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Vascular 3 > Module 1: Renal Vasculature > Flashcards

Module 1: Renal Vasculature Flashcards

1
Q

where do the renal arteries arise from

A
  • arise from the aorta just distal to the SMA
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2
Q

what is the pathway of the RRA

A
  • arise from anterolateral aspect of the aorta traveling posterior to IVC
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3
Q

what is the pathway of the LRA

A
  • arises from lateral or posterolateral aspect of the aorta
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4
Q

can renal arteries be duplicated

A
  • yes
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5
Q

in what directions doe the renal arteries branch into

A
  • anterior and posterior vessel

- travel anterior and posterior to the renal pelvis

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6
Q

how many anterior segmental arteries are there

A
  • 4
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7
Q

how many posterior segmental arteries are there

A
  • 1
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8
Q

what do the segmental arteries branch into

A
  • interlobar arteries in the parenchyma
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9
Q

what do the interlobar arteries branch into and where

A
  • arcuate arteries

- corticomedullary junction

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10
Q

what do the arcuate arteries branch into and where

A
  • interlobular arteries

- peripheral cortex

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11
Q

protocol for renal assessment

A
  • asses kidney size (8-12cm)
  • arteries seen in transverse anterior midline
  • RRA followed transverse from midline
  • LRA followed coronally
  • asses entire length of the vessel
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12
Q

what three factors add to the difficulty of the renal interrogation

A
  • artery depth
  • respiration
  • abdominal gas
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13
Q

what is the pathway of the LRV

A
  • passes between the aorta and the SMA entering left side of IVC
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14
Q

what two smaller veins drain into the LRV

A
  • left suprarenal

- left gonadal

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15
Q

which renal vein is shorter right or left

A
  • RRV
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16
Q

on which side are more accessory veins commonly found

A
  • right
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17
Q

what is the flow pattern in the aorta proximal to the renal arteries

A
  • low resistance
  • sharp systolic upstroke with forward flow above t the baseline throughout diastole
  • feeding low resistance vascular bed
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18
Q

what is the normal velocity of flow in the aorta suprarenaly

A
  • 80-100cm/sec
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19
Q

what is the flow pattern in the aorta distal to the renal arteries

A
  • high resistance

- reverse flow component

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20
Q

what is the flow pattern in the main renal artery

A
  • low resistance forward flow
  • sharp systolic peak
  • supplies low resistance vascular bed
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21
Q

what is the normal velocity of the main renal artery

A
  • 74-127cm/sec
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22
Q

where is the main renal artery sampled ideally

A
  • prox mid and distal
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23
Q

what velocity in the main renal artery suggests a stenosis >/= 60%

A
  • > 180cm/sec
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24
Q

what is the normal renal artery PSV to aortic ratio (RAR)

A

< 3.5

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25
Q

what is the normal flow pattern in the segmental artery

A
  • sharp systolic upstroke and dicrotic notch

- looks like distal renal artery with slower velocities due to multiple branches

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26
Q

normal characteristics of segmental artery flow

A
  • presence of ESP
  • AT < 0.07s
  • RI < 0.75
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27
Q

abnormal characteristics of segmental artery flow

A
  • AT > 0.1s
  • tardus parvus waveform
  • loss of ESP
  • flatted systolic upstroke
  • reduced color flow in kidney unilaterally
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28
Q

where are the interlobar arteries found and where are they sampled

A
  • found between the collecting system calyces

- upper mid and lower pole of each kidney

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29
Q

what is the normal flow patterns of the interlobar arteries

A
  • like segmental waveform

- 30-40cm/s

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30
Q

what is another name for the arcuate and interlobular arteries collectively and where are the found

A
  • parenchymal arteries

- cortical region of kidney

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31
Q

what is the normal velocity of the parenchymal arteries

A
  • 20-30cm/s
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32
Q

what is the end diastolic ration (EDR) used for

A
  • determine an increase in resistance
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33
Q

what is the EDR equation

A
  • end diastolic velocity (EDV) / peak systolic velocity (PSV)
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34
Q

what is the normal and abnormal EDR values

A

normal: >/= 0.33
abnormal: < 0.23

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35
Q

what is the flow pattern of the renal veins near the IVC

A
  • pulsatile flow due to proximity to the heart
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36
Q

what is the flow pattern of the renal veins distal to the IVC

A
  • phasic flow
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37
Q

what condition can be caused by stenosis or occlusion in the renal arteries

A
  • renal ischemia leading to hypertension causing parenchymal damage
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38
Q

what ultrasound tool helps to indicate presence of a stenosis

A
  • color flow
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39
Q

what ultrasound tool helps to quantify stenosis severity

A
  • doppler spectral
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40
Q

what reduction in diameter indicates a hemodynamically significant stenosis in the renal arteries

A
  • 50-60%
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41
Q

in what three conditions should renal artery stenosis be thoroughly investigated in

A
  • young patients with hypertension
  • patients with uncontrollable hypertension
  • patients with renal insufficiency and discrepant kidney size
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42
Q

what is the most common cause of stenosis in patients >50

A

atherosclerosis

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43
Q

what is a common cause fo stenosis in patients < 40

A

fibromuscular dysplasia (FMD)

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44
Q

what are 4 less common causes of stenosis in the renal arteries

A
  • vasculitis
  • neurofibromatosis
  • congenital bands
  • extrinsic compression
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45
Q

what is the most correctable cause of hypertension

A
  • renal artery stenosis
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46
Q

what PSV and renal/aortic ration indicates significant stenosis

A
  • PSV >180cm/s

- RAR >3.5

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47
Q

what acceleration time AT suggests a renal stenosis of >60%

A

AT >0.07sec

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48
Q

what intervention is often used to persevere patency of the vessels

A
  • stents
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49
Q

what are 4 signs of severe renal artery stenosis

A
  • decreased renal size (renal atrophy)
  • renal infarct (hypoechoic area within the kidney)
  • renal hypo perfusion
  • narrowed artery with area of aliasing and increased PSV
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50
Q

what are 2 signs of renal artery occlusion

A
  • decreased kidney size
  • no main artery visualized
  • absent or very low flow and dampened intrarenal flow
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51
Q

what 2 other conditions can cause increased resistance in the kidneys

A
  • urinary tract obstruction

- acute or chronic parenchymal disease

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52
Q

what are 2 common signs and symptoms of patients with acute RV thrombosis

A
  • pain

- hematuria

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53
Q

what are 2 ultrasound findings of RV thrombosis

A
  • enlarged kidney and altered parenchymal echogenicity

- enlarged renal vein with absent doppler signal

54
Q

what are the signs and symptoms of chronic RV thrombosis

A
  • asyptomatic
  • nephrotic syndrome
  • hematuria
55
Q

in what 2 ways can the RV become blocked

A
  • intraluminal thrombus

- extrinsic compression

56
Q

what is the most common factor causing RV thrombosis

A
  • primary renal disease
57
Q

what 5 other factors can cause RV thrombus

A
  • hyper coagulable states
  • renal, IVC, Ovarian tumor thrombus
  • abdominal surgery
  • trauma
  • dehydration
58
Q

what is the eventual progression of RV thrombosis

A
  • leads to parenchymal disease&raquo_space; renal failure
59
Q

can venous flow still be present in the kidney in the presence of and RV thrombus

A
  • yes

- due to collateral vessels

60
Q

what is the standard treatment for chronic renal failure

A
  • renal transplants
61
Q

what is an allograft

A
  • any tissue transplanted from one human to another
62
Q

where can a renal allograft be harvested from

A
  • living, related donor

- brain dead donor

63
Q

where is the transplanted kidney often located

A
  • right iliac fossa between peritoneum and iliac muscle
64
Q

is the native kidney and ureter removed after a transplant

A
  • no they are left in place
65
Q

what can develop on the native kidneys of long term dialysis patients

A
  • cysts

- neoplasms

66
Q

where is the allografted ureter placed and what does it form

A
  • passes obliquely through the muscular layer of the bladder
  • non refusing UV junction
67
Q

how is the allografted vein anastomosed

A
  • end to side anastomoses to the iliac vein
68
Q

what is the appearance of the transplanted kidney compared to the native kidney

A
  • very similar
69
Q

what are 3 considerations to take when scanning the post transplanted kidney

A
  • cortex may appear more echogenic due to superficial placement of kidney
  • kidney may enlarge over a period of a month following transplant
  • slight dilation of the collecting tubules (hydro) is common
70
Q

when should a baseline post transplant study be done

A
  • within 72 hours after surgery
71
Q

what are 7 complications that can occur with a kidney transplant

A
  • rejection
  • acute tubular necrosis
  • perigraft fluid
  • pseudo aneurysm
  • AV fistula
  • venous/arterial thrombosis
  • arterial stenosis
72
Q

when can rejection be diagnosed sonographically

A
  • should not be diagnosed with ultrasound unless several rejection abnormalities present
73
Q

what will doppler look like with a rejection

A
  • high resistance doppler waveforms minimal diastolic flow

- RI >/=0.7

74
Q

what causes acute tubular necrosis post surgery

A
  • ischemia
75
Q

how is doppler affected with acute tubular necrosis

A
  • not usually altered

- increase in PI maybe

76
Q

are perigraft fluid collections commonly seen

A
  • yes post op
77
Q

what are 4 different types of perigraft fluid collections

A
  • hematomas
  • seromas
  • abscesses
  • urinomas
78
Q

how is color doppler used when a fluid collection is identified

A
  • use to see if there is active bleeding into the collections
79
Q

where do most pseudo aneurysms occur and what from

A
  • renal parenchyma
  • arterial laceration after biopsy
  • can also be seen near arterial anastomosis site
80
Q

what should we try to identify in the neck of the pseudoaneurysm

A
  • high velocity jet
81
Q

what causes an AV fistula

A
  • biopsy trauma
82
Q

are AV fistulas symptomatic or asymptomatic

A
  • asymptomatic
83
Q

what condition can AV fistulas be associated with

A

sustained hypertension

84
Q

what color and spectral doppler information can be obtained from an AV fistula

A
  • coordinations doppler identifies fistula as a bright spot in renal parenchyma due to disturbed flow
  • high velocity inferrer flow in the feeder artery appears like a bruit
85
Q

are venous/arterial thrombosis common after transplants

A
  • no
86
Q

when does thrombosis occurs with a transplant

A
  • immediately post op
87
Q

what will venous arterial thrombus look like on ultrasound

A
  • enlarged kidney
  • renal vein distended
  • absent flow signal in renal vein/artery
88
Q

what is the most common vascular complication in transplant patients

A
  • arterial stenosis
89
Q

where is transplant stenosis usually located and why does it occur

A
  • site of anastomosis

- due to a surgical issue

90
Q

will older transplants have more or less stenosis

A
  • long segment of stenosis due to scarring or hyperplasia
91
Q

what will doppler look like with an arterial stenosis post transplant

A
  • increased velocity in stenotic segment

- post stenotic turbulence and distal dampening in severe stenosis

92
Q

what are the 9 indications for a fistula or graft doppler ultrasound

A
  • inadequate dialysis
  • thromboses access
  • perigraft mass
  • upper extremity swelling
  • decreased thrill or pulse
  • suspected steal
  • infection
  • bleeding
  • post revision follow up
93
Q

what are the 3 methods of evaluation of grafts or fistulas

A
  • duplex ultrasound
  • arteriography
  • fistulography
94
Q

where should we sample the PSV during the graft protocol

A
  • native artery prox
  • arterial anastomoses
  • graft
  • venous anastomosis
  • venous outflow
95
Q

where should we sample the PSV during the fistula protocol

A
  • sample 2-3 sites distal to arterial anastomoses
96
Q

what measurement should we be doing when interrogating fistulas and grafts

A
  • volume flow
97
Q

what is the volume flow equation

A

Q(ml/min) = TAV x area x 60

98
Q

how do we rule out steal from native circulation with duplex ultrasound

A
  • assess retrograde flow in the inflow artery distal to anastomosis
99
Q

what type of thrombus is commonly seen with dialysis graft patients

A
  • SCV thrombus

- rule out with upper extremity DVT exam

100
Q

what is the normal flow pattern of the arterial limb

A
  • high velocity
  • continuous forward flow through diastole
  • marked spectral broadening
101
Q

what is the normal flow pattern of the venous limb

A
  • slightly lower velocities than arterial limb

- mosts common site of stenosis /thrombosis

102
Q

what is the normal PSV in a graft/fistula

A

100-400cm/s

103
Q

what is the normal EDV in graft/fistula

A

60-200cm/s

104
Q

what would an occlusion look like in a graft/fistula

A
  • no flow detected in graft
  • no flow in vein distal to fistula
  • high resistance in artery leading to graft or fistula
  • low venous outflow
105
Q

what is the criteria (PSV and velocity ratio) for > 50% graft stenosis

A
  • PSV > 400cm/s

- VR >/= 2:1 (50%) ; 3:1 (75%)

106
Q

what is the criteria ( PSV and velocity ratio) for >50% fistula stenosis

A
  • PSV > 400cm/s
  • VR >/= 2:1 (50%); 3:1 (75%)
    + outflow cephalic vein >/= 3:1
107
Q

graft flow volumes- what does < 350ml/min indicate

A

poor dialysis, pending graft failure

108
Q

graft flow volumes - what does < 500 ml/min indicate

A

increased risk of graft failure

109
Q

graft flow volumes - what does > 800ml/min indicate

A

normal flow range

110
Q

graft flow volumes - what does > 1500ml/min indicate

A

possible congestive heart failure

111
Q

AV fistula flow volumes - what does >500ml/min with 4mm outflow vein indicate

A

adequate dialysis

112
Q

AV fistula flow volumes - what does >800ml/min indicate

A

normal

113
Q

what are the 8 most common abnormalities seen with grafts and fistulas

A
  • venous flow obstruction
  • venous anastomosis stenosis
  • pseudo aneurysms
  • diffuse aneurysmal dilation
  • hematoma
  • perigraft abscess
  • intimal flaps
  • arterial anastomotic stenosis
114
Q

what 4 things is ultrasound used for with dialysis grafts and fistulas

A
  • identify graft lesions and monitor them
  • initial baseline exams for follow up studies
  • to help assess the maturity of an AV fistula graft
  • identify grafts in jeopardy of failure
115
Q

what is hemodialysis

A
  • removal of certain elements from the blood through a semipermeable membrane while being circulated outside the body
116
Q

what kind of vessel is required fro hemodialysis

A
  • requires an easily accessed vessel than can tolerate multiple punctures and high flow
117
Q

what is an AV fistula

A
  • surgically created by connecting and artery and vein together to accomplish high flow situation where blood flows directly from the high pressure artery to a low pressure vein
118
Q

what is a AV graft

A
  • surgically inserted prosthetic graft or vein conduit connecting and artery and vein
119
Q

what 6 things are hemodialysis grafts evaluated for with ultrasound

A
  • stenosis
  • thrombosis
  • aneurysms
  • pseudo aneurysms
  • hematomas
  • arterial steal from hand
120
Q

what is the most common cause of graft failure in the first month of insertion

A

thrombosis of graft

121
Q

are PSV’s or PSV ratios used more frequently when determining severity of stenosis

A
  • PSV ratios
122
Q

what is the normal PSV ratio for dialysis grafts

A

<2.0

123
Q

what is the normal PSV ration for dialysis fistulas

A

< 3.0

124
Q

arterial inflow in graft/fistula waveform above and below anastomosis

A
  • above = low resistance

- below = high resistance

125
Q

gray scale signs of abnormal grafts/ fistulas

A
  • decreased lumen
  • color jet
  • increased velocities and post stenotic turbulence indicated significant stenosis
126
Q

waveforms of abnormal grafts/fistulas

A
  • decreased venous spontaneity and phasicity suggests obstruction in the outflow vein
  • evaluate spontaneity, phasicity, and pulsatilityof the SCV and internal jugular veins
127
Q

what abnormal PSV and PSV ratio indicate a >50% at venous anastomosis of a prosthetic graft

A
  • PSV > 400cm/s

- PSV ratio >/= 1.9

128
Q

what abnormal PSV ratio indicates >50% stenosis at the arterial inflow or venous outflow of a fistula

A
  • PSV ratio > 2.0
129
Q

what abnormal PSV ratio indicates >50% stenosis at the fistula anastomosis

A
  • PSV ratio >3.0
130
Q

what volume flow rate indicated suboptimal graft performance

A

<800 ml/min

131
Q

what volume flow rate indicates suboptimal fistula performance

A

< 500 ml/min

Vascular 3 (3 decks)

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