Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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Renal Artery Stenosis (Left) Oblique color Doppler ultrasound shows a normal right renal artery, which consistently arises from the anterolateral aspect of the aorta and travels posterior to the IVC and left renal vein st. (Right) Oblique color Doppler ultrasound shows the origin of the left renal artery ſt, which varies from anterolateral to posterolateral, but always lies posterior to the left renal vein st. Diagnoses: Urinary Tract (Left) Spectral Doppler ultrasound of a downstream (arcuate) artery demonstrates a slow upstroke and RI < 0.5 in a transplant kidney with renal artery stenosis. (Right) Left common iliac artery injection shows a high-grade stenosis of the transplant renal artery , which arises from the external iliac. This was angioplastied, with some improvement in transplant function. (Left) Coronal MIP in a 30- year-old woman with fibromuscular dysplasia shows an irregular corrugated or beaded appearance of the mid right renal artery , with relative sparing of the ostium and proximal portion of artery . This patient's aneurysmal SMA is also seen in the image . (Right) In another patient with FMD, oblique DSA shows a series of ridges in the distal right renal artery . This is a middle-aged woman with poorly controlled hypertension. FMD is more common on the right, but is often bilateral. 515

Renal Vein Thrombosis Diagnoses: Urinary Tract TERMINOLOGY • Clot formation in renal vein IMAGING • Unilateral > bilateral • Kidney enlarged acutely in 75% cases • Renal vein dilated acutely • Possible inferior vena cava (IVC) thrombus extension • Altered renal artery spectral waveforms ○ ↑ systolic pulsatility (narrow, sharp systolic peaks) ○ Persistent retrograde diastolic flow • Do not mistake splenic vein for left renal vein ○ Splenic vein anterior to superior mesenteric artery ○ Left renal veinposterior to superior mesenteric artery PATHOLOGY • Nephrotic syndrome: Most common cause of renal vein thrombosis in adults KEY FACTS • Hypovolemia/renal hypoperfusion: Most common cause of renal vein thrombosis in children • Risk in neonates is associated with fetal distress, perinatal asphyxia, diabetic mothers, and volume contraction CLINICAL ISSUES • Outcome depends on cause, time to diagnosis, duration of occlusion, recanalization, collateralization • Prognosis overall good; frequent spontaneous recovery • Anticoagulation: Heparin then Coumadin or low molecular weight heparin for maintenance • Thrombolysis/surgical thrombectomy: Heroic measure for life-threatening situations • Suprarenal caval filter (IVC thrombus) DIAGNOSTIC CHECKLIST • Persistent diastolic flow reversal in renal artery suggests renal vein thrombosis (Left) Longitudinal ultrasound of the left kidney in a premature infant shows an edematous and nearly featureless kidney caused by acute renal vein thrombosis. (Right) Spectral Doppler at the renal hilum in the same patient shows absent end diastolic flow , which corresponds to an elevated resistive index of 1.0. In contrast, the contralateral kidney (not shown) had a spectral tracing with substantial diastolic flow above baseline with a normal resistive index (RI) of 0.65. (Left) Ten years later, longitudinal grayscale ultrasound in the same patient shows a mildly hypertrophied contralateral (right) kidney at 10.5 cm long (calipers). Note that in adults, this type of subsequent compensatory hypertrophy would not be expected. (Right) The left kidney (calipers) in the same patient who had venous thrombosis during the neonatal period has grown very little, now quite small in size for the patient's age, measuring 5.1 cm in length. 516

Renal Vein Thrombosis<br />

Diagnoses: Urinary Tract<br />

TERMINOLOGY<br />

• Clot formation in renal vein<br />

IMAGING<br />

• Unilateral > bilateral<br />

• Kidney enlarged acutely in 75% cases<br />

• Renal vein dilated acutely<br />

• Possible inferior vena cava (IVC) thrombus extension<br />

• Altered renal artery spectral waveforms<br />

○ ↑ systolic pulsatility (narrow, sharp systolic peaks)<br />

○ Persistent retrograde diastolic flow<br />

• Do not mistake splenic vein for left renal vein<br />

○ Splenic vein anterior to superior mesenteric artery<br />

○ Left renal veinposterior to superior mesenteric artery<br />

PATHOLOGY<br />

• Nephrotic syndrome: Most common cause of renal vein<br />

thrombosis in adults<br />

KEY FACTS<br />

• Hypovolemia/renal hypoperfusion: Most common cause of<br />

renal vein thrombosis in children<br />

• Risk in neonates is associated with fetal distress, perinatal<br />

asphyxia, diabetic mothers, <strong>and</strong> volume contraction<br />

CLINICAL ISSUES<br />

• Outcome depends on cause, time to diagnosis, duration of<br />

occlusion, recanalization, collateralization<br />

• Prognosis overall good; frequent spontaneous recovery<br />

• Anticoagulation: Heparin then Coumadin or low molecular<br />

weight heparin for maintenance<br />

• Thrombolysis/surgical thrombectomy: Heroic measure for<br />

life-threatening situations<br />

• Suprarenal caval filter (IVC thrombus)<br />

DIAGNOSTIC CHECKLIST<br />

• Persistent diastolic flow reversal in renal artery suggests<br />

renal vein thrombosis<br />

(Left) Longitudinal ultrasound<br />

of the left kidney in a<br />

premature infant shows an<br />

edematous <strong>and</strong> nearly<br />

featureless kidney caused by<br />

acute renal vein thrombosis.<br />

(Right) Spectral Doppler at the<br />

renal hilum in the same<br />

patient shows absent end<br />

diastolic flow , which<br />

corresponds to an elevated<br />

resistive index of 1.0. In<br />

contrast, the contralateral<br />

kidney (not shown) had a<br />

spectral tracing with<br />

substantial diastolic flow<br />

above baseline with a normal<br />

resistive index (RI) of 0.65.<br />

(Left) Ten years later,<br />

longitudinal grayscale<br />

ultrasound in the same patient<br />

shows a mildly hypertrophied<br />

contralateral (right) kidney at<br />

10.5 cm long (calipers). Note<br />

that in adults, this type of<br />

subsequent compensatory<br />

hypertrophy would not be<br />

expected. (Right) The left<br />

kidney (calipers) in the same<br />

patient who had venous<br />

thrombosis during the<br />

neonatal period has grown<br />

very little, now quite small in<br />

size for the patient's age,<br />

measuring 5.1 cm in length.<br />

516

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