Ultrasound Evaluation of Renal Artery Stenosis

Cindy A. Owen, RDMS, RVT

Diagnostic Ultrasound Services at Baptist Memorial Hospital Desoto
Southaven, MS

1. Objectives
2. Introduction
3. Anatomy
4. Scanning Technique
5. Renal Artery Stenosis- The Problem
6. Renal Doppler Waveform Analysis
7. Ultrasound Diagnosis of Renal Artery Stenosis
8. Summary
9. Bibliography
10. CME Quiz

Objectives

• Understand the normal and variant anatomy of the renal vascular

system

• Describe the RAR and acceleration time

• Describe the appearance and meaning of a tardus parvus Doppler

waveform

• Outline the protocol for a renal artery Doppler exam

Introduction

Hypertension affects up to 65 million adults in the United States. A small subset of these
patients have renovascular hypertension due to obstruction of the renal arteries.
Fortunately, this type of hypertension can be corrected with treatment of the offending
renal artery stenosis. Many hypertensive patients are referred for duplex ultrasound to
screen for the presence of renal artery stenosis. While ultrasound imaging with Doppler
analysis is a useful tool for evaluation of the renal arteries, it is often underused because it
can be technically challenging and time-consuming. This article discusses methods to
improve results through optimization of scanning technique, patient positioning and
enhanced understanding of the technical aspects of the examination.

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 Two methods are used in ultrasound evaluation of renal artery stenosis; a direct and an
indirect approach. A combination of these methods is recommended to optimize results.
The direct approach involves Doppler interrogation along the entire length of the main
renal artery and any accessory renal arteries. The indirect approach involves evaluation of
the segmental or interlobar arteries within the kidney. This technique infers stenosis of the
main renal artery through recognition of alterations of the normal waveform shape
obtained from the intrarenal arteries. Both methods will be discussed in detail.
Anatomy

In most individuals, the renal arteries arise from the abdominal aorta immediately distal to
the origin of the superior mesenteric artery (SMA). The right renal artery passes
underneath the inferior vena cava (IVC) and posterior to the right renal vein (Fig 1).

A B
Figure 1 - Sagittal ultrasound image in grayscale (A)
and color (B) showing the IVC in long axis and right
renal artery (arrow) in short axis as it courses
underneath the IVC. B. Color Doppler shows flow
within the IVC, hepatic veins and renal artery.

The left renal artery origin courses posterior to the splenic and left renal vein (Fig 2).

2
 Figure 2 - Illustration showing the left renal vein and
artery. The left renal vein passes between the aorta
and SMA. The left renal artery is located posterior to
the renal vein. The top right ultrasound image is a
sagittal view of the abdominal aorta. The left renal vein
can be seen in its short axis between the SMA and
aorta. The bottom right ultrasound image is a
transverse color Doppler view showing the anatomical
relationship between the SMA, celiac trunk, aorta, IVC
and left renal vein.

Upon reaching the renal hilum, the main renal arteries divide into anterior and posterior
segmental arteries. These further divide to feed the multiple segments of the kidney. The
segmental arteries, in turn, give rise to the interlobar arteries which course alongside the
renal pyramids toward the periphery of the kidney. The interlobar arteries branch into
arcuate arteries at the corticomedullary junction. The arcuate arteries travel across the top
of the renal pyramids and give rise to the interlobular arteries (Fig 3). These are the tiny
parenchymal branches that course toward the kidney surface. The interlobular arteries
subdivide into the afferent glomerular arterioles.

Figure 3- Color Doppler image demonstrating

normal intrarenal vasculature. Both arteries
and veins are color encoded. The arteries are
encoded red, as the flow is coursing toward the
probe to the periphery of the kidney. The veins
are encoded blue (color assignment is NOT
inverted). The PRF must be set to a low level
to show the slow flow within the kidney, but it is
preferable to set it high enough that the
arteries and veins can be differentiated. The
exact PRF to achieve this distinction varies
from patient to patient (due to variance in

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 intrarenal flow velocity) as well as the Doppler
frequency used.

The renal veins empty into the IVC. They are located anterior to each renal artery. The left
renal vein courses between the SMA and the abdominal aorta in its path to the IVC. The
right renal vein courses directly to the IVC from the renal hilum.

Variant anatomy is common in the renal vascular system. Approximately 30% of

individuals have more than a single renal artery on each side (Fig 4,5). Supernumery
arteries may occur unilaterally or bilaterally. Most accessory renal arteries arise from the
abdominal aorta, but they may also originate from the common iliac, superior or inferior
mesenteric, adrenal, and right hepatic arteries. Early division of the main renal artery
occurs in about 15% of the population.

A B

C D
Figure 4 - Sagittal grayscale and coronal color images in two
patients with supernumery right renal arteries. For identification
of multiple right renal arteries, it is helpful to obtain a long axis
view of the IVC. Careful scrutiny underneath the IVC reveals two

4
 right renal arteries in the first patient (A) and three right renal
arteries (C) in the second patient. Another useful view to
demonstrate supernumery renal arteries is a coronal image of
the aorta. This view provides an excellent angle for imaging the
origins of both the right and left renal arteries using color/Power
Doppler. The first patient (B) shows two right renal arteries and
one left renal artery using power Doppler. As power Doppler
does not demonstrate flow direction, the left renal vein is the
same color as the artery and could easily be mistaken for a
duplicate left renal artery. Careful inspection, however, shows
that the vessel does not join the aorta, but courses anterior to it.
Doppler can be used to confirm its' identity. Power Doppler was
also used on the second patient to demonstrate three right renal
arteries and a single left renal artery.

A B

C D
Figure 5- Color Doppler depiction of supernumery renal
arteries. The first patient has a single right renal artery and
duplicate left renal arteries. Compared to the right side,
detecting supernumery left renal arteries is more challenging on
ultrasound. Image A shows a coronal, long axis color Doppler

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 image of the aorta showing a single right renal artery and two
left renal arteries. A transverse color Doppler view on the same
patient (B) shows both left renal arteries arising from the aorta.
The left renal vein is seen anterior to the arteries. The single
right renal artery is demonstrated in the same view. When
searching for supernumery renal arteries in the transverse
orientation, color Doppler is activated and each main renal
artery identified. The probe is slowly moved superior and inferior
to search for additional renal arteries. Any vessels identified
must be traced to the kidney to confirm their identity.
Supernumery renal arteries are often easy to identify in utero in
the second or third trimester. Multiple renal arteries are seen in
each fetus (C and D) using a coronal approach and color
Doppler.

Anomalous anatomy affects the venous drainage as well as the arterial inflow. The left
renal vein may follow a retroaortic course passing posterior to the aorta instead between
the aorta and SMA. Alternatively, the renal vein may be circumaortic, dividing before
reaching the aorta with one branch coursing anteriorly and another posteriorly (Fig 6).

A B

C D

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 Figure 6- Anomalous left renal vein in two patients. The first
patient has a retroaortic left renal vein. A transverse color
Doppler image shows the renal vein passing posterior to the
aorta before emptying into the IVC (A). A sagittal power Doppler
image shows the left renal vein in cross section just underneath
the abdominal aorta (B). The second patient has a circumaortic
left renal vein. The transverse grayscale image shows the left
renal vein dividing before reaching the aorta with one branch
passing posterior and the other anterior between the SMA and
aorta (C). A sagittal color Doppler image captured in diastole
shows the renal vein in cross section on each side of the
abdominal aorta (D).
Scanning Technique

Anterior Approach
Even when the renal arteries are clearly imaged from an anterior approach, the proximal
course of the right renal artery is often perpendicular to the beam. This is an excellent
angle for Bmode imaging but is not suitable for Doppler. Moving the probe slightly to the
left of midline and angling it toward the patient’s right side can sometimes improve the
Doppler angle (Fig 7). Color Doppler helps to localize the artery and define the Doppler
angle. Immediately after arising from the aorta, the right renal artery passes underneath
the IVC. It is sometimes difficult to distinguish the border between the IVC and renal
artery, but color Doppler will help. Setting the color PRF (velocity scale) high enough so
that aliasing is minimized improves the boundary definition. When the PRF is low, the flow
signal is aliased making it difficult to determine flow direction, detect turbulence or even to
differentiate the vessel border between the IVC and renal artery (Fig 8). The mid to distal
right renal artery is not often imaged adequately from an anterior approach and when it is,
the distance to the Doppler gate is usually large. This decreases Doppler sensitivity and
reduces the PRF at which aliasing will occur, making it more difficult to accurately
measure high velocities.

A B
Figure 7- Transverse Bmode view of the abdominal aorta and
right renal artery from an anterior approach. The ultrasound
probe is oriented at midline and the Doppler cursor placed in the

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 proximal right renal artery (A). The angle of incidence of the
Doppler beam to the flow is unacceptable at approximately 89
degrees. By moving the probe to the left of midline and angling
toward the patient’s right, an acceptable Doppler angle of 60
degrees is achieved (B).

A B
Figure 8- Transverse color Doppler images of the right renal
artery passing underneath the IVC. It is difficult to recognize the
right renal artery or distinguish the boundary between the IVC
and right renal artery when using a low PRF. This is because
color Doppler aliasing tends to hide the boundary between the
two vessels (A). By increasing the PRF, flow direction becomes
more apparent and the right renal artery is readily identified
separate from the IVC (B).

The origin of the left renal artery is posterior compared to the right renal renal artery. On
grayscale alone, the left renal artery is usually difficult to see from an anterior approach,
but once color is activated the proximal portion is often well visualized. The left renal vein
is an excellent landmark for locating the renal artery (Fig 9). It is frequently detected before
the artery and appears as a large red vessel (flow is toward the transducer so the renal
vein will be color encoded red unless the color is inverted). The renal artery will be seen
posterior and slightly inferior to the renal vein and will be color encoded blue (flow coursing
away from the transducer). By positioning the transducer slightly to the right of midline and
angling toward the left, an adequate Doppler angle can usually be achieved for the
proximal portion of the artery. The mid to distal left renal artery is often not seen in this
view except in ideal patients.

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 A B
Figure 9- Transverse color Doppler images of the abdominal
aorta, left renal vein and artery. The left renal vein is a good
landmark for locating the artery. The renal vein is usually
recognized first as a red vessel just lateral to the aorta (A).
Careful inspection will reveal the renal artery as a blue vessel
(color Doppler is NOT inverted), located just posterior to the
renal vein.

Flank Approach
The flank approach is usually the most successful view for imaging the entire length of
both renal arteries. An excellent Doppler angle (60 degrees or less) can nearly always be
achieved with this view. There are several variations to the flank approach. It’s often
necessary to slightly vary the window until an optimal view is found for each individual
patient.

To evaluate the right renal artery, the patient is rolled into a left decubitus position. The
patient is asked to relax the abdominal muscles as much as possible. The probe is placed
in a sagittal view in the soft part of the abdomen below the rib cage. The probe is
manipulated slightly until the aorta and IVC are seen in long axis. Usually, a portion of the
right lobe of the liver is visible at the top of the image. By slightly varying the probe angle,
both renal arteries can be seen arising from the aorta. This has been described as the
“banana peel” view. The right renal artery will course toward the probe and the left will
course away. This is an excellent view for obtaining a Doppler signal from each renal
artery origin as well as the abdominal aorta (Fig 10).

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 A B

C D
Figure 10 - Flank approach showing the abdominal aorta and
origin of both renal arteries. The patient is rolled into a left lateral
decubitus or left oblique position and the probe placed
underneath the right rib cage in a sagittal orientation. The probe
is tilted to the right or left until a long axis view of the aorta and
IVC is obtained (A). Color Doppler shows the origin of both renal
arteries from the abdominal aorta. The right renal artery courses
toward the probe and the left courses away from the probe (B).
The Doppler sample volume is placed within the proximal right
renal artery. In this view, an acceptable Doppler angle of 60
degrees or less is easily obtained (C). The Doppler reading of
the abdominal aorta is taken near the level of the renal arteries.
This value is applied to the RAR (D).

Next, the probe is oriented into a transverse plane and positioned at the renal hilum to
image the mid and distal portion of the right renal artery. Color Doppler is activated and
the color box sized so that it is long in the axial dimension and narrow in the lateral
dimension. By making it long, we are able to see the entire length of the renal artery from
the aorta to the renal hilum. By keeping it narrow, we are able to keep the color frame rate
high. When the probe is positioned correctly, a transverse view of the kidney will be seen
at the top left of the image and the aorta will be seen in transverse at the bottom right. The
renal artery will be seen just posterior to the vein. The Doppler gate can be tracked from
the renal artery origin to its division at the renal hilum (Fig 11). Of course, every patient’s
anatomy is unique and it will be necessary to make slight adjustments for each patient.

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 Figure 11 - Transverse color Doppler image
using the flank approach. This image shows a
long axis view of the right renal artery from its’
origin all the way to the renal hilum. The aorta
is seen in cross section at the bottom of the
image and the kidney is seen in cross section
at the top of the image. The patient is in a left
lateral decubitus or left oblique position, and
the probe is oriented transverse to the body
instead of sagittal. In this view, the Doppler
cursor can be tracked through the entire length
of the renal artery. The renal vein is seen just
anterior to the artery. The liver and kidney
provide an excellent sonographic window for
imaging the renal artery using this approach.

To evaluate the left renal artery, the patient is rolled into a right decubitus position. The
probe is positioned in a sagittal plane over the left kidney. Again, color Doppler is activated
and the color box sized so that it is long and narrow. The color box is positioned at the mid
point of the kidney. It will be necessary to vary the probe angle until both the abdominal
aorta and left kidney are visible in the image. Imaging of the renal artery can be performed
though either a sagittal or transverse orientation of the kidney. Color will show both the
renal vein and artery coursing between the aorta and the kidney. Usually the entire length
of the renal artery can be seen in this view, although when vessel tortuosity is present, the
renal artery may be seen in segments.

Intrarenal Arteries
Evaluation of the intrarenal arteries is best done through a flank approach with the patient
rolled into a decubitus position. The probe is placed along a lateral or slightly posterior
approach. There should be no spleen or liver visible between the probe and the kidney.
This ensures that the distance to the intrarenal vessels is minimized. Color Doppler is
essential to map the vascular anatomy. The intrarenal Doppler waveforms must be
obtained at angles less than 30 degrees or the early systolic peak may not be visualized
(Fig 12). Color Doppler helps to estimate the best angle of approach for Doppler. Typically,
the probe is rotated more posteriorly to improve the Doppler angle to for the upper pole
intrarenal arteries. For the mid kidney, the probe is centered in a coronal plane. The best
Doppler angle for the lower pole intrarenal arteries is usually obtained by rotating the
probe slightly anterior to the mid coronal line.

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 A B
Figure 12 - Color and spectral Doppler image of the intrarenal
vasculature. The patient is rolled onto a lateral decubitus
position for optimal evaluation of the intrarenal arteries. The
probe is aligned along the posterior axillary line. Color Doppler
identifies the vessels and helps to locate a segmental or
interlobar artery at an optimal angle of 30 degrees or less (A).
The Doppler sample volume is enlarged to improve the chances
of keeping it within the tiny vessels. The Doppler sweep speed
is set so that only 2-3 seconds at a time is seen on the display
and the PRF is adjusted so that the waveform fills the spectral
window. A probe with a Doppler frequency of 3.5 MHz or higher
is preferred. High Doppler frequencies provide larger
waveforms because the frequency shift is greater compared to
lower frequencies. These steps ensure that the waveform is as
large as possible. The patient is asked to suspend respiration
and a Doppler reading is taken from within one of the arteries
best aligned to the cursor. If the waveform does not
demonstrate an early systolic peak, several readings may be
necessary until there is confidence that the waveform quality is
sufficient and the ESP is truly absent. In this example, the ESP
is absent due to stenosis of the proximal renal artery of > 60%.

Renal Artery Stenosis- The Problem

The term renovascular hypertension (RVHT) is used to describe elevated blood pressure
that is primarily caused by renal artery stenosis. This type of hypertension accounts for
approximately 1-10% of patients with hypertension. Since RVHT is potentially curable with
correction of the renal artery stenosis (RAS), patients having clinical findings of RVHT are
often referred for a Doppler exam to evaluate their renal arteries. If stenosis is detected,
intervention can be planned. Clinical findings associated with RVHT are listed in the table
below. Obstruction of the renal arteries may be caused by atherosclerotic disease or
arterial dysplasias. In younger patients, RVHT most often develops as a result
fibromuscular dysplasia. This is more common in females than males. Older patients with

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RVHT are typically male who develop renal artery stenosis due to atherosclerotic disease.

Clinical Findings in Renovascular

Hypertension
• Hypertension that is difficult to control
with medical treatment
• Hypertension associated with renal
failure or progressive renal insufficiency
• Severe hypertension (diastolic blood
pressure >120 mm Hg)
• Onset of hypertension before age 30 or
after age 50
• Abrupt onset of hypertension
• Generalized atherosclerosis
• Negative family history of hypertension
• Abdominal bruit

Atherosclerotic stenosis of the renal arteries most commonly affects the most proximal
segment of the vessel, whereas, fibromuscular dysplasia is most often seen in the mid to
distal aspect of the renal arteries. Fibromuscular dysplasia causes a pattern of arterial wall
thickening alternating with areas of small aneurysmal dilatation. This produces a beaded
appearance on angiography that has been described as a “string of pearls” (Fig 13). Renal
artery dysplasia usually presents in younger patients compared to renal artery stenosis
due to atherosclerosis. Females are much more commonly affected than males.

In some patients, correction of the renal artery stenosis does not result in improved renal
function or resolution of hypertension. Ultrasound may play a role in helping to determine
which patients will benefit from intervention. Radermacher published a study in 2001
suggesting that patients with a renal artery resistive index (RI) greater than 0.80 are
unlikely to benefit from interventional therapy, whereas patients with an RI less than 0.80
are more likely to show improvement. The resistive index tends to be high in patients with
chronic renal disease or those with renal damage due to a long history of hypertension.

13
 Figure 13- Angiogram in patient with
fibromuscular dysplasia. Fibromuscular
dysplasia produces a "string of pearls"
appearance on angiography. It usually affects
the mid to distal segment of the artery.

Renal Doppler Waveform Analysis

The normal Doppler waveform obtained from the renal artery demonstrates a low
resistance profile with continuous forward flow throughout the cardiac cycle. The resistive
index is less than 0.70. Increased vascular resistance with decreased diastolic flow may
be seen in hydronephrosis, renal vein thrombosis and chronic renal disease. RI increases
with decreasing diastolic flow. An absence of flow in diastole results in an RI of 1.0.

Waveforms obtained from the main renal arteries demonstrate a rapid upstroke in systole
when normal. The intrarenal waveform obtained from a segmental or interlobar artery has
an acceleration time (AT) of less than .07 seconds. A small notch is visible near peak
systole and is known as the early systolic peak (ESP). The normal peak systolic velocity of
the main renal artery is less than 150 cm/sec. The velocity decreases in the distal
intrarenal arteries (Fig 14).

A B
Figure 14- Normal Doppler waveforms obtained from the main
renal artery and segmental renal artery. A low resistance
waveform with sharp systolic upstroke is expected in the normal
main renal artery (A). The early systolic peak (arrow) is seen as
a small notch in systole in the normal intrarenal arterial
waveform. The systolic upstroke is rapid with an acceleration
time of 0.07 seconds or less.

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 Ultrasound Diagnosis of Renal Artery Stenosis

Contrast angiography (CA) is the gold standard in the diagnosis of renal artery stenosis
(RAS). Due to its invasive nature, however, CA is not suitable for screening. Multiple
studies have shown that Doppler Ultrasound can be an effective tool in the diagnosis of
RAS. Both a direct (evaluation of the main renal artery) and indirect (evaluation of the
segmental/interlobar arteries) method of diagnosing RAS have been shown to be useful.
Direct and indirect methods have both been shown to have sensitivity and specificity in the
low to mid 90% range. The most reliable approach combines the two methods. Other tests
used for detection of RAS include radionuclide scanning, MRA and Spiral CT.

Direct evaluation of the main renal artery

The exam begins with imaging of the kidneys. The length of each kidney is measured and
compared to the contralateral kidney. The normal kidney measures from 8.5 - 13 cm in
long axis. Differences greater than 2 cm in length between the kidneys is suggestive of
renal artery occlusion on the side of the smaller kidney. Normal renal parenchyma
measures greater than 1 cm in thickness. The parenchyma surface should be smooth with
an echogenicity equal to or slightly less than the normal liver parenchyma (Fig 15).

A B
Figure 15- Sagittal views of the kidney. Image A shows a
patient with normal kidney echogenicity (equal to or less than
the liver). Image B shows a patient with abnormal kidney
echogenicity that is hyperechoic compared to the liver.

The direct method involves Doppler interrogation of the entire length of the main renal
artery, including any accessory renal arteries. Although stenosis is usually located near
the renal artery origin, fibromuscular dysplasia is more often located in the mid to distal
segment, thus requiring a look at the entire length of each artery. Since a stenosis in an
accessory renal artery can cause renovascular hypertension, it is important to search for
and interrogate these vessels.

The highest velocity found in the renal artery is compared to that of the abdominal aorta
(at the level of the renal arteries). This is termed the renal/aortic ratio or RAR. Color
Doppler imaging is useful to identify and map the main renal arteries and to locate
accessory renal arteries. Doppler angle correction is more accurate with the use of color

15
 Doppler since visualization of the path of the vessel is improved.

Velocities greater than 200 cm/sec have been shown to indicate a >60% RAS. Post-
stenotic turbulence must be documented beyond any focal velocity increase to confirm
stenosis. Bruits seen in color Doppler or in the spectral waveform can also increase
diagnostic confidence and aid in localization of a stenosis. The RAR is calculated by
dividing the highest peak systolic velocity in the renal artery by the normal aortic velocity.
An RAR greater than 3.5 is considered abnormal (Fig 16).

A B

C D

E F

16
 G H

I J
Figure 16 - Images obtained from a patient with bilateral renal
artery stenosis. Image A is a color Doppler image of a stenotic
right renal artery origin. A color bruit is seen in the tissue
surrounding the area of the post stenotic turbulence. The
presence of the bruit can help to identify the location of the
stenosis and increase diagnostic confidence. A Doppler
reading(B) obtained near the renal artery origin shows velocities
over 600 cm/s in systole and over 300 cm/s in diastole
consistent with a high grade stenosis. Note that rolling the
patient into a decubitus position and angling the probe back
toward the aorta have purposefully decreased the angulation of
the renal artery. The arrows are pointing to a bruit that is evident
on the spectral display. Image C shows a spectral waveform
obtained in the area of poststenotic turbulence just beyond the
maximal area of stenosis. The velocity is lower at 317 cm/s and
the waveform profile is irregular due to the turbulent flow. The
Doppler waveform obtained from the segmental renal arteries
within the right kidney shows a tardus parvus shape with
absence of the ESP (D). The AT measures 0.11 sec. A color
Doppler image of the stenotic left renal artery origin is seen in
image E. The higest velocity obtained was approximately 350
cm/s (F). Image G shows poststenotic turbulence and a spectral

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 bruit in the waveform. The waveform obtained from the left
intrarenal artery shows an absence of the ESP and a tardus and
parvus shape consistent with stenosis of the main renal artery
(H). Angiography confirmed bilateral renal artery stenosis (I).
Angioplasty and stenting of the both renal arteries was
performed (J).

Attention to Doppler technique is key in this exam. The Doppler angle must be 60 degrees
or less and aligned parallel to the vessel wall. Angles greater than 60 degrees tend to
result in overestimation of the velocity. Misalignment of the angle correction cursor so that
it is not parallel with the vessel wall is a common cause of incorrect velocity
measurements. The image is often frozen when obtaining Doppler readings in duplex
exams. If the probe position is adjusted to improve the Doppler trace while the image is
frozen, the image no longer accurately portrays the Doppler location and the angle may
not be measured correctly. To avoid this pitfall, it is necessary to update the image after
manipulating the probe. A low Doppler frequency is recommended (usually 2-3 MHz) to
reduce aliasing of the waveform and improve penetration. The system pulse repetition
frequency (PRF) is monitored and increased whenever aliasing is encountered so that the
systolic peak can be demonstrated without wraparound. Doppler waveforms with aliasing
will result in inaccurate peak systolic measurements unless the aliased and non aliased
signal velocities are manually added together (Fig 17).

A B
Figure 17- Image A shows aliasing of the spectral waveform.
The frequency shift is too high for the PRF setting. The velocity
values measured from the waveform do not reflect an accurate
peak systolic velocity because that portion of the waveform is
aliased (cut off and displayed below the baseline). By raising the
PRF and lowering the baseline, the peak velocity is displayed
correctly and an accurate velocity is obtained.

Even in the best hands, it is difficult to detect accessory renal arteries on all patients. This

18
most often successful. The patient is asked to relax the abdomen thus allowing it to rest on
the table surface. The probe is positioned in the soft part of the adipose tissue just lateral
to midline. In this view, the abdominal aorta and origin of the renal arteries can be seen
(Fig 18). Scanning these patients from an anterior approach usually results in failure
because the beam must now penetrate the largest mass of adipose tissue. Furthermore,
the patient typically resists the probe pressure by tensing their abdomen in this position.
Another common problem is difficulty in obtaining a satisfactory Doppler angle. However,
by using multiple approaches, it is usually possible to obtain an adequate angle of
incidence.

Direct criteria for detection of >60% RAS

• Peak systolic velocity > 200 cm/sec
• RAR > 3.5
• Post-stenotic turbulence

Figure 18 - Image A shows the most advantageous

scanning position on obese patients. The patient is
positioned in a lateral decubitus position and asked to
relax the abdomen. This lets most of the adipose
tissue fall forward onto the scanning bed. The probe
is then placed in the soft part of the abdomen in a
sagittal plane. This decreases the distance to the
abdominal vessels compared to scanning from an
anterior approach through the adipose tissue. The
probe is angled slighly back and forth until a long axis
view of the abdominal aorta is obtained. Color

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 Doppler highlights the origins of both renal arteries
and a Doppler reading obtained from the left renal
artery (B). This approach not only decreases the
distance to the vessels, it allows achievement of
Doppler angles that are 60 degrees or less.

Indirect evaluation
The indirect evaluation for renal artery stenosis adds another layer of information to that
already obtained from the direct method. By combining the two methods, a more accurate
exam can be obtained. Indirect evaluation involves Doppler interrogation of the segmental
or interlobar arteries within the kidney. A complete exam includes evaluation of the upper,
mid and lower pole segmental arteries. If a stenotic accessory artery is feeding one of the
renal poles, an abnormal waveform will be detected in that segment. This helps to
compensate for any missed accessory renal arteries with the direct method.

Color or power Doppler is essential in identifying the intrarenal vessels and determining an
optimal angle of incidence. High-grade stenosis of a feeding artery, delays the systolic rise
in arteries immediately distal to it. The resulting waveform shape is termed tardus parvus.
Normal intrarenal segmental and interlobar arteries display an early systolic peak (ESP) or
notch at the beginning of systole. The ESP is absent with stenosis of the main renal artery
exceeding 60%.

A B
Figure 19- Correct and incorrect measurement of AT. It is
important to carefully place the calipers on the waveform to
obtain an accurate measurement of the acceleration time. The
first caliper must be placed at the beginning of the systolic rise.
In image A, the caliper is placed correctly (open arrow) and the
AT measures 0.05 sec. In image B, the caliper is placed
incorrectly (closed arrow), too far from the systolic rise, and the
AT is incorrectly measured resulting in a false positive value of
0.11 sec.
The systolic acceleration time (AT) is measured from start of the systolic upstroke to the
first peak or ESP (Fig 19). Systolic acceleration times greater than 0.07 second are

20
 consistent with a main renal artery stenosis exceeding 60%. The RI is measured and
compared between kidneys. A difference in RI between the ipsilateral and contralateral
kidney increases suspicion for renal artery stenosis on the side with the lowest RI. This
difference is significant when it exceeds –5. Other parameters that have been
recommended include acceleration (ACC) and acceleration index (AI). We rely most
heavily on pattern recognition (presence of ESP, tardus and parvus waveform), AT and RI
(Fig 20).

A B
Figure 20 - Normal and abnormal waveform patterns from
segmental renal arteries. Column A shows a range of normal
waveforms. The ESP is detected on each waveform. In some
cases, the ESP is the highest peak, but in others, the highest
peak occurs later in systole. The AT is always measured to the
first systolic peak, which is the ESP in normal waveforms.
Column B shows a range of abnormal waveforms with
increasing levels of renal artery stenosis from top to bottom.
Since the ESP is absent on abnormal waveforms, the AT is
measured from the beginning of systole to the systolic peak.
These waveforms are termed tardus parvus due to the delayed
systolic acceleration.
Indirect criteria for detection of >60% RAS
• Absence of ESP
• AT > .07 sec
• Tardus Parvus waveform
• RI difference between kidneys exceeding
-5

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 Attention to technique is crucial in performing this examination. The study is best
performed with the patient in a decubitus or oblique position. The scan plane is through
the posterior axillary line. This results in a shorter Doppler distance and a better Doppler
angle to the intrarenal vessels (Fig 21). It is very important to adjust the scan position in
order to achieve a Doppler angle of incidence that is between 0- 30º to each vessel
interrogated. A Doppler angle greater than 30º may not allow demonstration of the ESP.
Color Doppler delineates the vessel path so that an optimal angle can be obtained.

Figure 21- Scanning approach for indirect

evaluation. To best image the intrarenal
vasculature, the patient is rolled into a lateral
decubitus position for each kidney. The probe is
placed along the axillary line. The kidney is close
to the surface in this view and the segmental renal
arteries will course directly toward the probe at
small angles. This is ideal for obtaining Doppler
signals from within the kidney. It is not
recommended to scan from an anterior approach
through the liver. This increases the distance to
the kidney and will result in weaker Doppler
signals obtained at steeper angles.

Adequate evaluation of the intrarenal Doppler trace requires large, strong, well-defined
spectral waveforms. The Doppler sweep speed is set so that the display shows only 2-3
seconds at a time. This will spread out each cardiac cycle so that its components are more
easily seen and measured. The system PRF is adjusted so that the waveform fills the
entire spectral window. A higher frequency (3- 5 MHz) is used compared to direct renal
artery interrogation. This will produce a larger frequency shift and correspondingly larger
waveform, enhancing definition of the ESP and improving caliper placement for
measurements.

High resistance within the intrarenal arteries reduces the sensitivity of the indirect
technique. With high resistance, the ESP becomes exaggerated and may not disappear
with stenosis (Fig 22). Likewise, it takes an even greater amount of stenosis before the
acceleration time becomes abnormal and a tardus parvus waveform develops. Stenosis
may still be suspected on the basis of waveform comparison between sides and noting an
RI difference between kidneys. However, it’s best to rely on the direct interrogation of the
renal arteries whenever the RI is greater than 0.70.

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 Figure 22- Exaggerated ESP associated with
high resistance waveforms. The RI is 0.78.
With increased resistance, the early systolic
peak becomes exaggerated and will persist
even though stenosis is present in the main
renal artery. When the RI is greater than 0.70,
the indirect technique becomes less sensitive
for detection of stenosis in the main renal
artery as it will take a greater degree of
narrowing before indirect signs such as a
tardus parvus waveform shape, increased
acceleration time or loss of the ESP occurs.
Over reliance on the indirect technique in these
cases can result in a false negative
examination.

Other limitations associated with indirect evaluation for RAS include the inability to
differentiate between severe stenosis and occlusion of the main renal artery. Collateral
flow to the kidney in renal artery occlusion can produce an intrarenal Doppler presentation
similar to that seen with severe RAS. Additionally, indirect Doppler evaluation is not
sensitive to the detection of RAS less than 60%. Since, renal artery stenoses of less than
60% are not thought to be hemodynamically significant and do not result in renovascular
hypertension, this limitation may not be of great significance.

It's important to emphasize that use of poor Doppler angles and low Doppler frequencies
can result in nonvisualization of the ESP. The ESP is best seen at Doppler angles less
than 30º and Doppler frequencies of 3 MHz or greater. It is necessary to obtain Doppler
samplings at the upper, mid and lower pole of the kidney; otherwise, renovascular
hypertension due to stenosis of an accessory renal artery will be missed. Bilateral tardus
parvus waveforms could potentially be the result of a proximal stenosis in the aorta or
aortic aneurysm rather than bilateral RAS. Direct interrogation of the renal arteries will help
to determine if stenosis is present. Evaluation of the abdominal aorta should be performed
to rule out aneurysm.
Summary

Ultrasound evaluation for renal artery stenosis can be accurately accomplished with both
direct and indirect methods. Combining the two methods overcomes some of the
limitations specific to each. Attention to technique is crucial for success with both methods.
Color and/or Power Doppler improves visualization of the anatomy and is essential for
determining an optimal angle with the indirect technique.
References

1. Halpern EJ, Needleman L, Nack TL, East SA. Renal artery stenosis:

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