彩色多普勒超声诊断移植肾动脉重度狭窄1例

患者男,31岁.2001年10月因"尿毒症"行"肾移植术",术后每周复查尿常规及BUN(29～30mg/d1)、Cr(2.2～2.5mg/dl)均相对稳定.     

彩色多普勒超声检测自体肾和移植肾的肾动脉狭窄

目的 探讨彩色多普勒超声在检测自体肾和移植肾肾动脉狭窄(RAS)中的价值和局限性。方法 回顾性对照分析了临床可疑RAS的30例自体肾和14例移植肾的彩色多普勒超声(US)与磁共振动脉造影(MRA)及动脉血管造影的结果。并将狭窄肾动脉扩张／再通术前后的肾动脉血流速度，肾内小动脉多普勒波形特征(升速时间-AT，升速指数-AI，阻力指数-RI)进行了比较。结果 30例自体肾RAS的超声诊断中有2例假阳性和2例假阴性。14例移植肾RAS阳性的超声检查无误差。肾动脉血流速度和肾内小动脉的多普勒波形在RAS纠正术前后有显著改变。结论 尽管彩色多普勒超声在检测RAS中有局限性，其仍被列为对可疑RAS病例的初步影像检查，并在观测随访RAS纠正术后的肾血流灌注及狭窄复发中有重要作用。综合分析肾动脉及肾内动脉的血流速度和多普勒波形特征并参考有关临床资料有助于提高超声诊断RAS的准确性。     

移植肾动脉狭窄的彩色多普勒超声诊断

移植肾动脉狭窄(transplant renal artery stenosis，TRAS)是肾移植术后的常见并发症，能够导致药物难以控制性高血压和(或)肾功能损害。可能诱发的因素为修补时肾动脉损伤、动脉弯曲、吻合技术不佳、排异反应、供体肾动脉或受体髂动脉粥样硬化。随着血管介入治疗技术的迅速发展，TRAS能够用血管成形术矫正，因而采用无创性检查方法诊断需要介入治疗的TRAS尤为重要。1983年Reinitz等首次应用多普勒技术成功地诊断TRAS。20年来，许多作者对TRAS的多普勒超声诊断进行了有益的探索，取得了令人可喜的成绩。近几年来，国内也有数篇报道涉及TRAS的彩色多普勒超声(CDFI)诊断。     

肾动脉狭窄的彩色多普勒超声诊断及量化分析

目的　评价彩色多普勒血流显像 (CDFI)在肾血管性高血压患者肾动脉狭窄 (RAS)中的诊断标准及量化分析。方法　应用彩色多普勒对 50例健康者的 69支肾动脉与 31例RAS患者的 35支肾动脉分别测量肾动脉主干峰值流速 (Vp)、肾动脉与邻近腹主动脉峰值流速比值 (RAR)、肾内段动脉收缩期加速度时间 (AT) ,同时测量患病组的RAS程度并与Vp、RAR、AT加以比较进行量化分析。结果　检出 31支肾动脉Vp≥ 1 80cm/s,RAR≥2 .5 ,AT≥ 0 .0 8s为诊断RAS的量化标准 (狭窄程度为 50 %～ 85 % )。 4支肾动脉Vp≤0 .6cm/s,RAR≤ 0 .6(狭窄程度为 86 %～ 99% )。肾动脉完全闭塞时 ,肾动脉内未见彩色血流信号。其中 1 0例行肾动脉造影数字减影均示肾动脉内径狭窄 ,狭窄度均 >50 % ,阳性符合率达 1 0 0 %。结论　CDFI不但可以较准确诊断RAS ,还可评价狭窄的程度。Vp、RAR值的波动范围可能与病理状态下血管狭窄比率相当 ,结合肾的大小 ,可作为判断RAS程度的指标     

彩色多普勒超声联合超声造影对移植肾动脉狭窄的诊断价值

目的:探讨彩色多普勒超声(color Doppler ultrasonography, CDUS)血流动力学参数联合超声造影(contrast-enhanced ultrasound, CEUS)定量参数对移植肾动脉狭窄(transplant renal artery stenosis, TRAS)的诊断价值。方法:分析2011年9月至2020年5月在复旦大学附属中山医院经DSA或MRA确诊的TRAS患者21例(狭窄组)及同期行肾移植且随访肾功能正常的患者37例(对照组)的CDUS及CEUS资料,比较2组CDUS血流动力学参数[主肾动脉收缩期峰值流速(PSV)、峰值流速后比、叶间动脉阻力指数(RI)]及CEUS定量参数[皮质感兴趣区上升时间(RT)、髓质RT、皮质达峰时间(TTP)、髓质TTP]的差异,分析上述各个参数与TRAS程度间的相关性,并通过ROC曲线分析上述参数单独及联合应用时诊断TRAS的效能。结果:狭窄组主肾动脉PSV、峰值流速后比、皮质RT、髓质RT、皮质TTP及髓质TTP的值均高于或长于对照组,叶间动脉RI低于对照组(P0.05);主肾动脉PSV、叶间动脉RI、峰值流速后比、皮质RT、髓质RT、皮质TTP、髓质TTP与TRAS程度均存在中度相关性(r值分别为0.617、-0.409、0.599、0.600、0.518、0.638、0.648),其中叶间动脉RI与狭窄程度负相关,其余超声参数与狭窄程度正相关(P0.05)。CDUS血流动力学参数总体灵敏度高于CEUS定量参数,总体特异度低于CEUS定量参数;CEUS定量参数(除髓质RT外)的曲线下面积普遍大于CDUS血流动力学参数。主肾动脉PSV2.43 m/s及皮质TTP9.26 s是诊断TRAS的重要参数(P0.05),两者联合诊断TRAS的AUC为0.965、准确度为91.40%,高于所有单一参数。结论:CDUS及CEUS均可用于诊断TRAS,CDUS血流动力学参数联合CEUS定量参数可提高TRAS诊断的准确度,从而在一定程度上减少CDUS疑诊病例不必要的放射性检查。     

肾动脉狭窄的彩色多普勒超声诊断

肾动脉位置深在 ,相对较细 ,且受肠道气体、肥胖等多种因素的影响 ,是彩色多普勒超声 (简称彩超 )较难探测的器官之一。本文就肾动脉狭窄 (ＲＡＳ)的多普勒超声诊断指标及其测量、诊断标准及存在问题等方面进行评价。1　正常肾动脉的血流频谱正常肾动脉及其分支的血流频谱呈低阻波型 ,收缩早期频谱上升陡直 ,而后 ,缓慢下降 ,整个舒张期血流速度较高。收缩早期常有切迹 ,称之为收缩早期切迹 ,它的存在使收缩期频谱呈双峰 ,多数第一峰大于第二峰 ,少数第二峰大于第一峰。频窗可以消失。从主肾动脉至肾内各级动脉分支 ,流速是递减的。多数正常…     

彩色多普勒超声诊断肾动脉粥样硬化性狭窄

目的探讨彩色多普勒超声诊断肾动脉粥样硬化性狭窄的价值。方法61例患者共122支肾动脉同时行彩色多普勒超声及血管造影。结果彩色多普勒超声诊断肾动脉狭窄的敏感性为90％,特异性为96％;诊断显著狭窄的敏感性为86％,特异性为99％;诊断＜50％狭窄的敏感性为82％,特异性为96％;诊断狭窄位置准确率为97％。结论肾动脉彩色多普勒超声对于肾动脉狭窄、初筛诊断以及评价肾动脉狭窄介入治疗的近、远期疗效,是一种非常理想的选择。     

肾动脉狭窄与肾动脉栓塞的彩色多普勒超声检测与临床意义

目的：探讨肾动脉狭窄与肾动脉栓塞的彩色多普勒超声检测及临床意义。方法：使用高档彩色多普勒超声诊断仪对确诊为肾动脉狭窄及肾动脉栓塞患者进行二维声像图及彩色多普勒检测,并与正常或健侧肾脏对照。结果：肾动脉狭窄及肾动脉栓塞的二维超声形态学、彩色血流信号及多普勒血流动力学有特异性的变化,其探测成功率及诊断敏感性均较好。结论：彩色多普勒超声对肾动脉狭窄与肾动脉栓塞有显著的临床意义。     

彩色多普勒超声在肾动脉狭窄诊断中的应用

目的评价彩色多普勒超声对肾动脉狭窄（ARAS）的诊断指标及准确性。方法 1999年10月2008年12月对患有高血压病的58例共113根肾动脉进行彩色多普勒超声检查。每例患者均测量肾动脉峰值流速（PSV）与肾内段动脉的阻力指数及肾脏长轴。在双盲条件下,以患者肾动脉造影、MRI血管造影及CT血管造影为标准,评价彩色多普勒超声诊断ARAS的诊断指标及准确性。结果彩色多普勒超声诊断肾动脉狭窄的敏感性为60%,特异性为83%,阳性预测值为83%,阴性预测值为61%。患侧肾长轴小于健侧肾长轴,患侧肾峰值流速高于健侧肾峰值流速,患侧肾阻力指数低于健侧肾阻力指数。结论肾动脉彩色多普勒超声对于肾动脉狭窄初筛诊断以及评价肾动脉狭窄介入治疗后的近、远期疗效,是一种简便可靠的无创检查手段。     

移植肾初期肾动脉狭窄的超声诊断

目的 探讨肾移植术后初期肾动脉狭窄的超声诊断。方法 回顾分析厦门大学附属翔安医院2019年4月-2021年12月超声科检查的103例肾移植患者的超声及临床资料。结果 共28例超声提示肾主动脉或动脉吻合口血流信号紊乱及PSV增快,PSV>250cm/s。其中11例在术后3个月的超声定期监测中PSV处于稳定增快状态,最终经DSA或CTA检查,动脉吻合口狭窄8例,肾主动脉距吻合口5mm处狭窄1例。另2例PSV增快为肾主动脉成角所致。其余17例在术后3个月的超声定期监测中,PSV逐渐下降,最终PSV≤250cm/s。肾主动脉PSV持续增快病例组9例术后肌酐值下降缓慢未达正常范围;肾动脉PSV逐渐下降组,肌酐值随之降至正常范围。超声显示PSV增快及血流信号紊乱的病例中真性狭窄的比例为32.1%(9/28)。结论 肾移植术后短期内吻合口及其旁软组织增厚水肿可致肾动脉PSV增快及紊乱血流信号,并非一定是真性狭窄。肾移植后初期肾主动脉容易成角导致PSV增快。术后初期应用超声监测肾动脉PSV变化趋势尤为必要,减少侵入性检查。超声监测中结合肌酐值的变化趋势对移植肾动脉狭窄的判定有重要意义。     

彩色多普勒超声诊断肾动脉狭窄的Meta分析

目的探索彩色多普勒超声检查对肾动脉狭窄的诊断价值。方法计算机检索1995年1月至2013年8月国内外公开发表的以肾动脉造影检查结果为金标准的关于超声诊断肾动脉狭窄的中、英文文献,提取文献相关数据。根据Cochrane协作网推荐的方法对文献进行质量评价,并用Meta DiSc 1.4软件进行统计分析。结果共纳入文献10篇,彩色多普勒超声诊断肾动脉狭窄的合并敏感性和特异性分别为0.86(CI:0.83~0.89)、0.96(CI:0.95~0.97),诊断比值比为141.08(CI:51.19~384.33),合并阳性和阴性似然比分别为20.54(CI:8.80~47.93)、0.16(CI:0.12~0.21),总受试者工作特征曲线下面积为0.9049。结论彩色多普勒超声检查对肾动脉狭窄具有较高临床诊断价值。     

Evaluation of severe transplant renal artery stenosis with Doppler sonography

PURPOSE: To evaluate and determine Doppler criteria for predicting a severe transplant renal artery stenosis (80%-99% diameter reduction) and to compare the Doppler findings in patients with end-to-end and end-to-side anastomosis. METHODS: We performed Doppler sonography on 16 consecutive patients with transplant renal artery stenosis (TRAS) confirmed by digital subtraction arteriography (DSA). Fourteen patients had end-to-end anastomosis, and 2 had end-to-side anastomosis. Eleven patients were re-evaluated with color Doppler sonography within 4 days after intervention. Seven Doppler parameters, including the peak systolic velocity (PSV) in the renal, iliac and interlobar artery, Pre-PSV ratio (the ratio of the PSV in the renal artery to that in the iliac artery), Post-PSV ratio (the ratio of the PSV in the renal artery to that in the interlobar arteries, acceleration time and resistance index, were measured. In the patients with severe TRAS the measurements of these parameters were compared before and after successful intervention. RESULTS: In the 16 patients with a single transplanted kidney, arteriography demonstrated 14 main renal arteries with severe stenosis, and 3 renal arteries with moderate stenosis. When using the cutoff values of Post-PSV ratio >13, renal artery PSV >4 m/sec, acceleration time >0.06 second, and resistance index <0.5 for the detection of all 14 severe stenoses, the sensitivities were 100%, 71%, 93%, and 50%, respectively. For assessing all 14 severe stenoses and 12 severe stenoses of end-to-end anastomosis, the cutoff value of Pre-PSV ratio >5 had sensitivities of 86% and 100%, respectively. Pre-PSV ratios in severe stenoses of end-to-end anastomosis (range, 5.1-11.5) were significantly greater than those recorded in severe stenoses of end-to-side anastomosis (range, 2.8-3.1). Statistically significant differences before and after successful intervention were found for all 7 Doppler parameters in the 7 patients with severe stenosis. CONCLUSIONS: An 80%-99% diameter reduction of the renal artery can be diagnosed based on a Post-PSV ratio >13 for patients with either end-to-end or end-to-side anastomosis. A Pre-PSV ratio >5 for patients with end-to-end anastomosis and acceleration time >0.06 second are helpful in the diagnosis of severe TRAS.     

Duplex Doppler sonography of transplant renal artery stenosis

PURPOSE: The aim of this study was to evaluate the accuracy of duplex Doppler sonography in diagnosing transplant renal artery stenosis (TRAS) and to determine which parameter is the most reliable for making that diagnosis. METHODS: Over a 3-year period, we sonographically evaluated patients who were referred for investigation of possible TRAS. We investigated the following parameters: peak systolic velocity (PSV) in the external iliac and renal arteries, acceleration time and acceleration in the intrarenal arteries, acceleration time in the renal artery, resistance index, and the ratio of the PSVs in the renal and external iliac arteries. We also used MR angiography and digital subtraction arteriography to verify the degree of stenosis. After the evaluations, the patients were classified into 2 groups, 1 with and the other without significant stenosis (> 50% narrowing of the lumen) on digital subtraction arteriography. We also included a control group of patients who had undergone renal transplantation at least 6 months before, had had a good course after transplantation, had a diastolic blood pressure of 90 mm Hg or less, and were taking a maximum of 1 antihypertensive drug. RESULTS: Our study population consisted of 22 patients suspected to have TRAS (10 without and 12 with confirmed significant stenosis) and 19 control patients. We found statistically significant differences between the mean values of these 3 groups except for the PSV in the iliac artery and the resistance index in the intrarenal arteries. The most accurate parameters to use in diagnosing TRAS were an acceleration time of 0.1 second or higher in the renal and intrarenal arteries, a PSV of greater than 200 cm/second in the renal artery, and a ratio of PSVs in the renal and external iliac arteries of greater than 1.8. CONCLUSIONS: Duplex Doppler sonography is an excellent method for screening patients suspected to have TRAS and can help select which of those patients should undergo digital subtraction arteriography.     

Reliability of intrarenal Doppler sonographic parameters of renal artery stenosis

PURPOSE: The goal of this study was to retrospectively evaluate false-negative results of Doppler sonography in the diagnosis of renal artery stenosis (RAS) using intrarenal criteria. METHODS: We reviewed the clinical data and Doppler sonographic data for all patients in whom a diagnosis of RAS had been confirmed angiographically between November 1992 and January 2001. Mean intrarenal acceleration and acceleration time values-data obtained directly from color Doppler sonography-and findings of angiographic examination of the kidneys and stenotic renal arteries were evaluated. RESULTS: During the study period, 55 cases of RAS had been angiographically confirmed in 46 patients (25 male and 21 female; mean age, 50 +/- 19 years [+/- standard deviation]). Intrarenal arterial acceleration, acceleration time values, or both were abnormal in 42 kidneys (76%) (group A) and normal in 13 kidneys (24%) (group B). The mean age +/- standard deviation was significantly higher for patients in group B (60 +/- 12 years) than for those in group A (47 +/- 20 years) (p > 0.05). In group B, most of the stenotic lesions were atherosclerotic, and in all kidneys but 1, the lesions were located at the renal ostium or the proximal half of the artery. CONCLUSIONS: Isolated use of intrarenal Doppler sonographic criteria for RAS may lead to an unacceptably high incidence of false-negative results in the diagnosis of this condition, especially in elderly patients.     

Value of Doppler sonography for predicting clinical outcome after renal artery revascularization in atherosclerotic renal artery stenosis.

OBJECTIVE: The purpose of this study was to prospectively evaluate the usefulness of Doppler sonography for predicting blood pressure and renal function improvement after percutaneous renal angioplasty in patients with unilateral atherosclerotic renal artery stenosis. METHODS: Thirty-six patients with successfully revascularized unilateral atherosclerotic renal artery stenosis were included. Patients were evaluated by Doppler sonography before treatment, with the resistive index (RI) and acceleration being measured in both kidneys. Blood pressure, number of antihypertensive drugs, and serum creatinine concentration were assessed before treatment and thereafter during a 23 +/- 15-month (mean +/- SD) period. RESULTS: In 20 of the 36 patients (55%), the RI was less than 0.80 before revascularization. After treatment, blood pressure improved in 17 (85%) of those 20 patients and improved in 8 (50%) of 16 patients with an RI of greater than 0.80 (P < .05). Twenty-five patients had renal insufficiency pretreatment, and 11 (44%) had a baseline RI of less than 0.80. Improvement in renal function after angioplasty was shown in 5 (45%) of these 11 patients and in 4 (28.5%) of 14 in the group with high RI (P > .05, not significant). On analysis of acceleration, blood pressure improved in 9 (69%) of 13 patients with acceleration of greater than 3 m/s(2) and in 16 (69.5%) of 23 with acceleration of less than 3 m/s(2) (P > .05). In patients with renal insufficiency, 5 (50%) of 10 cases with normal baseline acceleration and 4 (27%) of 15 with low acceleration showed improvement in renal function (P > .05). CONCLUSIONS: An elevated RI should not exclude patients from a revascularization procedure because, although renal RI does correlate with blood pressure response to revascularization, it is not a useful parameter in predicting renal function outcome. Acceleration has no prognostic value.     

Evaluation of renal artery stenosis with velocity parameters of Doppler sonography.

OBJECTIVE: The purpose of this study was to evaluate the accuracy of velocity parameters for the diagnosis of renal artery stenosis (RAS) with color Doppler sonography and to determine the optimal threshold values for these parameters. METHODS: The study group was composed of 187 renal arteries, which were examined by color Doppler sonography and angiography. Four Doppler parameters, including the peak systolic velocities (PSVs) in the renal and interlobar arteries, the renal-aortic ratio, and the renal-interlobar ratio (RIR), were measured. Receiver operating characteristic curve analysis was performed to determine the optimal parameter. The sensitivity, specificity, and negative and positive predictive values at various threshold values were calculated. RESULTS: Doppler sonographic examination was technically successful in 96% of renal arteries (180/187). The RIR was determined to be the best parameter. With threshold values of RIR greater than 5, PSV greater than 150 cm/s in the renal artery, renal-aortic ratio greater than 2, and PSV less than 25 cm/s in the interlobar artery, the sensitivity values were 88%, 81%, 70%, and 74%, respectively. An RIR greater than 5 and PSV less than 15 cm/s in the interlobar artery provided the optimal combination of parameters, with sensitivity and specificity of 91% and 87%, respectively. CONCLUSIONS: The RIR is the best velocity parameter in the detection of RAS (> or =50%), and its best cutoff is 5. Valuing influencing factors of PSV in the renal artery will help reduce misdiagnosis. The combination of RIR greater than 5 and PSV less than 15 cm/s in the interlobar artery provides the best diagnostic efficiency of RAS.     

Doppler ultrasound and renal artery stenosis: An overview

Renovascular disease is a complex disorder, most commonly caused by fibromuscular dysplasia and atherosclerotic diseases. It can be found in one of three forms: asymptomatic renal artery stenosis (RAS), renovascular hypertension, and ischemic nephropathy. Particularly, the atherosclerotic form is a progressive disease that may lead to gradual and silent loss of renal function. Thus, early diagnosis of RAS is an important clinical objective since interventional therapy may improve or cure hypertension and preserve renal function. Screening for RAS is indicated in suspected renovascular hypertension or ischemic nephropathy, in order to identify patients in whom an endoluminal or surgical revascularization is advisable. Screening tests for RAS have improved considerably over the last decade. While captopril renography was widely used in the past, Doppler ultrasound (US) of the renal arteries (RAs), angio-CT, or magnetic resonance angiography (MRA) have replaced other modalities and they are now considered the screening tests of choice. An arteriogram is rarely needed for diagnostic purposes only. Color-Doppler US (CDUS) is a noninvasive, repeatable, relatively inexpensive diagnostic procedure which can accurately screen for renovascular diseases if performed by an expert. Moreover, the evaluation of the resistive index (RI) at Doppler US may be very useful in RAS affected patients for predicting the response to revascularization. However, when a discrepancy exists between clinical data and the results of Doppler US, additional tests are mandatory.     

多层螺旋CT扫描在移植肾动脉狭窄中的应用

目的探讨CT血管造影(MSCTA)在移植肾动脉狭窄(TRAS)中的监测评价作用。方法 15例TRAS实施了MSCTA,后处理方法为MPR、CPR、VR、MPVR、MIP及VP。对所有后处理方法进行分析,观察移植肾动脉的情况,比较各自优缺点。结果 TRAS的CT征象表现为狭窄局部血管明显变细,肾实质强化减低。CT后处理方法:①MPR仅有1例可以将移植肾的肾动脉显示于同一层面中;②CPR的13例可在冠、矢状面上显示移植肾动脉全程情况;③VR的15例均可通过旋转体位清晰观察迂曲的移植肾动脉走行状态和血管狭窄外观;④MPVR的15例可同时显示出移植肾动脉及TRAS情况;⑤MIP中9例可以同一平面上显示TRAS的部位;⑥VP的15例可以较好地显示移植肾动脉管腔内部情况,狭窄程度显示清晰。15例TRAS中吻合口狭窄者8例,吻合口远处狭窄者4例,吻合口和远处均有狭窄者2例,全程狭窄者1例。结论 MSCTA作为术后监测TRAS的影像学检查技术,能够直接清晰的显示移植肾动脉狭窄部位、形态,而且可以指导PTA及观测血管内支架植入疗效,将在临床上发挥越来越重要的应用价值。