Eur. Radiol.

(2001) 11: 1902±1915

DOI 10.1007/s003300101012 U LT R A S O U N D *

Alexander V. Zubarev Ultrasound of renal vessels

Published online: 30 August 2001

 Springer-Verlag 2001
* Categorical Course ECR 2002
)
A. V. Zubarev ( )
Department of Radiology,
Postgraduate Education and Research
Center, Government Medical Center,
M. Timoshenko 21, 121359 Moscow,
Russia
Phone: +7-95-7 64 23 92
Fax: +7-95-1 49 58 27
Abstract Kidneys are known as
well-perfused organs and may un-
dergo a variety amount of vascular
pathological conditions such as re-
nal artery stenosis, renal vein
thrombosis, arteriovenous fistula,
and aneurysms. Sonography is usu-
ally the first imaging method for re-
nal vascular diseases. Modern US
machines are now able to outline
with great detail both main renal
vessels and intraparenchymal vas-
culature of the kidney using color
and power Doppler techniques.
Knowledge about the use of differ-
ent Doppler imaging modalities and
typical sonographic findings of the
most frequently conditions affecting
renal vessels are of great impor-
tance. This article reviews the clini-
cal applications of US and Doppler
US techniques including basics and
technological advances in the field
of renal vascular diseases.
Keywords Kidney ´ Renal vessels ´
Ultrasound ´ Doppler studies

techniques can be used to recognize shape of vessels

Introduction
Sonography of the kidneys is well known as an excellent
modality and initial procedure in the examination of
patients with renal pathology. Although able to provide
a vast array of information about the morphology of the
kidney and the renal sinus, conventional US is not gen-
erally helpful in providing evaluation of changes affect-
ing the renal vessels. Such information can be obtained
through Doppler techniques. Modern commercially
available machines are now able to outline with great
detail both main renal vessels and intraparenchymal
vasculature of the kidney using color and power Dop-
pler techniques. By means of spectral analysis, Doppler
US can provide evaluation of flow characteristics, such
as direction and velocity, and give an estimate of intra-
parenchymal flow resistances. Visualization of the renal
vessels can be dramatically improved by using contrast
enhancement. In clinical practice, the enhanced US sig-
nal provided by contrast agents can reduce the number
of technically nondiagnostic cases as well as the number
of false-negative results. Furthermore, new technologi-
cal advances can play an increasing role in renal vascu-
lar imaging US. Three-dimensional volume-rendering
with complex course and to analyze relationships among
the different structures of the kidney. They can provide
panoramic volumetric images of the large abdominal
vessels, further outlining the relationships of renal ves-
sels with the abdominal aorta. Blood flow morphology
maps can be also displayed within the background of the
B-mode data. Combination with contrast agents pro-
vides the potential to image the whole vascular renal
network and, through special measurement techniques,
to estimate vascular volume and transit time, parame-
ters which relate directly to tissue perfusion.
The purpose of this paper is to review the clinical
applications of US and Doppler US techniques in the
field of renal vascular diseases.
Examination technique and normal findings
Anatomy
The renal arteries (RA) originate from the lateral sides
of the aorta, typically at the level of the superior border
of the second lumbar vertebra, directed slightly anteri-
 1903

orly, approximately 1±1.5 cm below the superior mes-

enteric artery origin. The right RA branches from the
aorta, directs anteriorly for a few centimeters and then
descends obliquely, passing posteriorly to the inferior
vena cava, in a postero-lateral direction toward the kid-
ney. The left RA has a more horizontal and typically
shorter course. It runs from the aorta, posteriorly to the
left renal vein, into the renal hilum.
Approximately 30 % of patients with normally posi-
tioned kidney have multiple renal arteries, with one or
more accessory vessels [1, 2, 3]. Most of them arise close
to the main RA, although they can originate inferiorly,
some distance away, supplying a portion of the lower
pole. Because of this variation in anatomy, accessory
renal arteries are difficult to detect on Doppler studies,
and most are missed.
The main RA divides at the hilum, either within or
outside of the kidney, into anterior and posterior
branches that further divide into segmental and then
interlobar arteries. Renal arteries are terminal vessels
that do not communicate with each other. They are di- Fig. 1 Anatomy of the main renal vessels. 1 Transverse mid ab-
vided into four vascular regions: apical; anterior; poste- dominal section; 2 Oblique longitudinal approach; Ao aorta in a
rior; and inferior [4]. Each segmental branch supplies transverse section; IVC inferior vena cava in transverse section;
RRV right renal vein; RRA right renal artery; LRV left renal vein;
one of these regions. Approximately 90 % of the normal LRA left renal artery
renal blood flow goes to the cortex; only 10 % supplies
the medulla. The interlobar arteries further divide into a
network of arcuate arteries that run at the corticomed-
ullary junction and give off the cortical (interlobular)
branches, which run radially to the renal periphery, and
the medullary branches, which supply the renal pyra-
mids.
The renal veins approximately follow the arteries
and join at the hilum to form the main renal vein. In-
trarenal veins have collaterals, which unite with each
other. The right renal vein runs in a postero-anterior
direction, with a relatively short course to enter the vena
cava. The left vein is more horizontal and crosses ante-
riorly to the aorta and posteriorly to the superior mes-
enteric artery to enter the vena cava, at the level of the
first lumbar vertebra. It is worth remembering that the
left gonadal vein, adrenal vein, and the lumbar veins
usually enter the left renal vein.

Transducer position
Fig. 2 Power Doppler US image of the both normal renal arteries.
Main renal arteries Abdominal transverse section

The first requirement is to choose a good scan plane.

This is a key point. The main renal arteries can be im-
aged in an abdominal transverse section, by placing the
transducer in a midpoint between the xiphoid process
and the umbilicus (Fig. 1). By applying compression
with the transducer, the bowel loops can be displaced, to
see the aorta in a transverse section, together with the
origin of both renal arteries. With the axial approach,
the arteries often may be followed to the renal hilum,
especially on the right side where the liver can be used
as an acoustic window (Fig. 2). In patients with abun-
dant bowel gas obscuring visualization of the aorta, an-
gling the probe cranially or caudally can help to over-
come the problem and allow identification of the ves-
sels.
1904
a
b sels is then displayed in blue.
Fig. 3 a Color Doppler US image in oblique longitudinal section.
Hypoplasia of the right renal artery. b Same patient. Correlative
conventional angiography
An alternative method of imaging the origins of RA is
the use of an oblique longitudinal approach with the pa-
tient in a 45  right anterior oblique position (Fig. 1). The
transducer should be placed in the right subcostal posi-
tion to obtain longitudinal view of the right kidney. Then
the probe should be moved in a medial direction follow-
ing the course of the right renal vein from the hilum to the
inferior vena cava. The transducer is angled until the
aorta, together with the origins of both RA, appears. The
disadvantage of this approach is that only the origins of
the vessels are shown. Nevertheless, this projection is
best for determining whether accessory arteries, aplasia,
or hypoplasia (Fig. 3) of the renal arteries are present.
The left renal artery and vein also can be seen from
the left flank, using the kidney itself as an acoustic win-
Fig. 4 Color Doppler imaging of the left renal artery and vein from
the left flank using the kidney as an acoustic window
dow to obtain coronal scan planes of the renal hilum and
the aorta with the origins of the left renal vessels
(Fig. 4).
Normal findings
When the origins of renal arteries are imaged with color
Doppler in the transverse position, the first segment of
the right renal artery has flow directed toward the
transducer, then represented in red color. Color change
is detected shortly after the origin, where the direction
of flow goes posteriorly. Most of the course of the ves-
If the origins of renal arteries are imaged in the ob-
lique longitudinal section, right RA passes directly to-
ward the transducer from the aorta and is colored red,
whereas left RA courses away from the transducer and
is blue (Fig. 5).
On color Doppler examination, flow within the renal
vein is opposite in color to that within the renal artery.
Power Doppler can delineate a better image of the
proximal RA without the absence of flow in the arterial
segments that run horizontal to the US beam, but with
loss of directional and velocity information. Power
Doppler provides superb visualization of the entire re-
nal vascular tree from the main RA to the arcuate ar-
teries and beyond. The segmental renal branches lie
within the echogenic renal hilum. Interlobar arteries can
be visualized lateral to the renal pyramids, and the arc-
uate vessels run behind the renal pyramids parallel to
the renal cortex. With power Doppler several further
generations of vessels (the interlobular arteries) are
seen radiating to the renal capsule (Fig. 6).

Fig. 5 Color Doppler imaging of the both renal arteries and the
aorta. Longitudinal section. Right renal artery shown as red, left
renal artery shown as blue
Fig. 6 Power Doppler US image of the right kidney with renal
vessels. Good visualization of the entire renal vascular tree
Pulsed Doppler
The longitudinal position can be recommended for
measuring the Doppler spectrum of both renal arteries
due to optimal angle of both RA in this position. The
Doppler signal in the RA is a low-resistance signal,
similar to that found in all the parenchymal organs of
the body. The important features of this signal are the
rapid systolic rise and the continuous high-velocity flow
throughout diastole (Fig. 7). A small spike occurs at the
end of the systolic rise (the so-called early systolic
1905
Fig. 7 Spectral Doppler US image from the right renal artery in
normal subjects. Note small spike that occurs at the end of systolic
rise. This feature is seen only in the normal main renal artery
peak). It is an important feature to identify when mea-
suring the systolic acceleration. This feature is seen only
in the main renal artery and its major branches. The
peak systolic velocity (PSV) in the main renal artery and
its major branches should be less then 100 cm/s [5]. The
velocity slowly decreases in the intrarenal arteries as
they branch into the kidney. The diastolic velocity is a
little less than half of the systolic velocity. This value
normally is expressed as a ratio of end diastole to peak
systolic flow, the most commonly used ratio being the
resistance index or Pourcelot resistive index (RI), which
measures less then 0.7 in the normal kidney [5]. The re-
nal/aortic ratio is used to ªnormalizeº measurements of
the velocity within the renal artery. A summary of the
most common parameters used to evaluate the flow
patterns within the renal arteries is shown in Table 1.
The RI values, as measured in healthy subjects, show
a significant dependence on age and the area sampled.
The values in the main RA are higher in the hilar region
(0.65  0.17) than in the more distal small arteries, and
they are lowest in the interlobar arteries (0.54  0.20).
The RI values are higher in elderly patients. The age-
dependent RI values are shown in the Table 2.
In clinical practice the value of RI 0.7 is used to dis-
criminate between normal and pathologic resistances to
flow. Although it is nonspecific, an elevated RI of
greater than 0.7 suggests renal parenchymal disease
processes or postrenal obstruction [5].
The renal vein Doppler shift signal is continuous in
the smaller veins and with slightly phasic changes with
respiration in the main veins. The left renal vein shows
little or no phasic swing during the cardiac cycle,
whereas the right one shows a variable amount of pul-
1906

Table 1 Normal renal Doppler indices. S peak systolic velocity; D

end diastolic velocity. (From [6])
Index Formula Normal value
S: main renal artery 60±100 sm/s
(< 180 sm/s)
Resistance index S±D/S 0.56±0.7 (< 0.7)
Pulsatility index S±D/mean 0.7±0.14
Renal/aortic ratio Renal systolic velocity/ < 3.0
aortic systolic velocity
Systolic rise time Time to early systolic 0.11  0.06
peak
Systolic acceleration 11  8 m/s2

Table 2 Normal resistive index values in the interlobar arteries

according to patient age. (From [7])
Age (years) Mean Mean  2 SD
< 20 0.567 0.523±0.611 Fig. 8 Spectral Doppler US image of the left renal vein in normal
21±30 0.573 0.528±0.618 subjects. Spectral trace shows little swing within the cardiac cycle
31±40 0.588 0.546±0.630
41±50 0.618 0.561±0.675
51±60 0.688 0.603±0.733 riosclerosis, and less commonly fibromuscular dysplasia,
61±70 0.732 0.649±0.815 can lead to renovascular hypertension. Atheromatous
71±80 0.781 0.707±0.855
> 80 0.832 ± lesions involve the proximal renal artery, whereas fi-
bromuscular dysplasia involves the distal main renal ar-
tery and segmental renal arteries. Detection of RAS is
important since it is a potentially curable cause of hy-
satility, reflecting changes in right atrial pressure. This pertension, by the use of radiologic techniques or sur-
can be related to its shorter course, and to the common gery, and is a direct contraindication to the use of an-
absence of valvular structures within it (Fig. 8). giotensin converting enzyme inhibitors during medical
The rate of technically inadequate color Doppler US therapy of hypertension. Conventional angiography is
examinations of the main RA varies between 9 % [8] currently the gold standard in the detection of renal ar-
and 23.5 % [9]. Some optimistic reports, such as those tery stenosis. Unfortunately, it is an invasive test and is
from Robertson et al. [10], who carefully controlled the not suitable as a screening procedure. Magnetic reso-
duration of the examination limiting attempts to 20 min nance angiography is a very promising modality in this
(allowing a longer time was impractical in that clinical field and, albeit expensive, is non-invasive but cannot be
setting) found an identification rate of 95.5 % of right used as a screening, widely available test [13]. Contrast-
and 82 % of left renal arteries; however, others, such as enhanced helical CT is a promising test also, especially
Berland et al. [11], are less optimistic. From their study when multidetector equipment is used. The need of io-
with clinical comparisons with angiography, duplex dinated contrast medium, however, does not allow its
scanning showed unsatisfactory results: Only 58 % of widespread use as a screening test, given possible neph-
the main RA and no accessory RA were found [11]. In rotoxicity. Doppler US is a non-invasive, widespread
this way, contrast agents should have application in and relatively inexpensive diagnostic modality. It is not
cases where the Doppler signal is difficult to obtain, ei- surprising, therefore, that it has been extensively inves-
ther because of a weak signal or because of signal at- tigated as a screening test for renal artery stenosis
tenuation by overlying tissue [12]. The enhanced signal (Fig. 9) [14, 15].
provided by the contrast agent should reduce the num- Duplex US criteria of RAS can be divided into two
ber of technically nondiagnostic cases and the number groups based on direct findings obtained at the level of
of false-negative results. the stenosis (proximal criteria), or on flow changes ob-
served in the renal vasculature, distal to the site of
stenosis (distal criteria).
The proximal criteria are direct signs obtained at the
Renal artery stenosis
site of the stenosis. The first, most important sign is the
Renal artery stenosis (RAS) is a relatively rare but im- increase in peak systolic velocities (PSV). Velocities
portant cause of renovascular hypertension. Both arte- higher than 1.5 m/s are significant and should be used as

a
b
Fig. 9 a Power Doppler US image of the right renal artery with
echogenic plaque inside the vessel close to the origin. b Same pa-
tient. Correlative conventional angiography with the plaque in the
origin of the right RA
a criterion for RAS 50 %, and > 1.8 m/s for stenosis
60 % (Fig. 10). Comparison of the velocities in the aorta
with those in the renal arteries, the so-called renal/aortic
ratio (RAR), is also helpful. A PSV in the renal artery
three times higher than the aortic PSV indicates the
presence of RAS [16]. The use of the ratio (RAR) in-
stead of the absolute peak systolic value is preferable
since hypertension itself can cause an increase of peak
systolic flow velocities within all vessels of the hyper-
tensive patient. The second criterion is the presence of
poststenotic turbulences; these are seen as a widening of
the Doppler trace at spectral analysis of signals at the
stenosis and as a mosaic color pattern on the color
Doppler image (Fig. 11).
1907
Fig. 10 Spectral Doppler waveform from the stenotic area in the
right RA. Increased peak systolic velocities are seen
Fig. 11 Color Doppler imaging of the right RAS. Mosaic flow is
seen within the stenotic area
Distal criteria analyze the flow changes induced by
the stenosis at the level of intrarenal vessels. Patients
with severe renal artery stenosis commonly present with
pathologic intrarenal signals, the so-called tardus-par-
vus waveform, first described by Handa et al. [17]. Tar-
dus means slow and late and parvus means small and
little. Tardus refers to the fact that systolic acceleration
of the waveform is slowed, with consequent increase in
time to reach the systolic peak. Parvus refers to the fact
that the systolic peak is of low height, indicating slowed
velocity (Fig. 12). Poststenotic systolic peak are round-
ed with lengthened systolic rise time (or slow systolic
1908
a went Doppler scanning before and 1 h after administra-
b compliance. Such variables may explain why some au-
Fig. 12 a Normal renal artery waveform. The acceleration index
(AI) is the slope of the line (m/s2) connecting the two points rep-
resenting onset of systole and the early systolic peak complex. The
acceleration time (AT) is the time in seconds between those two
points. b A tardus-parvus renal artery waveform. Rounding and
flattening of the systolic peak and prolongation of the AT. The AI
is more horizontal
acceleration time ± the time in seconds from the onset of
the systole to peak systole), slower than 0.07 s. The ac-
celeration index (the slope of systolic upstroke) is de-
creased < 3m/s2 [18].
Although this phenomenon has been postulated to
be secondary to decreased perfusion pressure [19], the
explanation actually is more complicated, as systolic
acceleration also relates to peripheral resistance, vessel
compliance, and other variables, as well as to upstream
stenosis. For example, it has been shown that increasing
vessel compliance accentuates the decrease in systolic
acceleration independent of the transstenotic pressure
drop [20, 21].
Although generally confirming the efficiency of tar-
dus parvus, Stavros et al. pointed out that simple pattern
recognition of Doppler tracings from segmental renal
arteries was more valuable than calculating the acceler-
ation index and acceleration time, with loss of the nor-
mally seen early systolic peak indicating RAS [22]. Per-
sistence of the early systolic peak could be observed
only in patients with mild stenosis. In their study an ac-
celeration index less than 3.0 m/s2 had an accuracy of
85 %, a sensitivity of 89 %, and specificity of 83 % for
detecting RAS. An acceleration time of ³0.07 s was
89 % accurate, 78 % sensitive, and 94 % specific. The
tardus-parvus waveform was 96 % accurate, 95 % sensi-
tive, and 97 % specific for RAS [22].
Sensitivity of the technique may be improved by the
administration of Captopril. Rene et al. [23] studied 62
renal arteries in 31 hypertensive patients who under-
tion of Captopril prior to angiography. They concluded
that abnormalities of the tardus-parvus phenomenon of
RAS in distal vessels can be made more apparent after
administration of Captopril with an improvement of
sensitivity.
Many studies have shown that analysis of distal signs
observed at Doppler US can be a useful fist approach to
patients with suspected RAS [22, 24, 25]. Other reports
found recognition of tardus-parvus effect unsatisfactory
[26]. Many factors influence systolic acceleration and
may make the test non-specific. Extrarenal factors, such
as aortic/mitral valvular disease, left ventricular dys-
function, or even cardiovascular medications, might af-
fect systolic acceleration as well. Numerous factors,
such as age, hypertension, and diabetes, affect vessel
thors have not been able to reproduce these results [26].
Additional distal criteria have been developed: A
study by Schwerk et al. demonstrated that differences in
resistive index (RI) could help in diagnosing RAS [27].
Decreasing PSV in RAS results in lowering of resistive
index (RI) values. Right-to-left difference DRI between
kidneys greater than 0.05 had a sensitivity of 100 % for
RAS greater than 60 %. Halpern et al. suggested that
patients should be screened by distal measurements of
early systolic acceleration, because determining RAR
when segmental samplings are normal would be super-
fluous [28].
Using combined criteria (Table 3) pertaining to the
stenosis site and downstream patterns the sensitivity of
Doppler US varies from 64 to 89 %, and specificity from
82 to 99 % [9, 15, 25].
In renal transplants, which are easier to explore be-
cause of superficial location, as well as of knowledge of
the course of the renal artery from the surgical report,
the results were more convincing. Although Doppler
techniques are well suited as a screening test in trans-
planted kidneys, their use for suspected renal artery
stenosis in native kidneys has some problems. The main
problem is that it is difficult to visualize the whole of
both renal arteries in all patients [11]. Moreover, acces-

Table 3 Criteria for RAS. (From [29]). PSV peak systolic velocity;
RAR renal/aortic ratio; AT acceleration time; AI acceleration; RI
resistive index
Main RA
PSV in stenotic area > 1.8 m/s
RAR > 3.0
Intrarenal arteries
ESP Absent
AT > 0.07 s
AI < 3 m/s
RI > 0.8
DRI (left±right) > 5%
sory renal arteries are usually missed on Doppler stud-
ies, and stenosis of these may also cause hypertension.
Also, Doppler studies may be insensitive in patients
with mild stenosis; thus, the role of Doppler sonography
as a screening test in hypertensive patients remains
controversial. At present, its use cannot be separated
from a careful clinical evaluation of the patient popula-
tion. Given its technical difficulties, it has to be em-
ployed in patients well selected based on clinical criteria
of high probability of having RAS.
Ultrasound contrast agents have recently added new
possibilities to color and duplex Doppler in the detection
of RAS [30, 31]. They have been shown to increase the
percentage of diagnostic examinations in analyses of
main renal arteries [30]. With echo enhancers a renewal
of interest in Doppler studies of the main renal arteries is
occurring. Ultrasound contrast agents increase the in-
tensity of the Doppler signals, thus producing more rapid
and complete visualization of the intrarenal and extra-
renal arteries [29]. Contrast agents have application in
cases where the Doppler signal is difficult to obtain, ei-
ther because of signal attenuation by overlying tissue or
because of a weak signal [12]. Missouris et al. [32] suggest
that renal duplex scanning using contrast enhancement is
a promising new non-invasive technique in screening
patients with suspected RAS. Contrast enhancement
produces more reproducible spectral waveforms, im-
proves accuracy, and halves the examination time [32]. A
recent study by Claudon et al. [33] showed that the num-
ber of examinations with successful results increased
following enhanced Doppler US examination compared
with nonenhanced Doppler US, including patients with
obesity or renal dysfunction. Moreover, the agreement
between US data and angiography in RAS was higher
with enhanced Doppler US. They have shown that con-
trast media decrease examination time but do not cause
an increase in sensitivity [33].
Contrast media for US do not undergo renal filtra-
tion or tubular excretion and can be, on the whole, con-
sidered as purely vascular tracers. A new interesting
application of these agents in suspected RAS is quanti-
fication of the renal enhancement of color or power
1909
Doppler signals over time after intravenous injection of
a bolus of contrast medium. This technique produces
time±intensity curves, which, in renal artery stenosis,
have area under the curve larger than in normal kidneys
[34]. In severe stenosis, furthermore, there is also a de-
lay in the wash-in phase of the curve. At present, how-
ever, only preliminary results have been presented in
the literature, and further studies are needed before the
introduction of this technique in clinical practice.
Renal vein thrombosis
Renal vein thrombosis may occur in up to 40 % in dehy-
drated or septic infants [35]. In native kidneys, renal vein
thrombosis starts in small intrarenal veins in situations of
faulty coagulation mechanism and slowed flow [36]. The
post-glomerular circulation, because of slow flow, is par-
ticularly prone to thrombosis. In adults it most common-
ly appears in association with renal disease including
glomerulonephritis, systemic lupus erythematosus, di-
abetus mellitus, nephrotic syndrome, in severe hypo-
volemic shock, and following kidney transplantation.
The US features are non-specific, and only renal en-
largement, with decreased echogenicity in the early
stages followed by an increase in cortical reflectivity can
be detected [37]. Doppler US cannot accurately diagnose
thromboses of intraparenchymal veins. The presence of
venous Doppler signals within the kidney or renal vein,
in fact, does not exclude the diagnosis of a thrombosis
involving only one of the many intraparenchymal veins.
In fact, although in acute renal vein thrombosis, the
whole kidney is underperfused, and although only arte-
rial signals can be seen at the renal hilum, it must be re-
membered that venous collaterals develop rapidly, and
when this happens venous signals are re-established.
Then, the presence of parenchymal venous flow does not
exclude RVT, as collateral flow develops very quickly,
particularly in children (Fig. 13) [38]. Color Doppler can
be accurate for diagnosing chronic renal vein thrombosis
when the main renal vein can be directly visualized, and
flow signals cannot be detected in it [38].
Renal vein thrombosis can be caused also from tu-
mor involvement in patients with renal cell carcinoma
(RCC). Color Doppler sonography is accurate in dem-
onstrating tumor thrombus in the renal veins. The US
vascular features include distension of the renal vein,
full of echogenic material (Fig. 14). The presence of ar-
terial Doppler signals within the thrombus allows un-
equivocal demonstration of tumor involvement of the
vessel. In patients with renal transplant, with complete
thrombosis of the veins of the allograft, reduction of di-
astolic flow in RA and reversal of flow in diastole with
distended renal vein and absence of flow signals from
the renal vein have been reported as pathognomonic
signs of renal vein thrombosis [39].
1910
Fig. 13 Chronic thrombosis of the right renal vein. Absence of
flow in the main right renal vein. Collateral flow is clearly seen
Fig. 14 Power Doppler US image of the thrombosed right renal
vein
In very lean, but otherwise healthy subjects, the left
renal vein can become compressed between the aorta
and the superior mesenteric artery, resulting in the so-
called nutcracker syndrome (renal vein entrapment
syndrome) [40]. Kim et al. proposed that a cut-off value
of greater than 5.0 for the ratio of antero-posterior di-
ameter and the ratio of peak velocity (both the AP di-
ameter and PV being measured at hilar and aorto-mes-
enteric sites of the left renal vein) be used as a criterion
in diagnosing nutcracker syndrome [41].
Fig. 15 Color Doppler imaging of the abdominal infrarenal aneu-
rysm. Aneurysm arises below the origins of both renal arteries
Aneurysms
Aneurysms due to atherosclerosis usually occur in the
infrarenal aorta and common iliac arteries; however,
they are also found in the renal arteries. Most renal ar-
tery aneurysms have been found in persons 50±70 years
of age. Renal artery aneurysms can cause rupture,
thrombosis, embolization, and dissection [42]. Color
Doppler US provides an effective, non-invasive means
of diagnosing renal artery aneurysm. Aneurysms may
be identified along the course of the main renal artery as
an outpouching containing color flow. Slow velocities
and a whirling pattern of flow can usually be observed
on Doppler studies.
Color Doppler US can provide a quick, easy way in
demonstration of aneurysmal dilatations of the vascular
wall in the abdominal aorta. Most fusiform and saccular
aneurysms of the aorta arise below the level of renal ar-
teries, but it is nevertheless important to determine
whether the renal vessels are involved, since this alters
patient management. Aortic dissection may extend into
a renal artery, thus interrupting renal blood flow. Scan-
ning along the longitudinal approach is the best way to
demonstrate the relationships between the aneurysm
and RA (Fig. 15).
Arteriovenous fistulas
Both congenital and postbiopsy renal AV fistulae can be
diagnosed on color Doppler examination. The most fre-
quent cause of AV fistula in both the native and trans-
planted kidney is complication of percutaneous biopsy
[43]. Small fistulas are not visible by conventional US,
 1911

a
Fig. 16 Arteriovenous postbiopsy fistula of the kidney. Spectral
Doppler waveform shows low-resistance afferent artery spectrum.
(Courtesy of L. E. Derchi, Genova)

and can be detected by color Doppler only. The AV fis-

tula often appears on color Doppler US as a non-specific
mosaic pattern with color aliasing, reflecting rapid flow
rate and fine movements of tissues surrounding it [44].
Two adjacent vessels can be usually recognized in which
waveform analysis shows decreased RI and increased
peak flow velocities in the afferent artery, and pulsatile
flow pattern in the efferent vein (Fig. 16). Steal phe-
nomena can case hypoperfusion of renal tissues sur-
rounding the fistula [43]. Large AV fistulas are seen as
cystic or complex structures in which color Doppler
demonstrates vortices of high-velocity, low-impedance
flow. Although rare, AV fistulas are potentially lethal b
pathologic conditions. Failure to recognize properly an Fig. 17 a, b Patient 12 years after transplantation of the kidney.
AV fistula, in fact, puts the patient at high risk of hemor- Renal allograft dysfunction. Chronic rejection. a Power Doppler of
rhagic complications during a renal biopsy. the allograft. Marked decreasing of the cortical vascularity. b A 3D
Power Doppler angiography shows reduced density and tortuosity
of the interlobular vessels

Renal allografts
The examination technique for renal allografts is much
easier than that for native kidneys, due to the superficial
location of the transplanted organ. The examination of
the transplanted kidney should be performed using su-
perficial 7.5-MHz probes to study cortical perfusion and
abdominal convex 3.5-MHz probes for direct visualiza-
tion of the deeper structures such as transplanted artery
and vein.
The allograft vascular imaging protocol should in-
clude visualization of the anastomotic region to exclude
vascular stenosis, anastomotic aneurysms, or false an-
eurysms. Also accurate detection of the course and flow
in the transplanted artery and vein should be performed
due to possible stenosis and occlusions. Using superfi-
cial probes and Power Doppler mode, flow within the
cortical region of the whole kidney should be studied.
Intrarenal resistance indices (RI, PI) should be sampled.
Arteriovenous fistula and false aneurysms could be
found after biopsy in transplanted kidney
In normal transplants the values of RI is less than 0.71,
and shows a slight decrease toward the periphery. A re-
duced diastolic flow velocity associated with an increase
in intrarenal resistance index can be detected in acute
and chronic rejection reactions, urinary obstruction, ar-
teriosclerosis of the vasculature, and acute tubular ne-
crosis [45, 46, 47]. The significance of the changes in RI
1912

and the diagnostic predictive value of these indices in

assessing the etiology of the transplant-related compli-
cations remain controversial [48, 49]. Using superficial
probes a tiny blush through the whole cortical region up
to the capsule should be seen in a normally functioning
renal allograft [50]. According to Martinoli et al. [60],
loss of visualization of interlobular vessels at Power
Doppler US could be regarded as an additional hallmark
of renal transplant dysfunction. But abnormalities of the
interlobular vascular pattern in some patients with
chronic rejection are probably nonspecific in identifying
the nature of renal transplant dysfunction (Fig. 17).
An anastomotic stenosis could be assumed when the
registered maximum systolic velocities exceed
150±200 sm/s, shows a local increase of more than 50 %,
or if the velocity related to the iliac artery increases be-
yond a factor of 2.6±3.0 [51, 52, 53]. In a study of 109
transplanted kidneys, a peak systolic velocity ³2.5sm/s
in the transplanted renal artery had a sensitivity of Fig. 18 Ultrasound contrast study of renal perfusion. Flash Echo
100 % and specificity 95 % for the detection of RAS, imaging. (Provided by Toshiba Medical Systems Europe)
although the use of measurements of RI, acceleration
index, and time in intrarenal vessels were less useful as
discriminating diagnostic tests between normal and
stenosed group of patients with transplants [54].
Occlusions of the transplanted or segmental arteries
show complete or regionally limited flow in the intrare-
nal vasculature [45, 55]. Absence of flow with pulsed
and color Doppler is a valuable additional sign con-
firming the diagnosis [56].
Arteriovenous fistulas can develop after percutane-
ous biopsies of kidney transplants. They are recognized
by focal massively disturbed flow, with high intrarenal
flow velocities [43].
Renal venous thrombosis can be confirmed by ab-
sence of venous flow intrarenally and in the renal vein,
as well as on the basis of high-impedance arterial Dop-
pler signals, which present reversed flow during the di-
astole [57].

Fig. 19 Three-dimensional US angiography of the both renal ar-

Technical advances
Modern commercially available machines are now able
to outline with great detail the intraparenchymal vascu-
lature of the kidney. Studies of cortical perfusion are
possible using relatively high-frequency (at least 5 MHz)
high-resolution transducers and preferably using Power
Doppler. The use of Power Doppler with contrast agents
not only facilitates this study but enables perfusion stud-
ies ± similar to those created by isotope studies ± to be
performed [58]. Signals from interlobular vessels are
visible in the whole cortex, including the most peripheral
region close to the capsule. Harmonic imaging with con-
trast agent injections can be used to map regional differ-
ences in flow as well as quantitative measurements of a
contrast agent's transit time and has the potential to as-
teries and the entire aorta
sess kidney abnormalities associated with renal blood
flow [59]. Studies of cortical perfusion are new, and
therefore only preliminary experiences have been re-
ported in the literature [56, 60, 61]; however, the first re-
sults are very promising in establishing a patholog-
ic±sonographic correlation in acute renal parenchymal
inflammation [62] and in renal allograft evaluation [56,
60, 61]. It must be remembered that care should be taken
in diagnoses of perfusion defects, since absence of de-
tectable flow at the interlobular level does not always
correspond to cortical areas that lack perfusion on other,
more reliable techniques, such as MR [60].

a a
b
Fig. 20 a A 3D US angiography of the right kidney. Maximum in-
tensity projection image demonstrates accessory renal artery. b A
3D volume-rendering image of the left kidney. Accessory left renal
artery
In clinical practice, the enhanced US signal provided
by contrast agents can reduce the number of technically
nondiagnostic cases, as well as the number of false-neg-
ative results.
With additional use of contrast agents and phase in-
version harmonic imaging the whole course of the renal
arteries could be imaged without motion or aliasing ar-
tifacts. Harmonic ultrasound with contrast agents added
blood flow morphology maps within the background of
1913
b
Fig. 21 a A 3D US angiography of the right renal arteries and
aorta. Accessory renal artery is clearly seen. b Same patient: cor-
relative conventional angiography
the B-mode volumetric data. Combination with contrast
agents provides the potential to image the whole vascu-
lar renal network and, through special measurement
technique (Flash Echo), to estimate vascular volume
and transit time, parameters which relate directly to tis-
sue perfusion (Fig. 18).
One of the promising and rapidly developing tech-
niques is three-dimensional US angiography [63, 64, 65,
66, 67]. Three-dimensional US can overcome some
drawbacks of 2D US and can provide the angiogram-like
images of both, renal arteries and the entire aorta
(Fig. 19). Careful freehand scanning with a smooth, lin-
ear translation, or sector sweep, can acquire 3D data sets
in a single breath-hold. Different approaches can be used
to acquire 3D data sets of renal vessel: anterior or ante-
1914

rolateral, for evaluation of both RA and entire aorta; and
coronal for visualization of renal vasculature, main RA,
and entire aorta. After acquisition of 3D data, postpro-
cessing is performed using maximum and minimum in-
tensity projections (MIP or MinIP) to obtain angiogram-
like 3D images for further analysis (Fig. 20). We believe
that 3D US angiography has the potential to become ex-
cellent for screening in evaluation of accessory renal ar-
teries especially in children, young adults, patients with
renal failure, allergy to iodinated contrast agents, fear of
ionizing radiation, or arterial catheterization. Magnetic
resonance angiography, with its high cost and less avail-
ability, should be reserved for problem cases.
It is known that accessory renal arteries are found
frequently. Previous researchers have reported poor
ability of color Doppler US to depict accessory renal
arteries [15]. Contrast agents and harmonic imaging
may have a role to play in future and increase the sen-
sitivity and specificity of color Doppler US in detection
of accessory renal arteries [68]. Three-dimensional US
angiography can enhance the possibility of 2D US in
evaluation of accessory renal arteries. An angiogram-
like image of 3D US angiography is becoming an excel-
lent alternative to conventional angiography (Fig. 21).
This method is promising as the primary study for ac-
cessory RA and for determining the relationships of the
origins of the RA to abdominal aneurysms, and can be
the preferred technique for patients with a contraindi-
cation to conventional angiography.
Further developments of computing power, wide-
spread diffusion of state-of-the-art US machines, ma-
trix-array transducers, harmonic imaging techniques
and reconstruction algorithms for surface and volume
rendering will lead real-time 3D US scans to become
routine in clinical practice.
Acknowledgements I am grateful for all the help provided by L.
Derchi during preparation of this article.

References
1. Bakker J, Beek FJ, Beutler JJ et al.
(1998) Renal artery stenosis and acces-
sory renal arteries: accuracy of detec-
tion and visualization with gadolinium-
enhanced breath-hold MR angiogra-
phy. Radiology 207: 497±504
2. Korst MB, Joosten FB, Postma CT et al.
(2000) Accuracy of normal-dose Con-
trast-enhanced MR angiography in as-
sessing renal artery stenosis and acces-
sory renal artery stenosis and accessory
renal arteries. Am J Roentgenol 174:
629±634
3. Neri E, Caramella D, Bisogni C et al.
(1999) Detection of accessory renal ar-
teries with virtual vascular endoscopy
of the aorta. Cardiovasc Intervent Ra-
diol 22: 1±6
4. Beregi J-P, Elkohen M, Deklunder G
et al. (1996) Helical CT angiography
compared with arteriography in the de-
tection of renal artery stenosis. Am J
Roentgenol 167: 495±501
5. Platt JF, Rubin JM, Ellis JH (1989)
Distinction between obstructive and
nonobstructive pyelocaliectasis with
duplex Doppler sonography. Am J
Roentgenol 153: 997±1000
6. McGahan JP, Goldberg BB (1998) Di-
agnostic ultrasound. A logical ap-
proach. Lippincott Raven, Philadel-
phia, pp 1288: 793
7. Krumme B, Kirschner T, Gondolf D
et al. (1994) Altersabhanigkeit des in-
trarenalen Resistance Index (RI) bei
essentiellen Hypertonikern. Bildge-
bung Imaging (Suppl) 2: 55
8. Zoller WG, Hermans H, Bogner JR
et al. (1990) Duplex sonography in the
diagnosis of renovascular hypertension.
Klin Wochenschr 68: 830±834
9. Postma CT, van Aalen J, de Boo T et al.
(1992) Doppler US scanning in the de-
tection of renal artery stenosis in hy-
pertensive patients. Br J Radiol 65:
857±860
10. Robertson R, Murphy A, Dubbins PA
(1988) Renal artery stenosis: the use of
duplex ultrasound as a screening tech-
nique. Br J Radiol 61: 196±201
11. Berland LL, Koslin DB, Routh WD
et al. (1990) Renal artery stenosis: pro-
spective evaluation of diagnosis with
color duplex US compared with angi-
ography. Work in progress. Radiology
174: 421±424
12. Cosgrove D (1997) Why do we need
contrast agents for ultrasound? Clin
Radiol 51 (Suppl):1±4
13. Debatin JF, Spritzer CE, Grist TM et al
(1991) Imaging of the renal arteries:
value of MR angiography. Am J
Roentgenol 157: 981±990
14. Soulez G, Oliva V, Turpin S et al. (2000)
Imaging of renovascular hypertension:
respective values of renal scintigraphy,
renal Doppler US, and MR angiogra-
phy. Radiographics 20: 1355±1368
15. Cobelli F de, Venturini M, Vanzulli A
et al. (2000) Renal arterial stenosis:
prospective comparison of color Dop-
pler ultrasound and breath-hold, three-
dimensional, dynamic, gadolinium-en-
hanced MR angiography. Radiology
214: 373±380
16. House MK, Dowling RJ, King P et al.
(1999) Using Doppler sonography to
reveal renal artery stenosis: an evalua-
tion of the optimal imaging parameters.
Am J Roentgenol 173: 761±765
17. Handa N, Fukunaga R, Uehara A et al.
(1986) Echo-Doppler velocimeter in
the diagnosis of hypertensive patients:
the renal artery Doppler technique. Ul-
trasound Med Biol 12: 945±952
18. Patriquin HB, Lafortune M, Jequeier J
et al. (1992) Stenosis of the renal artery:
assessment with Doppler sonography.
Radiology 184: 479±485
19. Lafortune M, Patriquin H, Demeule E
et al. (1992) Renal arterial stenosis: slo-
wed systole in the downstream circula-
tion: experimental study in dogs. Radi-
ology 184: 475±478
20. Bude RO, Rubin JM, Platt JF et al.
(1990) Pulsus tardus: its cause and po-
tential limitations in detection of arte-
rial stenosis. Radiology 134: 779±784
21. Bude RO, Rubin JM (1995) Detection
of renal artery stenosis with Doppler
sonography: it is more complicated than
originally thought. Radiology 196:
612±613
22. Stavros AT, Parker SH, Yakes WF, et al.
(1992) Segmental stenosis of the renal
artery: pattern recognition of tardus
and parvus abnormalities with duplex
sonography. Radiology 184: 487±492
23. Rene PC, Oliva VL, Bui BT et al.
(1995) Renal artery stenosis: evaluation
of Doppler US after inhibition of an-
giotensin-converting enzyme with Cap-
topril. Radiology 196: 675±679

24. Kaplan-Pavlovic S, Nadja C (1998)
Captopril renography and duplex Dop-
pler sonography in the diagnosis of ren-
ovascular hypertension. Nephrol Dial
Transplant 13: 313±317
25. Krumme B, Blum U, Schwertferger E
et al. (1996) Diagnosis of renovascular
disease by intra- and extrarenal Dop-
pler scanning. Kidney Int 50: 1288±1296
26. Kliewer MA, Tupler RH, Carroll BA
et al. (1993) Renal artery stenosis:
analysis of Doppler waveform parame-
ters and tardus-parvus pattern. Radiol-
ogy 189: 779±787
27. Schwerk WB, Restrepo IK, Stellwaag
M et al. (1994) Renal artery stenosis
grading with image-directed Doppler
US evaluation of renal resistive index.
Radiology 190: 785±790
28. Halpern EJ, Deane CR, Needleman L
et al. (1995) Normal renal artery spec-
tral Doppler waveform: a closer look.
Radiology 196: 667±673
29. Lavopierre AM, Dowling RJ, Little AF
et al. (2000) Ultrasound of the renal
vasculature. Ultrasound Quarterly 16:
123±132
30. Melany ML, Grant EG (1997) Clinical
experience with sonographic contrast
agents. Semin Ultrasound CT MR 18:
3±12
31. Dowling RJ, House MK, King PM et al.
(1999) Contrast-enhanced Doppler ul-
trasound for renal artery stenosis. Aus-
tralas Radiol 43: 206±209
32. Missouris CG, Allen MC, Balen FG
et al. (1996) Non-invasive screening for
renal artery stenosis with ultrasound
contrast enhancement. J Hypertens 14:
519±524
33. Claudon M, Plouin PF, Baxter GM
et al. (2000) Renal arteries in patients at
risk of renal arterial stenosis: multicen-
ter evaluation of the echo-enhancer SH
U 508A at Color an spectral Doppler
US. Radiology 214: 739±746
34. Lencioni RA, Pinto S, Napoli V et al.
(1999) Detection of renal artery stenos-
is by time±intensity analysis of renal
enhancement curve at harmonic power
Doppler imaging: a pilot clinical study.
Radiology 213: 363±364
35. Clark RA, Colley DP (1980) Radiolog-
ical evaluation of renal vein thrombosis.
CRC Crit Rev Diagn Imaging 13:
337±344
36. Gonzales R, Schwarts S, Sheldon C
et al. (1982) Bilateral renal vein throm-
bosis in infancy and childhood. Urol
Clin Am 9: 279±283
37. Scoutt LM, Brown JM, Hammers LW
(1997) Color Doppler evaluation of the
native kidney. Appl Radiol:9±23
38. Rosenfeld AT, Zeeman RK, Kronen JJ
et al. (1980) Ultrasound in experimen-
tal and clinical renal vein thrombosis.
Radiology 137: 735
39. Baxter GM, Morley P, Dall B (1991)
Acute renal vein thrombosis in renal
allografts: new Doppler ultrasonic find-
ings. Clin Radiol 43: 125
40. Wendel RG, Crawford ED, Hehman
KN et al. (1980) The nutcracker phe-
nomenon: an unusual cause for renal
bleeding of unknown origin. J Urol 123:
761±763
41. Kim SH, Cho SW, Kim HD et al. (1996)
Nutcracker syndrome: diagnosis with
Doppler US. Radiology 198: 93±97
42. Dong Q, Schoenberg SO, Carlos RC
et al. (1999) Diagnosis of renal vascular
disease with MR Angiography. Radio-
graphics 129: 1535±1554
43. Middleton WD, Kellman GM, Melson
GL et al. (1989) Postbiopsy renal trans-
plant arteriovenous fistulas: color Dop-
pler US characteristics. Radiology 171:
253±257
44. Takebayashi S, Aida N, Matsui K
(1991) Arteriovenous malformations of
the kidneys: diagnosis and follow-up
with color Doppler sonography in 6 pa-
tients. Am J Roentgenol 157: 991±995
45. Taylor KJW, Morse SS, Rigsby CM
(1987) Vascular complications in renal
allografts. Detection with Dupplex
Doppler US. Radiology 162: 31±38
46. Harris DC, Antico V, Allen S et al.
(1989) Doppler assessment in renal
transplantation. Transplant Proc 21:
1895±1896
47. Fluckiger F, Steiner S, Horn M et al.
(1990) Farbkodierte Dupplexsonogra-
phie und Widerstandsindex bei Nieren-
transplantation mit Dysfunktion. Fort-
schr Rontgenstr 153: 692±697
48. Mallek R, Mostbeck G, Kain R et al.
(1990) Vaskulare Nierentransplantat-
abstossung ± Ist eine duplexsonogra-
phische Diagnose moglich? Fortschr
Rontgenstr 152: 283±286
49. Meyer M, Paushter D, Steinmuller D
(1990) The use of duplex Doppler ul-
trasonography to evaluate renal al-
lograft dysfunction. Transplantation 50:
974±978
50. Claudon M, Blum AG, Martin Bertaux
A et al. (1995) Kidney transplantation
follow-up: value of power Doppler
sonography. Radiology 197: 496
51. Leichtman A, Sorrell K, Wombolt D
et al. (1989) Duplex imaging of the re-
nal transplant. Transplant Proc 21:
3607±3610
52. Deane C, Cairns H, Walters H et al.
(1990) Diagnosis of renal transplant ar-
tery stenosis by color Doppler ultra-
sonography. Transplant Proc 22: 1395
53. Alvarez G, Gonzalez-Molina M, Ca-
bello M et al. (1991) Pulsed and contin-
uous Doppler evaluation of renal dys-
function after kidney transplantation.
Eur J Radiol 12: 108±112
1915
54. Baxter GM, Ireland H, Moss J et al.
(1995) Color Doppler US in renal
transplant artery stenosis: which Dop-
pler index? Clin Radiol 50: 618±622
55. Grenier N, Douws C, Morel D et al.
(1991) Detection of vascular complica-
tions in renal allografts with color Dop-
pler flow imaging. Radiology 178:
217±223
56. Trillaud H, Merville P, Linh PTL et al.
(1998) Color Doppler sonography in
early renal transplantation follow-up:
resistive index measurements versus
power Doppler sonography. Am J
Roentgenol 171: 1611±1615
57. Krumme B (1994) Farbkodierte Du-
plexsonographie in der Diagnostic von
Nierenarterienstenosen nach allogener
Nierentransplantation. In: Keller E,
Krumme B (eds) Farbkodierte Duplex-
sonographie in der Nephrologie.
Springer, Berlin Heidelberg New York
58. Huber S, Steinbach R, Sommer O et al.
(2000) Contrast-enhanced power Dop-
pler harmonic imaging: influence on vi-
sualization of renal vasculature. Ultra-
sound Med Biol 26: 1109±1115
59. Sehgal CM, Arger PH, Pugh CR et al.
(1998) Comparison of power Doppler
and B-scan sonography for renal imag-
ing using a sonographic contrast agent.
J Ultrasound Med 17: 751±756
60. Martinoli C, Crespi G, Bertolotto M
et al. (1996) Interlobular vasculature in
renal transplants: a Power Doppler US
study with MR correlation. Radiology
200: 111±117
61. Claudon M, Grenier N (1997) Technol-
ogy advances in renal sonography. Di-
agn Imaging Europe:31±37
62. Clautice-Engle T, Jeffrey R (1997) Re-
nal hypoperfusion: value of power
Doppler imaging. Am J Roentgenol
168: 1227±1231
63. Keberle M, Jenett M, Beissert M et al.
(2000) Three-dimensional power Dop-
pler sonography in screening for carotid
artery disease. J Clin Ultrasound 28:
441±451
64. Lees W (1999) Three- and 4-dimen-
sional ultrasound imaging. Med Mundi
l43: 23±30
65. Merz E (1997) Current technical possi-
bilities of 3D ultrasound in gynaecology
and obstetrics. Ultraschall Med 18:
190±195
66. Shields LE, Lowery C, Deforge C et al.
(1998) 3-Scape real time 3D imaging for
ultrasound. Electromedica 66: 84±88
67. Weismann N Ä (2000) 3D expands hori-
zons in daily clinical practice. Diagn
Imaging (Suppl):12±15
68. Sandrick K (2000) 3D ultrasound: more
than just a pretty picture. Diagn Imag-
ing (Suppl):2±8