Anterior Approach.

The patient is lying supine and the probe is moved inferiorly and superiorly to identify the renal arteries and any supernumery arteries.Look in B-Mode and Colour Doppler to help idenify.

Anterior Approach

Anterior Approach.The renal arteries are clearly imaged in B Mode from an anterior approach ho ever as it is perpendicular to the ultrasound beam it is not suitable for Doppler assessment.

!n most individuals" the renal arteries arise from the abdominal aorta immediately distal to the origin of the superior mesenteric artery #$MA%. The right renal artery passes underneath the inferior vena cava #!&C% and posterior to the right renal vein

The left renal vein passes bet een the aorta and $MA. The left renal artery is located posterior to the renal vein. /

The aorta is e'amined for any abdominal aortic aneurysm.The velocity should be bet een () and *))cm per second.

This is a single renal artery posterior to the !&C

There are + renal arteries posterior to the !&C

There are , renal arteries posterior to the !&C

-bli.ue Approach

-bli.ue Approach.Angling /( degrees to right renal artery or rolling the patient in a semi left decubitus position to avoid the bo el gas and improve the Doppler angle.

-bli.ue Approach.Angling /( degrees to right renal artery.!n most individuals" the renal arteries arise from the abdominal aorta immediately distal to the origin of the $MA.By moving the probe to the right of midline and angling to ard the patient0s left" an acceptable Doppler angle of /(-1) degrees is achieved

2Coronal approach to visualise the renal artery from the aorta to the kidney.-n a tortuous vessel the mid section may not be seen.2

Coronal Approach.Angling 3) degrees to left renal artery.The patient is rolled decubitus and a coronal vie through the left loin.An intercostal vie through the ribs on a deep inspiration is ideal.

Normal waveform A normal aveform obtained from the main renal artery demonstrates a rapid

upstroke in systole and a lo resistance aveform ith continuous for ard flo throughout the cardiac cycle. The normal peak systolic velocity of the main renal artery is less than *() cm4sec. The resistive inde' is less than ).5) .

This coronal plane gives a better appreciation of the supernumery arteries.Another useful vie to demonstrate supernumery #duplicate% renal arteries is a coronal image of the aorta.

Aorta measurements A $pectral analysis is made of the aorta at the level of the renal arteries. The &elocity is taken ith an angle for accurate measurement. And another

measurement is taken ith no angle so it can be compared to the renal artery at a stenosis site to do a ratio.

Stenosis measurement This is a spectral trace done in the stenotic site ith an angle for an accurate velocity measurement.Less than *6)cm4sec is normal.

Renal artery : Aortic Ratio (RAR) This is the same trace but the angle is taken off and the measurement is compared to the aortic measurement #7A7% ith no angle so a ratio can be determined.

The length of the stenosis is measured and its distance from the renal artery origin.

An indirect assessment re.uires a good colour image to determine the position of the interlobar and interlobular arteries" hich in turn ill determine the best angle to get an accurate measurement of the 7! and AT.

This is a normal spectral trace of an interlobar #segmental% artery

Resistive Index The 7esistive !nde' #7!%is easily performed by placing a caliper on the early systolic peak #8$9%and the other caliper on the lo est diastole.The 7! is a ratio of peak systolic and end diastolic velocity.

Acceleration Time The Acceleration Time #AT% is done by placing a caliper on the level at hich the gradient begins to rise and finished at the first peak ie the 8arly systolic 9eak #8$9%.This should be less than 5)ms

Indirect method This is assessing the parenchymal haemodynamic changes in the aveform. !nitially there is an 8$9 but ith a stenosis this ill be lost and a tardus parvus aveform ill be the result. :ith chronic renal failure the aveform becomes high resistance #7!;).6)% hich unfortunately cannot be repaired. This is also associated ith high creatinine levels.

Indirect method *. The blood travels do n the aorta +. !nto the renal artery ,. $ome arteriosclerotic pla.ue pro'imally causing a stenosis and high velocity flo ith a 7enal to Aortic 7atio #7A7% ;,.(<* and &elocity ;*6) cm4sec.Therefore it is ;1)= stenosis /. There is post stenotic turbulent"aliasing flo (. There is loss of the 8$9 and and a slo rise #increased AT% 1. The interlobar #segmental% 5. !nterlobular #arcuate% assessment ill reflect the earlier stenosis ith abnormal AT;).)5sec

>LT7A$->?D -@ TA8 78?AL A7T87!8$

ROLE OF ULTRASOUND PREPARATION Fast for hours! No food! "rin# $litres of water over the two hours %rior to the a%%ointment!The &ladder can &e em%tied as needed! 'oo# the a%%ointment in the mornin( %refera&ly to reduce &owel (as! TRANSDUCER: )i(hest fre*uency curved linear array %ro&e %ossi&le! Start with +,)- and wor# down to $ or .,)- for lar(er %atients!/olour and "o%%ler ca%a&ilities ! Assess the de%th of %enetration re*uired and ada%t!

A hi(h swee% s%eed will im%rove accuracy of the measurement ta#en on the S%ectral Trace! INDICATIONS Renovascular )y%ertension0usually it is uncontrolled! ,ay &e caused &y Renal Artery Stenosis0%arenchymal disease0renal neo%lasms0renal vein throm&osis0or an adrenal mass! It may &e caused &y atherosclerosis in the renal artery or less commonly fi&romuscular dys%lasia(F,") %articularly in a youn( woman! LIMITATIONS This examination re*uires the %atient to &e coo%erative and hold res%iration in ins%iration and ex%iration de%endin( where the sono(ra%her can &est see the artery! If the %atient cannot hold their &reath then ade*uately (ettin( an accurate "o%%ler si(nal will &e im%ossi&le!

Return to to% of %a(e

$CA??!?B T8CA?!C>8
There are $ techni*ues that ideally are used in con1uction with each other0however in circumstances where the renal artery is not seen in its entirety then the indirect a%%roach can (ive an indication of vascular disease!

DIRECT
Assessin( the renal artery from the aorta to the #idney and any accessory arteries for any stenosis!A 2 34 stenosis is re%orted when there is a 2.!5:6 Renal to Aortic Ratio (RAR) or a 2673 cm/sec velocity in the renal artery at any %oint from the ori(in to the #idney!

INDIRECT
Assessin( the arteries within the #idney %arenchyma to assess any alteration in the waveforms!The RI should &e low resistance!The Acceleration Time (AT) should &e 8+3msec! The %ro&e is slowly moved su%erior and inferior to search for additional renal arteries! Any vessels identified must &e traced to the #idney to confirm their identity! The #idneys will atro%hy with chronic renal failure and the len(th should &e 29cm! The RI wil &e 23!7 for untreata&le medical renal disease! A?T87!-7 A997-ACA The renal arteries are clearly ima(ed in ' ,ode from an anterior0su&costal a%%roach

however as it is %er%endicular to the ultrasound &eam it is not suita&le for "o%%ler assessment! Su%ernumery (du%licate) arteries can &e seen loo#in( %osterior to the I:/ in ' ,ode and /olour in a sa(ittal %lane! -BL!C>8 A997-ACA 'y movin( the %ro&e to the left of midline and an(lin( toward the %atient;s ri(ht0 an acce%ta&le "o%%ler an(le of 3 de(rees is achieved! To avoid aliasin( set the colour scale hi(h enou(h so it is minimi-ed! If the scale is too low then it is difficult to determine which veesel is the vein and which vessel is the artery! C-7-?AL A997-ACA Roll the %atient into a decu&itus %osition to void &owel (as and im%rove visi&ility of the renal artery0es%ecially the mid to distal %ortion! 97-?8 A997-ACA The %atient is lyin( %rone or decu&itus and the %ro&e is moved from the s%ine laterally usin( the muscles as an acoustic window to find the #idney initially and then the renal hilum usin( /olour "o%%ler!

BA$!C AA7D C-9D !MAB!?B

D!78CT M8TA-D <ea# Systolic :elocity in the Aorta =ta#en a&ove the level of the renal arteries ori(in!Ta#en with and without an an(le for ratio with the renal artery! Renal Artery Assessment= initially with colour "o%%ler! Renal Artery S%ectral Analysis= >ri(in0<roximal0,id and "istal Artery !If a stenosis is sus%ected then a velocity with an an(le and a measurement with no an(le to com%are with the aorta to (ive a ratio (2.!5:6 is a 2 34 stenosis which is haemodynamically si(nificant) Interlo&ar/Se(mental Artery S%ectral Analysis= Acceleration Time (AT) and Resistive index (RI)!(AT 8+3msec and RI 23!7 for chronic renal disease) !?D!78CT M8TA-D Aorta ' ,ode =?on(itudinal and Transverse to assess for an a&dominal aortic aneurysm! @idney len(ths=cortex assessment for reduced si-e! <erfusion @idney= colour "o%%ler used to assess the %erfusion to the ed(e of the renal cortex! Resistive Index= S%ectral "o%%ler of #idney %arenchyma at the interlo&ar (se(mental) arteries and interlo&ular (arcuate)arteries! Acceleration Time