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CT Evaluation of Renovascular Disease¹

¹ From the Departments of Radiology (A.K., C.M.S., R.D.E., E.P.T., S.M.G.) and Urology (C.M.S., S.M.G.), University of Texas Medical School, Houston; the Department of Radiology, Lyndon B. Johnson General Hospital, 5656 Kelley St, Houston, TX 77026 (A.K., C.M.S., R.D.E., S.M.G.); and the Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, Md (E.K.F.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received May 3, 1999; revision requested July 13 and received May 1, 2000; accepted May 4. Address correspondence to A.K. (e-mail: akira.kawashima@uth.tmc.edu).

View larger version (134K): [in a new window]   Figure 1.   Global renal infarct in a 24-year-old man after blunt abdominal trauma. Contrast-enhanced helical CT scan shows abrupt termination of the proximal right main renal artery (solid arrow) without a nephrogram, findings consistent with renal artery occlusion. Note the retroperitoneal hematoma around the inferior vena cava (IVC) (open arrow).

View larger version (125K): [in a new window]   Figure 2.   Segmental renal infarct in a 34-year-old man after blunt abdominal trauma. Contrast-enhanced helical CT scan shows a sharply demarcated area of decreased enhancement in the posterior upper pole of the right kidney, a finding consistent with occlusion of the dorsal branch of the renal artery. Note the splenic laceration with a perisplenic hematoma (arrow).

View larger version (150K): [in a new window]   Figure 3.   Arteriovenous fistula in a 25-year-old man with a history of needle biopsy of the left kidney. Contrast-enhanced helical CT scan obtained during the early nephrographic phase shows marked enhancement in a large vascular lesion (V) and the left renal vein (straight arrow); the enhancement is similar to that in the aorta but greater than that in the right renal vein (curved arrow). The left kidney demonstrates a diminished nephrogram and atrophy (arrowheads), which are indicative of diffuse ischemia distal to the arteriovenous fistula.

View larger version (136K): [in a new window]   Figure 4.   Calcified renal artery aneurysm in a 60-year-old woman. Intravenous urography showed a ring of calcification in the proximity of the collecting system in the upper right kidney. Nonenhanced helical CT scan shows a calcified aneurysm (arrow).

View larger version (130K): [in a new window]   Figure 5a.   Renal artery aneurysm in a 48-year-old woman. Intravenous urography showed extrinsic compression of the right renal pelvis superomedially. (a) Contrast-enhanced helical CT scan shows a well-defined round mass (A) in the renal hilum with enhancement similar to that of the vessel, findings consistent with an aneurysm. Selective digital subtraction angiography showed a large aneurysm in the region of the renal artery bifurcation. The location of the neck of the aneurysm was not clear at angiography. (b) Helical CT scan obtained during intraarterial injection of contrast material into the right main renal artery via a catheter shows an aneurysm (A) arising at the bifurcation of the main renal artery (mra) into the anterior segmental renal artery (asra) and posterior segmental renal artery (psra). The posterior segmental artery arises directly from the wall of the aneurysm. P = renal pelvis. (c) Color-encoded shaded-surface display image from the helical CT data clearly shows the relationship of the saccular aneurysm (A) to the main renal artery (mra), anterior segmental renal artery (asra), and posterior segmental renal artery (psra). The arteries and aneurysm are encoded red; the collecting system (P) is encoded yellow. The patient underwent resection of the aneurysm and autotransplantation of the kidney into the right iliac fossa.

View larger version (141K): [in a new window]   Figure 5b.   Renal artery aneurysm in a 48-year-old woman. Intravenous urography showed extrinsic compression of the right renal pelvis superomedially. (a) Contrast-enhanced helical CT scan shows a well-defined round mass (A) in the renal hilum with enhancement similar to that of the vessel, findings consistent with an aneurysm. Selective digital subtraction angiography showed a large aneurysm in the region of the renal artery bifurcation. The location of the neck of the aneurysm was not clear at angiography. (b) Helical CT scan obtained during intraarterial injection of contrast material into the right main renal artery via a catheter shows an aneurysm (A) arising at the bifurcation of the main renal artery (mra) into the anterior segmental renal artery (asra) and posterior segmental renal artery (psra). The posterior segmental artery arises directly from the wall of the aneurysm. P = renal pelvis. (c) Color-encoded shaded-surface display image from the helical CT data clearly shows the relationship of the saccular aneurysm (A) to the main renal artery (mra), anterior segmental renal artery (asra), and posterior segmental renal artery (psra). The arteries and aneurysm are encoded red; the collecting system (P) is encoded yellow. The patient underwent resection of the aneurysm and autotransplantation of the kidney into the right iliac fossa.

View larger version (150K): [in a new window]   Figure 5c.   Renal artery aneurysm in a 48-year-old woman. Intravenous urography showed extrinsic compression of the right renal pelvis superomedially. (a) Contrast-enhanced helical CT scan shows a well-defined round mass (A) in the renal hilum with enhancement similar to that of the vessel, findings consistent with an aneurysm. Selective digital subtraction angiography showed a large aneurysm in the region of the renal artery bifurcation. The location of the neck of the aneurysm was not clear at angiography. (b) Helical CT scan obtained during intraarterial injection of contrast material into the right main renal artery via a catheter shows an aneurysm (A) arising at the bifurcation of the main renal artery (mra) into the anterior segmental renal artery (asra) and posterior segmental renal artery (psra). The posterior segmental artery arises directly from the wall of the aneurysm. P = renal pelvis. (c) Color-encoded shaded-surface display image from the helical CT data clearly shows the relationship of the saccular aneurysm (A) to the main renal artery (mra), anterior segmental renal artery (asra), and posterior segmental renal artery (psra). The arteries and aneurysm are encoded red; the collecting system (P) is encoded yellow. The patient underwent resection of the aneurysm and autotransplantation of the kidney into the right iliac fossa.

View larger version (155K): [in a new window]   Figure 6a.   Perinephric hemorrhage in a 40-year-old man with polyarteritis nodosa who presented with left flank pain of acute onset. Nonenhanced (a) and contrast-enhanced (b) helical CT scans show left perinephric (pn) and anterior pararenal (ap) hematomas, with a focal defect in the left renal cortex (arrow) shown on the contrast-enhanced scan (b). Note the multiple small focal areas of renal parenchymal scarring with a lobulated renal contour bilaterally. Selective right renal angiography showed small aneurysms.

View larger version (154K): [in a new window]   Figure 6b.   Perinephric hemorrhage in a 40-year-old man with polyarteritis nodosa who presented with left flank pain of acute onset. Nonenhanced (a) and contrast-enhanced (b) helical CT scans show left perinephric (pn) and anterior pararenal (ap) hematomas, with a focal defect in the left renal cortex (arrow) shown on the contrast-enhanced scan (b). Note the multiple small focal areas of renal parenchymal scarring with a lobulated renal contour bilaterally. Selective right renal angiography showed small aneurysms.

View larger version (124K): [in a new window]   Figure 7.   Nephromegaly in a 21-year-old woman with SLE who presented with abdominal pain. Contrast-enhanced helical CT scan shows nephromegaly with peripheral hypoattenuating striations (arrowheads). Selective renal angiography showed peripheral defects in the nephrogram.

View larger version (105K): [in a new window]   Figure 8.   Drug-induced vasculitis in a 45-year-old man with a history of cocaine and other drug abuse. Contrast-enhanced helical CT scan shows multiple infarcts in both kidneys and the spleen (straight solid arrow). Note the thrombus secondary to vasculitis in the superior mesenteric artery (curved arrow) and aorta (open arrow).

View larger version (143K): [in a new window]   Figure 9.   Ruptured angiomyolipomas in a 32-year-old man with a history of tuberous sclerosis. Contrast-enhanced CT scan shows multiple large fat-containing masses involving the kidneys bilaterally. Note the large intratumoral hematoma (H) with a perinephric hematoma (arrow). The left kidney (LK) is displaced anteriorly.

View larger version (136K): [in a new window]   Figure 10.   Ruptured renal cell carcinoma in a 60-year-old man. Contrast-enhanced CT scan shows a hypoattenuating mass (M) in the lower pole of the left kidney, which is displaced anteriorly by a perinephric hematoma with a fluid-fluid level (arrow). Selective renal angiography showed a hypovascular exophytic tumor in the lower pole of the left kidney with minimal coarse neovascularity.

View larger version (124K): [in a new window]   Figure 11.   Perinephric hematoma in a 53-year-old woman receiving anticoagulant therapy. Contrast-enhanced CT scan shows areas of active bleeding (arrows) adjacent to the left kidney within a large perinephric hematoma of lower attenuation.

View larger version (121K): [in a new window]   Figure 12.   Spontaneous renal sinus hemorrhage in a 72-year-old man receiving anticoagulant therapy. Contrast-enhanced CT scan shows a left renal sinus mass (H). Ureteroscopy showed no abnormality in the upper urinary tract. Note the thickening of the renal fascia (arrow).

View larger version (145K): [in a new window]   Figure 13.   Paraneoplastic thromboembolic disorder (Trousseau syndrome) in a 49-year-old woman with advanced pancreatic carcinoma. Contrast-enhanced helical CT scan shows a left renal infarct. Note the ill-defined, hypoattenuating mass (M) in the head of the pancreas with associated encasement of the superior mesenteric artery (open arrow) and thrombosis of the superior mesenteric vein (solid arrow). A filter is present in the IVC (C) for deep venous thrombosis. Two focal hypoattenuating metastases are present in the liver (arrowheads). Splenic and hepatic infarcts were also present.

View larger version (118K): [in a new window]   Figure 14.   Global renal infarct in a 21-year-old woman with polysplenia syndrome (polysplenia, situs ambiguous, and atrial septal defect) who presented with subacute bacterial endocarditis. Contrast-enhanced CT scan shows a global infarct of the right kidney with a rim of enhancement in the capsule (arrow). A = aorta, C = IVC, L = liver, S = spleen.

View larger version (104K): [in a new window]   Figure 15a.   Renal infarct in a 46-year-old woman with a thrombus in the thoracic aorta who experienced multiple episodes of thromboembolism. (a) Contrast-enhanced CT scan shows a wedge-shaped area of decreased enhancement (arrow) in the left midkidney, a finding consistent with a focal infarct. (b) Follow-up contrast-enhanced CT scan obtained 6 months later shows a cortical scar (arrow). (c) Sagittal reformation image of the thorax shows an irregular filling defect (arrow) in the descending aorta. Thrombectomy of the descending aorta was performed.

View larger version (116K): [in a new window]   Figure 15b.   Renal infarct in a 46-year-old woman with a thrombus in the thoracic aorta who experienced multiple episodes of thromboembolism. (a) Contrast-enhanced CT scan shows a wedge-shaped area of decreased enhancement (arrow) in the left midkidney, a finding consistent with a focal infarct. (b) Follow-up contrast-enhanced CT scan obtained 6 months later shows a cortical scar (arrow). (c) Sagittal reformation image of the thorax shows an irregular filling defect (arrow) in the descending aorta. Thrombectomy of the descending aorta was performed.

View larger version (124K): [in a new window]   Figure 15c.   Renal infarct in a 46-year-old woman with a thrombus in the thoracic aorta who experienced multiple episodes of thromboembolism. (a) Contrast-enhanced CT scan shows a wedge-shaped area of decreased enhancement (arrow) in the left midkidney, a finding consistent with a focal infarct. (b) Follow-up contrast-enhanced CT scan obtained 6 months later shows a cortical scar (arrow). (c) Sagittal reformation image of the thorax shows an irregular filling defect (arrow) in the descending aorta. Thrombectomy of the descending aorta was performed.

View larger version (143K): [in a new window]   Figure 16a.   Acute cortical necrosis in a 65-year-old woman who underwent bowel resection for an incarcerated ventral hernia. (a) Preoperative contrast-enhanced CT scan shows normally functioning kidneys. The postoperative course was complicated by sepsis. (b) Follow-up contrast-enhanced CT scan obtained 7 days after surgery shows bilateral lack of enhancement of the renal cortex.

View larger version (115K): [in a new window]   Figure 16b.   Acute cortical necrosis in a 65-year-old woman who underwent bowel resection for an incarcerated ventral hernia. (a) Preoperative contrast-enhanced CT scan shows normally functioning kidneys. The postoperative course was complicated by sepsis. (b) Follow-up contrast-enhanced CT scan obtained 7 days after surgery shows bilateral lack of enhancement of the renal cortex.

View larger version (117K): [in a new window]   Figure 17.   Acute cortical necrosis in a 13-year-old girl with sepsis. Contrast-enhanced helical CT scan shows lack of enhancement of the renal cortex. Note the narrow subcapsular rim of enhancement (arrows).

View larger version (146K): [in a new window]   Figure 18.   Renal artery stenosis in a patient with Takayasu disease. Volume-rendered image (posterior view) shows bilateral focal narrowing of the proximal main renal artery (arrows) with poststenotic dilatation. Extensive visceral collateral vessels and surgical clips are also present.

View larger version (99K): [in a new window]   Figure 19a.   Renal artery stenosis in a 59-year-old woman with hypertension. (a) Digital subtraction angiogram shows an approximately 30% stenosis of the right main renal artery (arrow). (b) Coronal maximum-intensity projection image shows two calcified plaques (arrows) projecting over the proximal right main renal artery. (c) Posteroinferior reconstruction image shows that the two calcified plaques (arrows) are eccentrically located with respect to the main renal artery. The degree of stenosis was underestimated on the angiogram (a).

View larger version (96K): [in a new window]   Figure 19b.   Renal artery stenosis in a 59-year-old woman with hypertension. (a) Digital subtraction angiogram shows an approximately 30% stenosis of the right main renal artery (arrow). (b) Coronal maximum-intensity projection image shows two calcified plaques (arrows) projecting over the proximal right main renal artery. (c) Posteroinferior reconstruction image shows that the two calcified plaques (arrows) are eccentrically located with respect to the main renal artery. The degree of stenosis was underestimated on the angiogram (a).

View larger version (95K): [in a new window]   Figure 19c.   Renal artery stenosis in a 59-year-old woman with hypertension. (a) Digital subtraction angiogram shows an approximately 30% stenosis of the right main renal artery (arrow). (b) Coronal maximum-intensity projection image shows two calcified plaques (arrows) projecting over the proximal right main renal artery. (c) Posteroinferior reconstruction image shows that the two calcified plaques (arrows) are eccentrically located with respect to the main renal artery. The degree of stenosis was underestimated on the angiogram (a).

View larger version (107K): [in a new window]   Figure 20a.   UPJ obstruction in a patient with a horseshoe kidney. (a) Coronal color-encoded shaded-surface display image shows a crossing artery (a) and vein (v) at the right UPJ. The collecting system (p) is encoded yellow. A ureteral stent (s) is encoded purple. Arteries are encoded red, and veins are encoded blue. Note the mesenteric vessels coursing over the bridge of the horseshoe kidney. (b) Same image with the ureteral stent (s) highlighted shows the relationship of the ureter to the crossing vessels. (Reprinted, with permission, from reference 82.)

View larger version (104K): [in a new window]   Figure 20b.   UPJ obstruction in a patient with a horseshoe kidney. (a) Coronal color-encoded shaded-surface display image shows a crossing artery (a) and vein (v) at the right UPJ. The collecting system (p) is encoded yellow. A ureteral stent (s) is encoded purple. Arteries are encoded red, and veins are encoded blue. Note the mesenteric vessels coursing over the bridge of the horseshoe kidney. (b) Same image with the ureteral stent (s) highlighted shows the relationship of the ureter to the crossing vessels. (Reprinted, with permission, from reference 82.)

View larger version (137K): [in a new window]   Figure 21.   Acute renal vein thrombosis in a 27-year-old woman with a history of SLE and thrombophlebitis. Contrast-enhanced helical CT scan obtained during the generalized nephrographic phase shows thrombus (arrows) in a thick-walled left renal vein extending to the IVC. Note the thickening of the wall of the left renal pelvis and the perinephric soft-tissue stranding.

View larger version (139K): [in a new window]   Figure 22a.   Chronic renal vein thrombosis in a 39-year-old man with a history of biopsy-proved membranous glomerulonephritis and nephrotic syndrome who presented with hematuria. (a) Intravenous urogram shows ureteral notching on the left side (arrows). (b) Contrast-enhanced helical CT scan shows a markedly attenuated left renal vein (arrow). (c) Excretory-phase CT scan obtained at the level of the lower pole of the kidney shows enhancement of the left ureter (arrow), a finding associated with periureteral collateral vessels.

View larger version (126K): [in a new window]   Figure 22b.   Chronic renal vein thrombosis in a 39-year-old man with a history of biopsy-proved membranous glomerulonephritis and nephrotic syndrome who presented with hematuria. (a) Intravenous urogram shows ureteral notching on the left side (arrows). (b) Contrast-enhanced helical CT scan shows a markedly attenuated left renal vein (arrow). (c) Excretory-phase CT scan obtained at the level of the lower pole of the kidney shows enhancement of the left ureter (arrow), a finding associated with periureteral collateral vessels.

View larger version (127K): [in a new window]   Figure 22c.   Chronic renal vein thrombosis in a 39-year-old man with a history of biopsy-proved membranous glomerulonephritis and nephrotic syndrome who presented with hematuria. (a) Intravenous urogram shows ureteral notching on the left side (arrows). (b) Contrast-enhanced helical CT scan shows a markedly attenuated left renal vein (arrow). (c) Excretory-phase CT scan obtained at the level of the lower pole of the kidney shows enhancement of the left ureter (arrow), a finding associated with periureteral collateral vessels.

View larger version (136K): [in a new window]   Figure 23a.   Tumor thrombus in a 54-year-old man with advanced renal cell carcinoma. (a) Contrast-enhanced helical CT scan obtained at the level of the upper pole of the right kidney shows an inhomogeneous renal mass (M) with calcifications. The IVC is filled with tumor thrombus (arrow). (b) CT scan at the level of the right renal hilum shows tumor thrombus in the right renal vein and extending into the IVC (arrow). Note the collateral vessels in the right perinephric space.

View larger version (138K): [in a new window]   Figure 23b.   Tumor thrombus in a 54-year-old man with advanced renal cell carcinoma. (a) Contrast-enhanced helical CT scan obtained at the level of the upper pole of the right kidney shows an inhomogeneous renal mass (M) with calcifications. The IVC is filled with tumor thrombus (arrow). (b) CT scan at the level of the right renal hilum shows tumor thrombus in the right renal vein and extending into the IVC (arrow). Note the collateral vessels in the right perinephric space.