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, Year n
ARAS > 30% (%)
ARAS > 50% (%)
Bilateral (%)
Vetrovec et al, 1989
116
29%
23%
Harding et al, 1992
1302
15%
28%
Jean et al, 1994
196
33%
18% -
Rihal et al, 2002
297
34%
19%
Weber-Mzell et al, 2002
177
25%
11%
26%
Routine screening for RAS during coronary angiography NOT indicated
White et al. Circulation.2006; 114:

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
Renal artery duplex
RAS +
RAS -
Angiography &
intervention
Technically
good study
Stop
Poor study
Angiography
MRA or CTA
RAS +
RAS -
Technically
good study
Stop
Poor study
Angiography
Angiography &
intervention
Captopril scintigraphy + -
Strong clinical
suspicion
Stop
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, CO2 angiography

7. upper poles oriented medially/posteriorly
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 10ο-20ο, LAO 10ο
Left: LAO 0ο-15ο
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: Scheinert et al. Catheter Cardiovasc Interv 2001; 54:

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

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 artery
Aberrant 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 <30y or severe hypertension at >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: