Ultrasonography in the Diagnosis of
Renovascular Disease
J. Radermacher
Abt. Nephrologie, Medizinische Hochschule Hannover, Germany
Correspondence to:
Dr. Jörg Radermacher
Abt. Nephrologie, Medizinische Hochschule Hannover
Carl-Neuberg Str. 1, 30625 Hannover, Germany
Tel: π49 511 5326305; Fax: π49 511 552366; E-mail: Radermacher.Joerg/mh-hannover.de
Key words: Resistance index, Pourcelot Index, renovascular hypertension, renovascular azotemia, ultrasonographic stenosis
criteria.
Introduction
CTA, MRT, captopril-enhanced scintigraphy and col-
our Doppler sonography all compete in the diagnosis
of renal artery stenosis and in experienced hands all
perform equally well. However, not all patients with
renal artery stenosis will benefit from angioplasty or
surgery. For this reason, it is not sufficient to diagnose
the presence of renal artery stenosis but one also has
to evaluate its functional significance. Most studies that
compare drug treatment with angioplasty for renal ar-
tery stenosis found only modest or no beneficial effects
of angioplasty on renal function and blood pressure.
Subgroups of patients with a high likelihood of a
favourable response have to be identified.
We will therefore focus on the diagnostic value of
ultrasonography for showing not only the presence but
also the functional significance of renal artery stenosis.
First, it will be shown how to diagnose and assess the
anatomical severity of renal artery stenosis using ultra-
sound. Second, we will show how ultrasonography
might help in establishing the functional severity of ste-
nosis, i.e. the presence of renovascular hypertension or
renovascular azotaemia.
Diagnosis of renal artery stenosis
There are two major ultrasonographic approaches to
establishing the diagnosis of renal artery stenosis: the
direct and the indirect approach. The direct approach
looks at flow acceleration at the site of stenosis, the
indirect approach examines post-stenotic flow phenom-
ena. Different flow velocities have been used as cut-off
points to establish the diagnosis of stenosis. The most
accepted cut-off maximum systolic velocities are 180 to
200 cm/s (Table 1). Using this approach, stenoses with
Ø 50% diameter reduction can be found with good
sensitivity and specificity. However, in about 10–20%
of patients, this approach fails because the renal arter-
2/2002 IMAGING DECISIONS
ies cannot be visualized due to excessive meteorism,
obesity, or the inability of patients to hold their breath
even for very short periods of time (Table 1). The in-
direct analyses make use of flow characteristics in intra-
renal arteries distal to the stenosis, which can be classi-
fied as tardus or parvus phenomena. A typical tardus
phenomenon is a prolonged acceleration time (⬎70
ms) or a decreased acceleration index. A typical parvus
phenomenon is the reduced resistance index at the site
of stenosis. The latter indirect parameter works best in
patients with two kidneys because there is no reliable
absolute cut-off point that defines a low resistance
index. The side-to-side difference in the resistance indi-
ces should be ⬍5%, otherwise a significant renal artery
stenosis may be suspected at the site with the lower
resistance index value (1, 2). The indirect parameters
can be measured in almost all patients but have the
disadvantage that only severe degrees of stenosis – ex-
ceeding 60–70% diameter reduction – will induce a
change in the intrarenal Doppler signal (Table 1). The
best approach seems to be to use a combination of the
two principal methods and to use indirect signs of ste-
nosis only if the renal artery cannot be sufficiently visu-
alized using the direct approach.
Direct approach
Patients are scanned in the supine position with the
upper body slightly elevated for comfort and to im-
prove the visual field. Fasting for 8 h or application of
carminatives may be performed but is not a prerequi-
site for a successful examination. Before examining the
renal arteries, a B-mode scan of the renal parenchyma
is obligatory, including the presentation of the kidney’s
size, form, parenchymal width, and echogenicity (3). A
2–4 MHz curved array transducer or a 2–3 MHz sec-
tor transducer is used to delineate the course of the
renal artery. The time-saving performance of a routine
examination requires the use of colour flow Doppler
16 U LT R A S O N O G R A P H Y I N T H E D I A G N O S I S O F R E N O VA S C U L A R D I S E A S E

Table 1: Stenosis criteria and the associated sensitivities and specificities in detecting angiographically controlled stenoses of the renal
arteries using duplex and colour flow duplex sonography

Patient Stenosis criteria Technical Degree of Sensitivity/

number failure stenosis specificity
(%) (%) (%)
Direct criteria

Hansen et al. (1990) (36) 74 RAR ⬎3.5 8 ⱖ60 93/98

Karasch et al. (1993) (37) 53 Vmax ⬎180 cm/s 15 ⱖ50 92/92
Olin et al. (1995) (38) 102 Vmax ⬎200 cm/s or RAR ⬎3.5 10 ⱖ60 98/98
Postma et al.(1992) (12) 61 Doppler freq. ⬎4 KHz and broadened 25 ⱖ50 63/86
Doppler spectrum
Schäberle et al. (1992) (9) 76 Vmax ⬎140 cm/s N/A ⱖ50 86/83
Indirect criteria (paravus-tardus)
Baxter et al. (1996) (24) 73 AT ⬎70 ms 16 ⱖ70 89/97
Kliewer et al. (1993) (22) 57 AT Ø70 ms 0 ⱖ50 82/20
Riehl et al. (1997) (17) 214 RI ⬍0.45 or Delta RI Ø8 % 0 ⱖ70 93/96
Schwerk et al. (1994) (2) 72 Delta RI 5 % 0 ⱖ50 82/92
0 ⱖ60 100/94
Speckamp et al. (1995) (25) 123 Delta AI Ø80% N/A ⱖ70 100/94
Stavros et al. (1992) (26) 56 Loss of ESP 0 ⱖ60 95/97
Strunk et al. (1995) (3) 50 AT Ø70 ms 4 ⱖ50 77/46
Combination of direct and indirect criteria
Krumme et al. (1996) (1) 135 Vmax ⬎180 cm/s and/or Delta RI Ø 5% 0 ⱖ50 89/92
Radermacher et al. (2000) (5) 226 Vmax ⬎180 cm/s and RRR ⬎4 0 ⱖ50 97/98
and/or AT Ø70 ms

Only publications with more than 50 patients investigated were considered. All Doppler sonographic studies had to be performed prospec-
tively and had to be compared with intra-arterial angiography as the established gold standard.
Technical failure: The renal artery or intrarenal arteries could not be analysed with Doppler ultrasonography.
Degree of stenosis: Cut-off value for stenosis (% diameter reduction) for which the test has been evaluated.
N/AΩdata not available
AIΩacceleration index; ATΩacceleration; RIΩresistance index (ΩPourcelot index); ESPΩearly systolic peak, RARΩrenal aortic ratio
RRRΩrenal/renal ratio

mode. It shortens the examination time because a devi- It is important to note that Doppler examinations
ation in flow velocity within a stenosis is clearly notice- have to be optimized and that reproducible measure-
able either by a lighter colour or, more frequently, by ments are only possible when the Doppler gate meets
an aliasing phenomenon. Doppler spectra can be selec- the vascular flow direction at the smallest possible
tively obtained from these specific regions of interest,
also reducing the examination time. In addition, quan-
titative measurements of flow velocities in the renal ar-
teries require angle-corrected measurements; because
renal arteries cannot be routinely seen in B-mode,
angle correction also requires the use of colour flow
Doppler. The proximal portion of the renal artery
where most atherosclerotic stenoses are found is usually
sought from a subxiphoidal position (Fig. 1). However,
in B-mode it can be helpful to look at transverse sec-
tions of the right renal artery underneath the caval vein
to find multiple right renal arteries. Direct visualization
of the renal arteries will be successful in 84–100% of
patients (4, 5) and is more easily performed in women
than in men, and in patients with a body mass index
below 30 kg/m2 than in those above. Distal and medial
parts of the renal arteries are best visualized through
the kidney from a dorsolateral or, rarely, from a ventro-
lateral or dorsal approach. The latter approach also Fig. 1. Proximal transverse section of the upper abdomen at
the level of the origin of the renal arteries. With color flow
allows measurements of intrarenal velocity spectra, Doppler sonography the proximal and medial part of the right
which are usually obtained from segmental renal arter- renal artery and the proximal part of the left renal artery can be
ies (Fig. 2). visualised in about 90% of cases.

IMAGING DECISIONS 2/2002

 U LT R A S O N O G R A P H Y I N T H E D I A G N O S I S O F R E N O VA S C U L A R D I S E A S E
Fig. 2. A color flow Doppler sonogram of the intrarenal arter-
ies and veins, using a dorsolumbar section. The arterial flow
directed toward the transducer is coded red, while the opposite
flow direction in the intrarenal veins is shown in blue. The pulse
repetition rate is preselected at a relatively low level on the
apparatus, since relatively slow flow velocities predominate in
both vascular systems.
incident angle (Figs 3 and 4). This means that trans-
ducer positions need to be selected that allow im-
aging of the target arterial segment of the renal arter-
ies at the most acute angle possible between the
vascular axis and the transducer. If colour flow mode
suggests a stenosis – in atherosclerotic stenoses usually
in the ostial portion of the renal artery – this usually
requires the transducer to be placed in either the left
or right flank region to achieve an acute angle. Flow
velocities from a Doppler spectrum are measured at
the point of maximum aliasing and an additional
flow velocity can be measured either in the aorta
proximal to the renal artery (renal aortic ratio) or in
a part of the renal artery itself that is located either
proximal or far distal to the stenosis (renal/renal
ratio). Calculating the renal/renal ratio – when tech-
nically possible – not only proves the presence of
stenosis but also allows quantification (see below).
2/2002 IMAGING DECISIONS
17
Fig. 3. An upper abdominal transverse section at the origin
of the right renal artery from the abdominal aorta. The Doppler
sample volume is located in the proximal segment of the right
renal artery. The pulse repetition frequency is chosen as high
as possible so that aliasing phenomena would only be found in
vessel segments with a high likelihood of a significant stenosis.
No reliable measurement could be made in the ostial part of
the renal artery because the ultrasound beam contacts this part
almost at a right angle.
Fig. 4. An oblique view of the right renal artery from a right
subcostal midclavicular approach. The origin of the right renal
artery is seen at an incident angle, allowing for reliable Doppler
measurements. When the same investigation is performed in
a subxiphoid transverse section through the upper abdomen
(Figure 1 and 4) the origin of the right renal artery cannot be
analyzed by Doppler ultrasound.
The normal frequency spectrum from a main renal
artery presents the typical form of a low resistance
artery (Fig. 3). The normal maximum systolic velocity
is given at 100–180 cm/s (6–10). The normal end-
diastolic flow velocity is 25–50 cm/s. Direct criteria
for a renal artery stenosis are the following:
– The angle-corrected maximum systolic flow velocity
in the renal artery is locally greater than 140/180/
18 U LT R A S O N O G R A P H Y I N T H E D I A G N O S I S O F R E N O VA S C U L A R D I S E A S E
Fig. 5. (a) A left renal artery stenosis after the origin from the
aorta, demonstrated by color flow Doppler sonography through
locally circumscribed aliasing, which reflects the elevated mean
flow velocity in this segment. (b) The maximum systolic flow
velocity in the stenosis was 630 cm/s. (c) Intrarenal segmental
artery with a delayed acceleration time (AT ⬎70 msec) as an
indirect sign of a renal artery stenosis in the proximal vascular
bed.
198 cm/s (9, 11) (Fig. 5). The cut-off value of 180
cm/s has found the widest acceptance. One author
also used a Doppler frequency above 4 MHz as a
Fig. 6. A Doppler sonogram of a normal segmental renal
artery, using a dorsolumbar section. The arterial flow directed
toward the transducer is coded red, while the opposite flow
direction in the intrarenal veins is shown in blue. The pulse
repetition rate is preselected at a relatively low level compared
to the main renal artery setting, since relatively slow flow velo-
cities predominate in both vascular systems. PSVΩVmax;
MDVΩVdias; RI is resistance index; PI is Pulsatility index; S/D
is systolic diastolic ratio, ATΩacceleration time.
Fig. 7. Mean change of mean arterial blood pressure (MAP –
line graph) and the amount of antihypertensive drugs taken
(AHT – bar graph) in patients before and after correction of
renal artery stenosis. The results are shown for 34 patients with
segmental renal artery resistance index (RI) values ⬍80 and
for 16 patients with RI values ⱖ80 who had at least 5 years of
follow up after correction of renal artery stenosis. The *denotes
a p value ⬍0.05 as tested by an unpaired t-test (Bonferroni
adjustment). In RI ⬍80 blood pressure decreased from base-
line 150/89∫22/12 mmHg to 135/80∫14/10 at the last follow
up visit (p⬍0.001), in RI ⱖ80 from 164/83∫21/16 to 163/
86∫19/10 mmHg (not significant). The number of antihyperten-
sive drugs denotes the number of different drug classes taken
and not the absolute number of pills. Antihypertensive drug
classes were: ACE-inhibitors; AT II-receptor blockers; b-block-
ers, calcium antagonist, alpha-blockers, direct vasodilators, di-
uretics and nitrates. *p⬍0.05. Error bars are S.E.M.
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 U LT R A S O N O G R A P H Y I N T H E D I A G N O S I S O F R E N O VA S C U L A R D I S E A S E 19

Table 2: Diseases with increased resistance index values

Diabetic glomerulosclerosis Increased renal volume

Hypertensive nephrosclerosis
Haemolytic uraemic
syndrome
Hepatorenal syndrome
Acute renal failure
Urinary tract obstruction,
hydronephrosis
High-grade reflux
Acute vascular rejection in
renal transplantation
Lupus nephritis with high
chronicity index and bad
prognosis
Normal echogenicity
parenchyma (15, 39–41)
RI correlates with impaired
renal function (42)
Decreased renal volume
Normal or increased
echogenicity of renal
parenchyma (15)
(43–46)
(47, 48)
Increased renal volume (49)
(50–54)
(55)
(56, 57)
(58)

Fig. 8. Mean change of creatinine clearance (GFR) in pa-
tients before and after correction of renal artery stenosis. The
results are shown for 96 patients with segmental renal artery
resistance index (RI) values ⬍80 and for 35 patients with RI
values ⱖΩ80. The *denotes a p value ⬍0.05 as tested by an
unpaired t-test (Bonferroni adjustment).
diagnostic criterion, but this methodology has not
been used by others (12).
– The angle-corrected flow velocity in the stenotic seg-
ment of the renal artery is more than 3.3–3.5 times
faster than flow velocity in the aorta (renal aortic
ratio) (11, 13, 14).
– The angle-corrected flow velocity in the stenotic seg-
ment of the renal artery is more than 4 times faster
than flow velocity in the a post- or prestenotic seg-
ment of the renal artery (5, 15) (renal/renal ratio).
Renal vein thrombosis (59–61)
This method also allows the determination of the
exact degree of stenosis using the formula: Area ste-
nosis (%)Ω100 * [1ª(post-stenotic velocity/intras-
tenotic velocity)]. The correlation coefficient of
Doppler-estimated degrees of stenoses compared
with the gold standard (planimetric calculation using
intravascular ultrasound) was 0.97 (16).
– The end-diastolic flow velocity increases.
– Clear spectral broadening appears (12).
Indirect approach
Intrarenal vessels, usually segmental renal arteries, are
identified in colour Doppler mode (Figs 2 and 6).

Fig. 9. Unadjusted odds ratios of dif-

ferent factors regarding worsening of re-
nal function. The squares depict the
odds ratio, the lines give the 95% confi-
dence interval. RIΩresistance index;
GFRΩcreatinine clearance; CADΩcoro-
nary artery disease; AODΩarterial oc-
clusive disease of the legs; CVDΩcere-
brovascular disease; nocturnal decrease
in blood pressure as determined from
ambulatory 24 hour blood pressure
measurements. The red square denotes
the odds ratio for a negative captopril
scintigraphy which was calculated from
published data (figure has been pub-
lished previously 30).

2/2002 IMAGING DECISIONS

20 U LT R A S O N O G R A P H Y I N T H E D I A G N O S I S O F R E N O VA S C U L A R D I S E A S E
Doppler spectra from two to three vessels from the
upper, medial, and lower portion of the right and left
kidneys are obtained and the values for each kidney
are averaged. Care is taken to obtain a good signal
quality, which means that only signals that can be de-
rived from vessels that run directly towards the scanner
or at a maximum angle of 30æ are used for analysis.
Indirect criteria for renal artery stenosis are the fol-
lowing:
Parvus phenomenon
– The flow velocity and the resistance index decrease
in distal arterial segments and intrarenally. (Either ab-
solute resistance index value of ⬍ 0.45–0.5 (17) or dif-
ference between left and right kidneys of ⬎5–10%) (1,
2, 18–20).
Tardus phenomenon (21)
– The acceleration time increases in post-stenotic dis-
tal arterial segments and intrarenally (acceleration
time ⬎70 ms (4, 5, 22–24) (Figure 5C).
– The acceleration index decreases to ⬍3.78 m/s (4)
or the ratio of acceleration indices between the
stenosed and the nonstenosed kidney is ⬎1.8 (25).
– The early systolic peak is lost (26).
Other
– Renal cortical perforating vessels with flow towards
the kidney (27).
As can be seen from Table 1, the indirect criteria
performed poorly when any stenosis from 50% up-
wards were included. The results were much better
when only stenoses of ⬎60–70% were included. The
direct criteria, on the other hand, had good sensitivity
and specificity for lower degrees of stenosis but could
not be obtained in 8–25% of patients.
The combination of both techniques allowed the
detection of stenoses of lesser severity with good accu-
racy and a diagnosis could be made in all patients
(Table 1).
Diagnosis of renovascular hypertension and
azotaemia
Only 60–80% of patients will benefit from correction
of renal artery stenosis in terms of lowered blood press-
ure or improved or at least stabilized renal function.
The reason for this could be underlying nephrosclerosis
due to chronic hypertension or underlying diabetic glo-
merulosclerosis. Both diseases have been associated
with increased vascular resistance, which can be esti-
mated ultrasonographically by measuring the renal re-
sistance index. This resistance index can be calculated
from the maximum systolic velocity (Vmax) and mini-
mum diastolic velocity (Vmin) from a Doppler spec-
trum. Resistance index (RI)Ω1ª(Vmin/Vmax)
The prognostic significance of the preinterventional
resistance index as a predictor of clinical success of
percutaneous transluminal angioplasties or operations
for renal artery stenosis is a topic of intense debate.
Frauchiger et al. (28) investigated 32 patients who
subsequently underwent correction of renal artery ste-
nosis with Doppler ultrasound. They found a cortical
diastolic to systolic (d/s) ratio of ⬍0.30 (correspond-
ing to a resistance index of ⬎0.70) to be prognostic
of treatment failure. None of 11 clinically successful
procedures had a d/s ratio of ⬍0.30 (RI ⬎0.70)
compared with 7 of 24 patients with treatment fail-
ure. Cohn et al., using the same cut-off value for d/
s ratio had similar findings in 23 patients (29). In
all patients with improved blood pressure and renal
function, the d/s ratio was ⬎0.30 (RI ⬍0.70),
whereas all patients whose blood pressure or renal
function failed to improve had a decreased d/s ratio.
More recently, we published a paper using a stricter
cut-off resistance index value of 0.80 (30). The re-
sistance index was measured prospectively in proxi-
mal segmental arteries of both kidneys. A resistance
index value of Ø0.80 in either kidney was considered
prognostic of treatment failure. Among the 35 pa-
tients with resistance index values of at least 0.80
before revascularization, mean ambulatory blood
pressure failed to decrease in 34 and renal function
declined in 28. Among the 96 patients with resistance
index values ⬍0.80, mean blood pressure decreased
in all but six and renal function worsened in only
three (Figs 7 and 8). A resistance index of Ø 0.80
was superior to all other tested parameters in pre-
dicting worsening renal function (Fig. 9).
The resistance index, as measured by Doppler ultra-
sonography, is influenced by a variety of physiological
factors. RI decreases from the main renal artery to the
segmental renal artery, the interlobar, the arcuate, and
finally the interlobular artery (31). The RI in the renal
arteries increases during inspiration, and increases even
more during the Valsalva manoeuvre (32, 33). Pulse
rate has an influence on resistance index, with brady-
cardia leading to a lower end-diastolic flow and a
higher resistance index and tachycardia causing the op-
posite. Schwerk et al. suggested a corrective formula to
account for different pulse rates (34); however, for pulse
rates in the range of 50 to 70 beats per minute, there
is little change in resistance index values. Resistance
index values increase with age (34, 35) and more so in
patients with hypertension.
In addition to physiological factors, some renal dis-
eases are also associated with increased RI values
(Table 2). Taken together, this means that a resistance
index of ⬎0.80 is a reliable sign of irreversible chronic
IMAGING DECISIONS 2/2002
 U LT R A S O N O G R A P H Y I N T H E D I A G N O S I S O F R E N O VA S C U L A R D I S E A S E
renal disease when it is measured in segmental renal
arteries, when Valsalva manoeuvre is avoided during
the determination, when extreme bradycardia is ruled
out, and when acute reversible renal diseases such as
acute renal failure, haemolytic uraemic syndrome, uri-
nary tract obstruction, and renal vein thrombosis can
be excluded.
Summary
To diagnose stenoses with ⬎50% diameter reduction,
in all patients a combination of Doppler parameters
making use of both direct and indirect signs of stenosis
should be used. In our hands, a renal/renal ratio of
⬎4 and, if this parameter was not measurable, an ac-
celeration time of ⬎70 ms was the best combination.
The reversibility of hypertension or impaired renal
function after successful correction of renal artery ste-
nosis can be assessed by measuring segmental artery
resistance indices. A resistance index value of Ø0.80
makes a treatment effect highly unlikely and these pa-
tients should not undergo angioplasty or surgery for
their stenosis. Studies to confirm this last statement
have yet to be performed.
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