Imaging of Renovascular Hypertension: Respective Values of Renal Scintigraphy, Renal Doppler US, and MR Angiography1
Gilles Soulez, MD ,
Vincent L. Oliva, MD ,
Sophie Turpin, MD ,
Raymond Lambert, MD ,
Viviane Nicolet, MD and
Eric Therasse, MD
1 From the Department of Radiology, Notre-Dame Hospital, Centre Hospitalier de l'Université de Montréal, 1560 rue Sherbrooke East, Montreal, Quebec, Canada H2L 4M1 (G.S., V.L.O., V.N.); and the Departments of Nuclear Medicine (S.T., R.L.) and Radiology (E.T.), Hotel-Dieu Hospital, Centre Hospitalier de l'Université de Montréal. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received May 6, 1999; revision requested June 29; final revision received September 8; accepted September 9. Address correspondence to G.S. (e-mail: gsoulez@netcom.ca).
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Figure 1a. Renovascular disease in a 60-year-old patient. (a) Baseline scintigram (posterior view) obtained with Tc-99m MAG3 shows mild and nonspecific abnormalities, with decreased amplitude and delayed peaking of the left renal curve (arrowhead) relative to the right renal curve (solid arrow). The time reference (open arrow) is 30 minutes. (b) Scintigram (posterior view) obtained after administration of captopril shows diminished uptake in the left kidney, with an abnormal curve (solid arrow) suggesting left-sided renovascular disease. The time reference (open arrow) is 30 minutes. (c) Aortogram shows a severe stenosis of the left renal artery. (d) Angiogram obtained after angioplasty and stent placement shows wide patency of the left renal artery. (e) Scintigraphic curves (top left, left renal collecting system; top right, left renal cortex; bottom left, right renal collecting system; bottom right, right renal cortex) obtained after correction of RAS show normalization of the captopril scintigraphic curve for the left kidney (top curves). The curves were obtained over 30 minutes. CA = cortical peak activity (between 1 and 3 minutes), CBF = curve with background correction, CR = cortical residual activity (between 20 and 23 minutes).
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Figure 1b. Renovascular disease in a 60-year-old patient. (a) Baseline scintigram (posterior view) obtained with Tc-99m MAG3 shows mild and nonspecific abnormalities, with decreased amplitude and delayed peaking of the left renal curve (arrowhead) relative to the right renal curve (solid arrow). The time reference (open arrow) is 30 minutes. (b) Scintigram (posterior view) obtained after administration of captopril shows diminished uptake in the left kidney, with an abnormal curve (solid arrow) suggesting left-sided renovascular disease. The time reference (open arrow) is 30 minutes. (c) Aortogram shows a severe stenosis of the left renal artery. (d) Angiogram obtained after angioplasty and stent placement shows wide patency of the left renal artery. (e) Scintigraphic curves (top left, left renal collecting system; top right, left renal cortex; bottom left, right renal collecting system; bottom right, right renal cortex) obtained after correction of RAS show normalization of the captopril scintigraphic curve for the left kidney (top curves). The curves were obtained over 30 minutes. CA = cortical peak activity (between 1 and 3 minutes), CBF = curve with background correction, CR = cortical residual activity (between 20 and 23 minutes).
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Figure 1c. Renovascular disease in a 60-year-old patient. (a) Baseline scintigram (posterior view) obtained with Tc-99m MAG3 shows mild and nonspecific abnormalities, with decreased amplitude and delayed peaking of the left renal curve (arrowhead) relative to the right renal curve (solid arrow). The time reference (open arrow) is 30 minutes. (b) Scintigram (posterior view) obtained after administration of captopril shows diminished uptake in the left kidney, with an abnormal curve (solid arrow) suggesting left-sided renovascular disease. The time reference (open arrow) is 30 minutes. (c) Aortogram shows a severe stenosis of the left renal artery. (d) Angiogram obtained after angioplasty and stent placement shows wide patency of the left renal artery. (e) Scintigraphic curves (top left, left renal collecting system; top right, left renal cortex; bottom left, right renal collecting system; bottom right, right renal cortex) obtained after correction of RAS show normalization of the captopril scintigraphic curve for the left kidney (top curves). The curves were obtained over 30 minutes. CA = cortical peak activity (between 1 and 3 minutes), CBF = curve with background correction, CR = cortical residual activity (between 20 and 23 minutes).
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Figure 1d. Renovascular disease in a 60-year-old patient. (a) Baseline scintigram (posterior view) obtained with Tc-99m MAG3 shows mild and nonspecific abnormalities, with decreased amplitude and delayed peaking of the left renal curve (arrowhead) relative to the right renal curve (solid arrow). The time reference (open arrow) is 30 minutes. (b) Scintigram (posterior view) obtained after administration of captopril shows diminished uptake in the left kidney, with an abnormal curve (solid arrow) suggesting left-sided renovascular disease. The time reference (open arrow) is 30 minutes. (c) Aortogram shows a severe stenosis of the left renal artery. (d) Angiogram obtained after angioplasty and stent placement shows wide patency of the left renal artery. (e) Scintigraphic curves (top left, left renal collecting system; top right, left renal cortex; bottom left, right renal collecting system; bottom right, right renal cortex) obtained after correction of RAS show normalization of the captopril scintigraphic curve for the left kidney (top curves). The curves were obtained over 30 minutes. CA = cortical peak activity (between 1 and 3 minutes), CBF = curve with background correction, CR = cortical residual activity (between 20 and 23 minutes).
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Figure 1e. Renovascular disease in a 60-year-old patient. (a) Baseline scintigram (posterior view) obtained with Tc-99m MAG3 shows mild and nonspecific abnormalities, with decreased amplitude and delayed peaking of the left renal curve (arrowhead) relative to the right renal curve (solid arrow). The time reference (open arrow) is 30 minutes. (b) Scintigram (posterior view) obtained after administration of captopril shows diminished uptake in the left kidney, with an abnormal curve (solid arrow) suggesting left-sided renovascular disease. The time reference (open arrow) is 30 minutes. (c) Aortogram shows a severe stenosis of the left renal artery. (d) Angiogram obtained after angioplasty and stent placement shows wide patency of the left renal artery. (e) Scintigraphic curves (top left, left renal collecting system; top right, left renal cortex; bottom left, right renal collecting system; bottom right, right renal cortex) obtained after correction of RAS show normalization of the captopril scintigraphic curve for the left kidney (top curves). The curves were obtained over 30 minutes. CA = cortical peak activity (between 1 and 3 minutes), CBF = curve with background correction, CR = cortical residual activity (between 20 and 23 minutes).
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Figure 2a. Indeterminate scintigraphic results in a 70-year-old patient with renal insufficiency. Baseline (a) and captopril (b) Tc-99m DTPA scintigrams (sequential images obtained at 2-minute intervals from top left to bottom right) show poor demonstration of both kidneys. No conclusion could be drawn about the possibility of renovascular disease.
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Figure 2b. Indeterminate scintigraphic results in a 70-year-old patient with renal insufficiency. Baseline (a) and captopril (b) Tc-99m DTPA scintigrams (sequential images obtained at 2-minute intervals from top left to bottom right) show poor demonstration of both kidneys. No conclusion could be drawn about the possibility of renovascular disease.
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Figure 3a. Stenotic accessory artery in a 55-year-old patient with hypertension. (a) Baseline Tc-99m DTPA scintigrams (sequential posterior views obtained at 2-minute intervals from top left to bottom right) show slight retention of the radiopharmaceutical in the left renal pelvis. (b) Captopril scintigrams show markedly decreased uptake in the upper half of the right kidney, a finding consistent with renovascular disease of a polar artery.
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Figure 3b. Stenotic accessory artery in a 55-year-old patient with hypertension. (a) Baseline Tc-99m DTPA scintigrams (sequential posterior views obtained at 2-minute intervals from top left to bottom right) show slight retention of the radiopharmaceutical in the left renal pelvis. (b) Captopril scintigrams show markedly decreased uptake in the upper half of the right kidney, a finding consistent with renovascular disease of a polar artery.
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Figure 4. Patterns of scintigraphic curves. 0 = normal, 1 = minor abnormalities but with Tmax greater than 5 minutes and (for Tc-99m MAG3 and I-131 OIH scintigrams) 20-minute/peak uptake ratio greater than 0.3, 2 = marked delayed excretion rate with preserved washout phase, 3 = delayed excretion rate without washout phase (accumulation curve), 4 = renal failure pattern with measurable kidney uptake, 5 = renal failure pattern without measurable kidney uptake (blood background-type curve).
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Figure 5a. Severe stenosis in a patient with a solitary left kidney who experienced recurring hypertension and renal failure 3 months after stent placement in the left renal artery. (a) Doppler spectrum from the proximal left renal artery shows flow acceleration of close to 300 cm/sec inside the stent. (b) Intrarenal Doppler spectrum shows a waveform with a pulsus tardus configuration, which indicates severe hemodynamic repercussions. (c) Arteriogram shows severe stenosis inside the stent (arrow). Thrombosis of the infrarenal aorta is also noted.
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Figure 5b. Severe stenosis in a patient with a solitary left kidney who experienced recurring hypertension and renal failure 3 months after stent placement in the left renal artery. (a) Doppler spectrum from the proximal left renal artery shows flow acceleration of close to 300 cm/sec inside the stent. (b) Intrarenal Doppler spectrum shows a waveform with a pulsus tardus configuration, which indicates severe hemodynamic repercussions. (c) Arteriogram shows severe stenosis inside the stent (arrow). Thrombosis of the infrarenal aorta is also noted.
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Figure 5c. Severe stenosis in a patient with a solitary left kidney who experienced recurring hypertension and renal failure 3 months after stent placement in the left renal artery. (a) Doppler spectrum from the proximal left renal artery shows flow acceleration of close to 300 cm/sec inside the stent. (b) Intrarenal Doppler spectrum shows a waveform with a pulsus tardus configuration, which indicates severe hemodynamic repercussions. (c) Arteriogram shows severe stenosis inside the stent (arrow). Thrombosis of the infrarenal aorta is also noted.
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Figure 6a. Signal enhancement with a contrast agent. (a) Gray-scale US scan of the abdominal aorta obtained with a right coronal approach shows the left renal artery (arrows). However, results of duplex US were nondiagnostic. (b) Color Doppler US scan obtained after injection of a contrast agent shows strong signal inside the aorta and left renal artery (arrow). The enhanced signal allowed evaluation of the left renal artery with pulsed Doppler US. (Courtesy of Michel Lafortune, MD, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Quebec, Canada.)
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Figure 6b. Signal enhancement with a contrast agent. (a) Gray-scale US scan of the abdominal aorta obtained with a right coronal approach shows the left renal artery (arrows). However, results of duplex US were nondiagnostic. (b) Color Doppler US scan obtained after injection of a contrast agent shows strong signal inside the aorta and left renal artery (arrow). The enhanced signal allowed evaluation of the left renal artery with pulsed Doppler US. (Courtesy of Michel Lafortune, MD, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Quebec, Canada.)
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Figure 7a. Stenosis of an accessory renal artery in a patient with recent acceleration of hypertension. (a) Doppler spectrum from the left kidney shows a waveform with a pulsus tardus configuration, which is consistent with severe RAS. (b) Doppler spectrum from the upper right kidney shows a normal waveform. (c) Doppler spectrum from the lower pole of the right kidney shows a waveform with a delayed systolic upstroke (arrow), which suggests stenosis of an accessory or branch renal artery. (d) Abdominal aortogram shows severe stenosis of the left renal artery (arrow). The origins of the right main and accessory renal arteries are not adequately visualized. (e) Selective arteriogram of the main right renal artery shows no stenosis. (f) Arteriogram of an accessory artery to the right lower pole shows ostial stenosis.
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Figure 7b. Stenosis of an accessory renal artery in a patient with recent acceleration of hypertension. (a) Doppler spectrum from the left kidney shows a waveform with a pulsus tardus configuration, which is consistent with severe RAS. (b) Doppler spectrum from the upper right kidney shows a normal waveform. (c) Doppler spectrum from the lower pole of the right kidney shows a waveform with a delayed systolic upstroke (arrow), which suggests stenosis of an accessory or branch renal artery. (d) Abdominal aortogram shows severe stenosis of the left renal artery (arrow). The origins of the right main and accessory renal arteries are not adequately visualized. (e) Selective arteriogram of the main right renal artery shows no stenosis. (f) Arteriogram of an accessory artery to the right lower pole shows ostial stenosis.
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Figure 7c. Stenosis of an accessory renal artery in a patient with recent acceleration of hypertension. (a) Doppler spectrum from the left kidney shows a waveform with a pulsus tardus configuration, which is consistent with severe RAS. (b) Doppler spectrum from the upper right kidney shows a normal waveform. (c) Doppler spectrum from the lower pole of the right kidney shows a waveform with a delayed systolic upstroke (arrow), which suggests stenosis of an accessory or branch renal artery. (d) Abdominal aortogram shows severe stenosis of the left renal artery (arrow). The origins of the right main and accessory renal arteries are not adequately visualized. (e) Selective arteriogram of the main right renal artery shows no stenosis. (f) Arteriogram of an accessory artery to the right lower pole shows ostial stenosis.
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Figure 7d. Stenosis of an accessory renal artery in a patient with recent acceleration of hypertension. (a) Doppler spectrum from the left kidney shows a waveform with a pulsus tardus configuration, which is consistent with severe RAS. (b) Doppler spectrum from the upper right kidney shows a normal waveform. (c) Doppler spectrum from the lower pole of the right kidney shows a waveform with a delayed systolic upstroke (arrow), which suggests stenosis of an accessory or branch renal artery. (d) Abdominal aortogram shows severe stenosis of the left renal artery (arrow). The origins of the right main and accessory renal arteries are not adequately visualized. (e) Selective arteriogram of the main right renal artery shows no stenosis. (f) Arteriogram of an accessory artery to the right lower pole shows ostial stenosis.
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Figure 7e. Stenosis of an accessory renal artery in a patient with recent acceleration of hypertension. (a) Doppler spectrum from the left kidney shows a waveform with a pulsus tardus configuration, which is consistent with severe RAS. (b) Doppler spectrum from the upper right kidney shows a normal waveform. (c) Doppler spectrum from the lower pole of the right kidney shows a waveform with a delayed systolic upstroke (arrow), which suggests stenosis of an accessory or branch renal artery. (d) Abdominal aortogram shows severe stenosis of the left renal artery (arrow). The origins of the right main and accessory renal arteries are not adequately visualized. (e) Selective arteriogram of the main right renal artery shows no stenosis. (f) Arteriogram of an accessory artery to the right lower pole shows ostial stenosis.
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Figure 7f. Stenosis of an accessory renal artery in a patient with recent acceleration of hypertension. (a) Doppler spectrum from the left kidney shows a waveform with a pulsus tardus configuration, which is consistent with severe RAS. (b) Doppler spectrum from the upper right kidney shows a normal waveform. (c) Doppler spectrum from the lower pole of the right kidney shows a waveform with a delayed systolic upstroke (arrow), which suggests stenosis of an accessory or branch renal artery. (d) Abdominal aortogram shows severe stenosis of the left renal artery (arrow). The origins of the right main and accessory renal arteries are not adequately visualized. (e) Selective arteriogram of the main right renal artery shows no stenosis. (f) Arteriogram of an accessory artery to the right lower pole shows ostial stenosis.
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Figure 8. Doppler waveform patterns. Types A and B represent normal Doppler spectra. In type A, a peak is present at the end of the early rise. In type B, no peak is present but the rise remains straight. Note that waveform VI is considered normal despite the high compliance peak; this particular type is most commonly seen in young patients. Type C represents abnormal spectra with varying degrees of a slowed early rise.
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Figure 9. Normal Doppler waveform with straight early upstroke and high compliance peak. One should measure acceleration along the initial portion of the upstroke (dotted line), avoiding the compliance peak.
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Figure 10a. Renovascular disease in a patient with severe hypertension. (a) Intrarenal Doppler spectrum from the left kidney shows a waveform with a straight systolic upstroke (arrows). (b) Intrarenal Doppler spectrum obtained after oral administration of 25 mg of captopril shows a waveform with a frankly abnormal systolic upstroke and a slowed early rise. (c) Arteriogram shows stenosis of the left renal artery.
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Figure 10b. Renovascular disease in a patient with severe hypertension. (a) Intrarenal Doppler spectrum from the left kidney shows a waveform with a straight systolic upstroke (arrows). (b) Intrarenal Doppler spectrum obtained after oral administration of 25 mg of captopril shows a waveform with a frankly abnormal systolic upstroke and a slowed early rise. (c) Arteriogram shows stenosis of the left renal artery.
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Figure 10c. Renovascular disease in a patient with severe hypertension. (a) Intrarenal Doppler spectrum from the left kidney shows a waveform with a straight systolic upstroke (arrows). (b) Intrarenal Doppler spectrum obtained after oral administration of 25 mg of captopril shows a waveform with a frankly abnormal systolic upstroke and a slowed early rise. (c) Arteriogram shows stenosis of the left renal artery.
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Figure 11a. Renovascular disease in a patient with hypertension and two right renal arteries. (a) Coronal maximum-intensity projection image from MR angiography shows an eccentric atheromatous lesion of the abdominal aorta adjacent to the upper right renal artery (black arrow); however, this lesion does not cause stenosis. The lower right renal artery has a proximal stenosis (arrowhead). A stenosis of the left renal artery is also demonstrated (white arrow). (b) Conventional aortogram shows the findings seen on the MR angiogram (a) with good correlation.
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Figure 11b. Renovascular disease in a patient with hypertension and two right renal arteries. (a) Coronal maximum-intensity projection image from MR angiography shows an eccentric atheromatous lesion of the abdominal aorta adjacent to the upper right renal artery (black arrow); however, this lesion does not cause stenosis. The lower right renal artery has a proximal stenosis (arrowhead). A stenosis of the left renal artery is also demonstrated (white arrow). (b) Conventional aortogram shows the findings seen on the MR angiogram (a) with good correlation.
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Figure 12a. Severe bilateral RAS in a patient with renal insufficiency and an aortobifemoral bypass. (a) Coronal maximum-intensity projection image from MR angiography shows severe bilateral renal stenoses (arrows), which appear as short occlusions. (b) Coronal source MR image shows left renal atrophy, suggesting that the left-sided stenosis is more severe. A large renal cyst is also seen. (c, d) Selective arteriograms show a 70% stenosis of the right renal artery (c) and a 90% stenosis of the left renal artery (d).
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Figure 12b. Severe bilateral RAS in a patient with renal insufficiency and an aortobifemoral bypass. (a) Coronal maximum-intensity projection image from MR angiography shows severe bilateral renal stenoses (arrows), which appear as short occlusions. (b) Coronal source MR image shows left renal atrophy, suggesting that the left-sided stenosis is more severe. A large renal cyst is also seen. (c, d) Selective arteriograms show a 70% stenosis of the right renal artery (c) and a 90% stenosis of the left renal artery (d).
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Figure 12c. Severe bilateral RAS in a patient with renal insufficiency and an aortobifemoral bypass. (a) Coronal maximum-intensity projection image from MR angiography shows severe bilateral renal stenoses (arrows), which appear as short occlusions. (b) Coronal source MR image shows left renal atrophy, suggesting that the left-sided stenosis is more severe. A large renal cyst is also seen. (c, d) Selective arteriograms show a 70% stenosis of the right renal artery (c) and a 90% stenosis of the left renal artery (d).
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Figure 12d. Severe bilateral RAS in a patient with renal insufficiency and an aortobifemoral bypass. (a) Coronal maximum-intensity projection image from MR angiography shows severe bilateral renal stenoses (arrows), which appear as short occlusions. (b) Coronal source MR image shows left renal atrophy, suggesting that the left-sided stenosis is more severe. A large renal cyst is also seen. (c, d) Selective arteriograms show a 70% stenosis of the right renal artery (c) and a 90% stenosis of the left renal artery (d).
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Figure 13a. Superimposition of the left renal vein in a patient with hypertension. (a) Coronal MR angiogram does not show the left renal artery clearly due to superimposition of the left renal vein. (b) Axial multiplanar reconstruction image shows both the artery and the vein clearly.
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Figure 13b. Superimposition of the left renal vein in a patient with hypertension. (a) Coronal MR angiogram does not show the left renal artery clearly due to superimposition of the left renal vein. (b) Axial multiplanar reconstruction image shows both the artery and the vein clearly.
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Figure 14a. Overestimation of stenosis in a patient with hypertension. (a) Coronal MR angiogram shows severe stenosis of the left main renal artery. No accessory artery is seen. (b) Conventional aortogram shows the stenosis of the left main renal artery, which was slightly overestimated on the MR angiogram (a). In addition, a small accessory artery is demonstrated at the upper pole of the kidney (arrowhead).
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Figure 14b. Overestimation of stenosis in a patient with hypertension. (a) Coronal MR angiogram shows severe stenosis of the left main renal artery. No accessory artery is seen. (b) Conventional aortogram shows the stenosis of the left main renal artery, which was slightly overestimated on the MR angiogram (a). In addition, a small accessory artery is demonstrated at the upper pole of the kidney (arrowhead).
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Figure 15a. Accessory artery in a 35-year-old patient with severe hypertension. (a) Coronal MR angiogram shows irregularities of the distal third of both main renal arteries, an appearance suggestive of fibromuscular dysplasia. (b) Conventional aortogram shows fibromuscular dysplasia involving both renal arteries. A possible accessory artery is seen on the right side (arrow). (c, d) Selective arteriograms of the right (c) and left (d) main renal arteries show mild fibromuscular dysplasia. Note the small parenchymal defect at the upper pole of the right kidney from the accessory artery.
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Figure 15b. Accessory artery in a 35-year-old patient with severe hypertension. (a) Coronal MR angiogram shows irregularities of the distal third of both main renal arteries, an appearance suggestive of fibromuscular dysplasia. (b) Conventional aortogram shows fibromuscular dysplasia involving both renal arteries. A possible accessory artery is seen on the right side (arrow). (c, d) Selective arteriograms of the right (c) and left (d) main renal arteries show mild fibromuscular dysplasia. Note the small parenchymal defect at the upper pole of the right kidney from the accessory artery.
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Figure 15c. Accessory artery in a 35-year-old patient with severe hypertension. (a) Coronal MR angiogram shows irregularities of the distal third of both main renal arteries, an appearance suggestive of fibromuscular dysplasia. (b) Conventional aortogram shows fibromuscular dysplasia involving both renal arteries. A possible accessory artery is seen on the right side (arrow). (c, d) Selective arteriograms of the right (c) and left (d) main renal arteries show mild fibromuscular dysplasia. Note the small parenchymal defect at the upper pole of the right kidney from the accessory artery.
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Figure 15d. Accessory artery in a 35-year-old patient with severe hypertension. (a) Coronal MR angiogram shows irregularities of the distal third of both main renal arteries, an appearance suggestive of fibromuscular dysplasia. (b) Conventional aortogram shows fibromuscular dysplasia involving both renal arteries. A possible accessory artery is seen on the right side (arrow). (c, d) Selective arteriograms of the right (c) and left (d) main renal arteries show mild fibromuscular dysplasia. Note the small parenchymal defect at the upper pole of the right kidney from the accessory artery.
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Figure 16. Diagnostic algorithm for patients with suspected renovascular disease. MRA = MR angiography, RF = renal failure.
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Copyright © 2000 by the Radiological Society of North America.
