Diagnostic Imaging Pathways - Hypertension (Renovascular Cause)
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with suspected renovascular hypertension.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1 |  |
Bilateral Renal Artery Stenosis Image 1 (Magnetic Resonance Angiography): Coronal image demonstrating bilateral renal artery stenosis. |
| 2a |  |
Bilateral Renal Artery Stenosis Image 2a, 2b and 2c (Digital Subtraction Angiography): Pre- and post-stent images of bilateral renal artery stenosis. |
| 2b |  |
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| 2c |  |
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Teaching Points
Teaching Points
- The suspicion of renovascular hypertension requires high clinical acumen
- Initial investigation is with an US of the kidneys, with Doppler interrogation of the renal arteries. The accuracy is dependant on the experience of the operator
- Further non-invasive investigation is based on the patient’s renal function. MRI with Gadolinium or CT Angiography are suitable tests
- Nuclear scintigraphy with Captopril enables assessment of renal function
- Angiography is the ‘Gold Standard’ and permits therapeutic intervention
angio
Angiography
- "Gold standard" for detection of renal artery stenosis 7
- Provides therapeutic opportunity
- Disadvantages: invasive with a risk of complications, expensive, requires administration of iodinated contrast material and exposure to ionising radiation
capto
Captopril Renal Scan
- Assesses perfusion, function, transit time and response to captopril
- Currently used to determine functional significance of detected renal artery stenosis
- Inferior to other imaging modalities as a diagnostic test for renal artery stenosis 3
- Captopril renal scan assessment of renal function can predict response to therapy 15
- Sensitivity of 64-93% and specificity of 71-97% for detection of renal artery stenosis when angiography used as standard of reference 3
- Limitations:
cta
Spiral Computed Tomography Angiography (CTA)
- Alternative to gadolinium MRA
- ~95% sensitivity and specificity 3
- Advantages - can identify non-renal causes of hypertension, and visualisation of both the arterial lumen and wall allows improved differentiation between truncal and ostial stenosis 7
- Disadvantages - ionising radiation, failure to identify small arteries <2mm and accurately assess renal arteries beyond renal hilum 7
invest
Further Investigations
- A recent double-blinded randomised controlled trial (ASTRAL) involving 806 patients with atherosclerotic renovascular disease has shown that endovascular revascularization plus medical therapy is no better than medical therapy alone in patients with atherosclerotic renovascular disease with respect to renal function, blood pressure, renal or cardiovascular events, or mortality. In addition, revascularization carries substantial risk like amputation of limb and death 22
- This suggests that there is little/no benefit in further investigating these patients in the absence of any therapeutic consequence. However in selected cases consideration of stenting or surgery may still be appropriate. Decision in those circumstances should be made after the patient has been assessed by the renal team and/or vascular surgeon
mra
Gadolinium Magnetic Resonance Angiography (MRA)
Note warning regarding gadolinium in severely impaired renal function Further information
- Most accurate non-invasive modality for detecting renal artery stenosis (>95% sensitivity and specificity) 3,8
- However due to the associated risk of nephrogenic systemic sclerosis caused by gadolinium containing contrast agents among patients with chronic kidney disease, caution should be taken while performing this investigation in patients with chronic kidney disease 20,21, 23-27
- Use of cyclic agents(e.g. gadoterate, gadobutrol and gadoteridol) are more appropriate 25
- Advantages 7
- Non-invasive
- No radiation
- Combined with other MR techniques can assess the significance of stenosis
- Can differentiate between truncal and ostial stenosis
- Disadvantages
prob
High Clinical Probability
Consider renovascular hypertension when 14
- Newly diagnosed hypertension presents with features that are atypical of essential hypertension such as young or very old patients, no family history, severely elevated blood pressure, epigastric bruit or coexisting clinical indicators of atherosclerosis (i.e. ischaemic heart disease, cerebral or peripheral vascular disease, or
- Resistant hypertension , or
- Angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II- receptor antagonist therapy is associated with increasing plasma creatinine levels
stent
Renal Artery Angioplasty And Stenting
- A recent double-blinded randomised controlled trial (ASTRAL) involving 806 patients with atherosclerotic renovascular disease has shown that endovascular revascularization plus medical therapy is no better than medical therapy alone in patients with atherosclerotic renovascular disease with respect to renal function, blood pressure, renal or cardiovascular events, or mortality. In addition, revascularization carries substantial risk like amputation of limb and death 22
- Since available data from randomized trials have not shown a benefit of revascularization over medical therapy, revascularization should be reserved for patients in whom aggressive medical therapy has failed and for patients who are participating in clinical trials 20
us
Ultrasound
- Best screening tool for renovascular hypertension 1,2
- Ultrasound assesses renal size and morphology and Doppler gives information regarding blood flow velocities and waveform
- 63-100% sensitivity and 73-100% specificity for renal artery stenosis 3
- A renal resistive index value of at least 0.8 reliably identifies patients with renal-artery stenosis in whom angioplasty or surgery will not improve renal function, blood pressure, or kidney survival 4
- Patients with abnormal US or high clinical suspicion of renal artery stenosis need to be further evaluated with MRA or CTA 56
- Advantages: non-invasive, relatively inexpensive, does not involve the use contrast material and no exposure to ionising radiation
- Limitations: difficult in obese patients and where breath holding and cooperation are poor 7
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Krumme B, Blum U, Schwertfeger E, et al. Diagnosis of renovascular disease by intra- and extrarenal Doppler scanning. Kidney Int. 1996;50:1288-92. (Level II/III evidence)
- Radermacher J, Brunkhorst R. Diagnosis and treatment of renovascular stenosis - a cost-benefit analysis. Nephro Dial Transplant. 1998;13:2761-7. (Level III evidence)
- Boudewijn G, Vasbinder GBC, Neelmans PJ, Kessels AGH, et al. Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med. 2001;135:401-11. (Level I/II evidence). View the reference
- Radermacher J, Chavan A, Bleck J, et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med. 2001;344:410-7. (Level I/II evidence). View the reference
- Krijnen P, Van Jaarsveld BC, Steyerberg EW, et al. A clinical prediction rule for renal artery stenosis. Ann Intern Med. 1998;129:705-11. (Level II evidence). View the reference
- Pedersen EB. New tools in diagnosing renal artery stenosis. Kidney Int. 2000;57:2657-77. (Review article)
- Rankin SC, Saunders AJS, Cook GJR, et al. Renovascular disease. Clin Radiol. 2000;55:1-12. (Review article)
- Qanadli SD, Soulez G, Therasse E, et al. Detection of renal artery stenosis: prospective comparison of captopril-enhanced Doppler sonography, captopril-enhanced scintigraphy, and MR Angiography. AJR Am J Roentgenol. 2001;177:1123-9. (Level III evidence)
- Van Jaarsveld BC, Krijnen P, Pieterman H, et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal artery stenosis. N Engl J Med. 2000;342:1007-14. (Level II evidence). View the reference
- Leertouwer TC, Gussenhoven EJ, Bosch JL, et al. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology. 2000;216:78-85. (Level II evidence). View the reference
- Weibull H, Bergqvist D, Bergentz S-E, et al. Percutaneous transluminal renal angioplasty versus surgical reconstruction of atherosclerotic renal artery stenosis: a prospective randomized study. J Vas Surg. 1993;18:841-52. (Level II evidence). View the reference
- Baumgartner I, von Aesch K, Do D-D, et al. Stent placement in ostial and nonostial atherosclerotic renal arterial stenoses: a prospective follow-up study. Radiology. 2000;216:498-505. (Level II evidence). View the reference
- van de Ven PJ, Kaatee R, Beutler JJ, et al. Arterial stenting and balloon angioplasty in ostial atherosclerotic renovascular disease: a randomised trial. Lancet. 1999;353:282-86. (Level II evidence). View the reference
- Parker SC, Hannah A, Brooks M, et al. Renal artery stenosis: a disease worth pursuing. Med J Aust. 2001;175:149-53. (Clinical update)
- Harward TR, Poindexter B, Huber TS, Carlton LM, Flynn TC, Seeger JM. Selection of patients for renal artery repair using captopril testing. Am J Surg. 1995;170:183-7. (Level III evidence)
- Ramsay LE, Waller PC. Blood pressure response to percutaneous transluminal angioplasty for renovascular hypertension: an overview of published series. Br Med J. 1990;300:569-72. (Level III evidence)
- Ramos F, Kotliar C, Alvarez D, et al. Renal function and outcome of PRTA and stenting for atherosclerotic renal artery stenosis. Kidney Int. 2003;63:276-82. (Level II/III evidence)
- Zeller T, Frank U, Muller C, et al. Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis. Circulation. 2003;108:2244-9. (Level II evidence). View the reference
- Watson PS, Hadjipetrou P, Cox SV, Piemonte TC, Eisenhauer AC. Effect of renal artery stenting on renal function and size in patients with atherosclerotic renovascular disease. Circulation. 2002;102:1671-77. (Level II evidence). View the reference
- Dworkin L, Cooper C. Renal-artery stenosis. N Engl J Med. 2009;361:1972-8. (Review article)
- Grobner T. Gadolinium - a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis? Nephrol Dial Transplant. 2006;21:1104-8. (Level II evidence). View the reference
- Wheatley K, Ives N, Gray R, Kalra P, Moss J, Baigent C, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361:1953-62. (Level I evidence)
- High WA, Ayers RS, Chandler J et al. Gadolinium is dectectable within the tissue of patients with nephrogenic systemic fibrosis. J Am Acad Dermatol. 2007;56:21-6. (Level III evidence)
- Boyd AS, Zic JA, Abraham JL. Gadolinium deposition in nephrogenic fibrosing dermopathy. J Am Acad Dermatol. 2007;56:27-30. (Review article)
- MRI Reference Group, Standards of Practice & Accreditation Commitee. RANZCR NSF Guidelines. October 2009. (Guideline document)
- Centers for Disease Control and Prevention (CDC). Nephrogenic fibrosing dermopathy associated with exposure to gadolinium-containing contrast agents--St. Louis, Missouri, 2002-2006. MMWR Morb Mortal Wkly Rep. 2007;56(7):137-41. (Level III evidence). View the reference
- Lim YL, Lee HY, Low SC, Chan LP, Goh NS, Pang SM. Possible role of gadolinium in nephrogenic systemic fibrosis: report of two cases and review of the literature. Clin Exp Dermatol. 2007;32(4):353-8. (Level IV evidence). View the reference
Further Reading
- Lee H-Y, Grant EG. Sonography in renovascular hypertension. J Ultrasound Med. 2002;21:431-41. (Review article)
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
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Consent to Procedure or Treatment Radiation Risks of X-rays and Scans Computed Tomography (CT) Angiography Magnetic Resonance Angiography (MRA) Magnetic Resonance Imaging (MRI) Renal Artery Angioplasty and Stent |
Contrast Medium (Gadolinium versus Iodine) Iodine-Containing Contrast Medium Magnetic Resonance Imaging (MRI) Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children Angioplasty and Stent Insertion |
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