
Identify main as well as accessory vesels
Localize site of stenosis or disease
Determine type of disease (atherosclerotic or FMD)
Provide hemodynamic significance
Determine likelihood of a favorable response to
revascularization
• Identify associated pathology (aorta, renal mass etc)
• Detect restenosis after percutaneous or surgical
revascularization
Proposed Algorithm for Diagnosis of RAS &
Renal Artery Angiography
Clinical suspicion of RAS/Indication for Revascularization
MRA or CTA
Renal artery duplex
RAS +
RAS -
RAS +
Angiography &
intervention
Captopril scintigraphy
RAS -
+
-
Angiography &
intervention
Technically
good study
Technically
Poor study
Technically
good study
Technically
Poor study
Stop
Angiography
Stop
Angiography
Strong clinical
suspicion
MRA: magnetic resonance angiography; CTA: Computed tomographic angiography
Adapted from Vascular Medicine by Creager et al
Stop
Renal Artery Angiography
•
Catheter-based angiography remains the standard
•
Digital subtraction angiography (imaging matrix 1024 x 1024; 16” image II)
•
Oblique views of the aorta to visualize renal artery origins
•
Pressure gradients should also be obtained, whenever feasible
•
Imaging hardware and software:
– Bolus chase, rapid image acquisition
– Vessel diameter analysis, regional pixel shifting, image stacking
– 3D reconstruction, angioscopic representation of DSA
•
Low osmolar iodinated contrast, gadolinium, CO2 angiography
Renal Anatomy
Between transverse processes of T12L3, left kidney more superior than right,
upper poles oriented medially/posteriorly
Renal Artery Angiography: Technical
Considerations
• Access:
– Groin: ideally contra-lateral, long sheaths
– Brachial: caudally angulated, aorto-iliac disease
• Flush aortography with multi-side hole catheter (L1-L2)
• Prior to selective renal artery catheterization an aortogram must be
performed
• Anterio-posterior & oblique views (visualization of renal artery
origins)
– Right: RAO 10ο-20ο, LAO 10ο
– Left: LAO 0ο-15ο
• Selective angiography of renal arteries
– Shaped sheaths
– Guiding catheters (Soft tip Omni, Cobra 2, Simmons, RDC etc)
– Support guide-wire within aorta
• Trans-lesional gradient (catheter, pressure wire)
Non-selective Renal Angiogram:
Early Division of Right Renal Artery
Renal Angiography and Intervention:
Transfemoral approach

Renal Artery Stenosis &
Complex Aortoiliac
Disease
Renal Artery Angiography: Brachial Approach
•
•
Complications lower with femoral route
Left brachial approach:
–
–
–
–
–
–
–
•
Acute caudal angulation
Inability to engage with reverse curve catheters
Aorto-iliac PAD
Infrarenal abdominal aneurysm
graft in the femoral region
rigid (non-elastic) arteries, tight calcified stenoses
dilated abdominal aorta
Complications with brachial approach greater
– In patients with a small or diseased brachial artery
– When a 7 French or larger sheath is required
•
•
Use of a multipurpose catheter from left brachial approach
Radial artery approach might be preferable over brachial because (lower
complication & higher patient satisfaction)
– Long sheaths and guidewires
– Problems with catheter pushability & guidewire torque control
– Sheath size is usually limited to 6 French
Hessel et al. Radiology 1981; 138:273-281 Scheinert et al. Catheter Cardiovasc Interv 2001; 54:442-447
Renal Artery Angiography: Translesional
Gradient
•
•
•
•
•
•
RAS less than 50% in diameter are not significant
“Gray zone” (50-70% diameter stenosis)
Four French (1.35mm) catheter across 4 mm renal artery
Pressure guide wire system
Thermodilution technique to measure flow (Angioflow)
Change in SBP could be a source of uncertainty:
– When gradient is small
– Simultaneous recording in the renal artery & aorta is preferable
• 20 mm or greater systolic gradient results from a
significant stenosis
• 10% peak systolic gradient or >5% difference in MAP
B. De Bruyne et al. JACC, Volume 48, Issue 9, Pages 1851-1855
Renal Artery Angiography
• Anatomic variations in the renal
vasculature occur in approximately 2540% of patients
• Accessory, renal arteries are the most
common arterial variation, with most of
these branches supplying the lower pole of
the kidney
• Kidney position in the retroperitoneum is
subject to variation as well
Non-selective Renal Angiogram: Aberrant
Renal Artery Below Right Renal Artery
Non-selective Renal Angiogram: Accessory
Renal Artery Below Right Renal Artery
Non-selective & Selective Renal
Angiography
Accessory renal artery
Aberrant renal artery
Renal Arteriography
• Conclusions:
– Careful patient selection
– Careful pre-procedural preparation & planning
– Start with flush aortography
– Selective renal arteriography
– Anticoagulation primarily with UFH
– Brachial/radial arterial access for challenging
anatomy
– Translesional gradient assessment of
intermediate stenoses (with pressure wire)
Clinical Clues to the Diagnosis of Renal
Artery Stenosis (RAS)
• Onset of HTN <30y or severe hypertension at >55y (Class I; LOE B)
• Accelerated, resistant, or malignant hypertension (Class I: LOE C)
• Unexplained atrophic kidney/size discrep. >1.5 cm (Class I; LOE B)
• Sudden, unexplained pulmonary edema (Class I; LOE B)
• Unexplained renal dysfunction (Class IIa; LOE B)
• Development of new azotemia or worsening renal function after
administration of an ACE inhibitor or ARB agent (Class I; LOE B)
• Multivessel CAD or PAD (Class IIb; LOE B)
• Unexplained CHF or refractory angina (Class IIb; LOE C)
White et al. Circulation.2006; 114: 1892-1895