1. Techniques of Renal Arteriography Subhash Banerjee, MD UT Southwestern Med. Ctr & VA North Texas Health care; Dallas, TX

2. Indications For Renal Artery Angiography & Revascularization Persistent hematuria of unresolved cause Detection of renal tumor vacularity, venous invasion embolization Suspected renal artery stenosis (RAS) Suspected transection of the renal artery (penetrating injury) Detection of inflammatory conditions, aneurysm or AVM Evaluation of renal vascular anatomy of prospective donors Evaluation of postoperative renal transplantation Diagnosis of thrombosis revealed by renal venography Collection of a sample of blood from the renal vein

3. Prevalence of Atherosclerotic (A)RAS at Cardiac Catheterization Study, Yearn ARAS > 30% (%) ARAS > 50% (%) Bilateral (%) Vetrovec et al, 1989 11629%23%29% Harding et al, 1992130229%15%28% Jean et al, 199419633%18%- Rihal et al, 200229734%19% Weber-Mzell et al, 2002 17725%11%26% White et al. Circulation.2006; 114: 1892-1895 Routine screening for RAS during coronary angiography NOT indicated

4. Objectives of Renal Arteriography Identify main as well as accessory vesels Localize site of stenosis or disease Determine type of disease (atherosclerotic or FMD) Provide hemodynamic significance Determine likelihood of a favorable response to revascularization Identify associated pathology (aorta, renal mass etc) Detect restenosis after percutaneous or surgical revascularization

5. Proposed Algorithm for Diagnosis of RAS & Renal Artery Angiography Clinical suspicion of RAS/Indication for Revascularization Captopril scintigraphy +- Strong clinical suspicion Stop MRA or CTA RAS +RAS - Technically good study Stop Technically Poor study Angiography Angiography & intervention Renal artery duplex RAS +RAS - Angiography & intervention Technically good study Stop Technically Poor study Angiography MRA: magnetic resonance angiography; CTA: Computed tomographic angiography Adapted from Vascular Medicine by Creager et al

6. Renal Artery Angiography Catheter-based angiography remains the standard Digital subtraction angiography (imaging matrix 1024 x 1024; 16” image II) Oblique views of the aorta to visualize renal artery origins Pressure gradients should also be obtained, whenever feasible Imaging hardware and software: –Bolus chase, rapid image acquisition –Vessel diameter analysis, regional pixel shifting, image stacking –3D reconstruction, angioscopic representation of DSA Low osmolar iodinated contrast, gadolinium, CO 2 angiography

7. Renal Anatomy Between transverse processes of T12- L3, left kidney more superior than right, upper poles oriented medially/posteriorly

8. Renal Artery Angiography: Technical Considerations Access: –Groin: ideally contra-lateral, long sheaths –Brachial: caudally angulated, aorto-iliac disease Flush aortography with multi-side hole catheter (L1-L2) Prior to selective renal artery catheterization an aortogram must be performed Anterio-posterior & oblique views (visualization of renal artery origins) –Right: RAO 10 ο -20 ο, LAO 10 ο –Left: LAO 0 ο -15 ο Selective angiography of renal arteries –Shaped sheaths –Guiding catheters (Soft tip Omni, Cobra 2, Simmons, RDC etc) –Support guide-wire within aorta Trans-lesional gradient (catheter, pressure wire)

9. Non-selective Renal Angiogram: Early Division of Right Renal Artery

10. Renal Angiography and Intervention: Transfemoral approach 

11. Renal Artery Stenosis & Complex Aortoiliac Disease

12. Renal Artery Angiography: Brachial Approach Complications lower with femoral route Left brachial approach: –Acute caudal angulation –Inability to engage with reverse curve catheters –Aorto-iliac PAD –Infrarenal abdominal aneurysm –graft in the femoral region –rigid (non-elastic) arteries, tight calcified stenoses –dilated abdominal aorta Complications with brachial approach greater –In patients with a small or diseased brachial artery –When a 7 French or larger sheath is required Use of a multipurpose catheter from left brachial approach Radial artery approach might be preferable over brachial because (lower complication & higher patient satisfaction) –Long sheaths and guidewires –Problems with catheter pushability & guidewire torque control –Sheath size is usually limited to 6 French Hessel et al. Radiology 1981; 138:273-281 Scheinert et al. Catheter Cardiovasc Interv 2001; 54:442-447

13. Renal Artery Angiography: Translesional Gradient RAS less than 50% in diameter are not significant “Gray zone” (50-70% diameter stenosis) Four French (1.35mm) catheter across 4 mm renal artery Pressure guide wire system Thermodilution technique to measure flow (Angioflow) Change in SBP could be a source of uncertainty: –When gradient is small –Simultaneous recording in the renal artery & aorta is preferable 20 mm or greater systolic gradient results from a significant stenosis 10% peak systolic gradient or >5% difference in MAP B. De Bruyne et al. JACC, Volume 48, Issue 9, Pages 1851-1855

14. Renal Artery Angiography Anatomic variations in the renal vasculature occur in approximately 25- 40% of patients Accessory, renal arteries are the most common arterial variation, with most of these branches supplying the lower pole of the kidney Kidney position in the retroperitoneum is subject to variation as well

15. Non-selective Renal Angiogram: Aberrant Renal Artery Below Right Renal Artery

16. Non-selective Renal Angiogram: Accessory Renal Artery Below Right Renal Artery

17. Non-selective & Selective Renal Angiography Accessory renal arteryAberrant renal artery

18. Renal Arteriography Conclusions: –Careful patient selection –Careful pre-procedural preparation & planning –Start with flush aortography –Selective renal arteriography –Anticoagulation primarily with UFH –Brachial/radial arterial access for challenging anatomy –Translesional gradient assessment of intermediate stenoses (with pressure wire)

20. Clinical Clues to the Diagnosis of Renal Artery Stenosis (RAS) Onset of HTN 55y (Class I; LOE B) Accelerated, resistant, or malignant hypertension (Class I: LOE C) Unexplained atrophic kidney/size discrep. >1.5 cm (Class I; LOE B) Sudden, unexplained pulmonary edema (Class I; LOE B) Unexplained renal dysfunction (Class IIa; LOE B) Development of new azotemia or worsening renal function after administration of an ACE inhibitor or ARB agent (Class I; LOE B) Multivessel CAD or PAD (Class IIb; LOE B) Unexplained CHF or refractory angina (Class IIb; LOE C) White et al. Circulation.2006; 114: 1892-1895