AIUM Practice Parameter for the Performance of Native ... · Native Renal Artery Duplex Sonography ... See the AIUM Practice Parameter for the Performance of an Ultrasound Examination

AIUM Practice Parameter for the Performance of

Native Renal ArteryDuplex Sonography

© 2013 by the American Institute of Ultrasound in Medicine

Parameter developed in conjunction with the American College of Radiology (ACR),

the Society for Pediatric Radiology (SPR), and the Society of Radiologists in

Ultrasound (SRU).

renalArtery.qxp_1115 12/1/15 3:33 PM Page 1

The American Institute of Ultrasound in Medicine (AIUM) is a multi-

disciplinary association dedicated to advancing the safe and effective

use of ultrasound in medicine through professional and public

education, research, development of parameters, and accreditation.

To promote this mission, the AIUM is pleased to publish, in conjunc-

tion with the American College of Radiology (ACR), the Society for

Pediatric Radiology (SPR), and the Society of Radiologists in

Ultrasound (SRU), this AIUM Practice Parameter for the Performance of

Native Renal Artery Duplex Sonography. We are indebted to the many

volunteers who contributed their time, knowledge, and energy to

bringing this document to completion.

The AIUM represents the entire range of clinical and basic science

interests in medical diagnostic ultrasound, and, with hundreds of

volunteers, the AIUM has promoted the safe and effective use of

ultrasound in clinical medicine for more than 50 years. This document

and others like it will continue to advance this mission.

Practice parameters of the AIUM are intended to provide the medical

ultrasound community with parameters for the performance and

recording of high-quality ultrasound examinations. The parameters

reflect what the AIUM considers the minimum criteria for a complete

examination in each area but are not intended to establish a legal stan-

dard of care. AIUM-accredited practices are expected to generally fol-

low the parameters with recognition that deviations from these param-

eters will be needed in some cases, depending on patient needs and

available equipment. Practices are encouraged to go beyond the

parameters to provide additional service and information as needed.

14750 Sweitzer Ln, Suite 100

Laurel, MD 20707-5906 USA

800-638-5352 • 301-498-4100

www.aium.org

©2013 American Institute of Ultrasound in Medicine


I. Introduction

The clinical aspects contained in specific sections of this parameter (Introduction, Indications,Specifications of the Examination, and Equipment Specifications) were revised collaborativelyby the American Institute of Ultrasound in Medicine (AIUM), the American College ofRadiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologistsin Ultrasound (SRU). Recommendations for personnel requirements, written request for theexamination, procedure documentation, and quality control vary among the organizations andare addressed by each separately.

Sonography using grayscale imaging, Doppler spectral analysis, and color Doppler imaging is aproven and useful procedure for evaluating the renovascular system. Occasionally, an additionaland/or specialized examination may be necessary. While it is not possible to detect everyabnormality, adherence to the following parameters will maximize the probability of detectingmost renovascular abnormalities.

II. Indications/Contraindications

Indications for renal artery duplex sonography include but are not limited to:

1. Evaluation of patients with hypertension, particularly when there is a moderate to highsuspicion of renovascular hypertension (eg, uncontrolled hypertension despite optimaltherapy, hypertension with a progressive decline in renal function, a progressive declinein renal function associated with angiotensin-converting enzyme inhibition therapy, andabrupt onset of hypertension)1,2;

2. Follow-up of patients with known renovascular disease who have undergone renal arterystent placement or other renal artery interventions or have known unilateral stenosis withconcern for stenosis in the contralateral kidney;

3. Evaluation of an abdominal or flank bruit;

4. Evaluation of a suspected vascular abnormality such as an aneurysm, pseudoaneurysm,arteriovenous malformation, or arteriovenous fistula;

5. Evaluation of renal insufficiency in a patient at risk for renovascular disease;

6. Evaluation of renal artery blood flow in patients with known aortic dissection, trauma, orother abnormalities that may compromise blood flow to the kidneys;

7. Evaluation of discrepant renal size; and

8. Concern for an aortic or renal artery orifice thrombus in infants who have or have had anaortic catheter, such as an umbilical artery catheter.

There are no absolute contraindications to performing this examination.

2013—AIUM PRACTICE PARAMETER—Native Renal Artery Duplex Sonography

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III. Qualifications and Responsibilities of Personnel

See www.aium.org for AIUM Official Statements including Standards and Guidelines for theAccreditation of Ultrasound Practices and relevant Physician Training Guidelines.

IV. Written Request for the Examination

The written or electronic request for an ultrasound examination should provide sufficientinformation to allow for the appropriate performance and interpretation of the examination.

The request for the examination must be originated by a physician or other appropriatelylicensed health care provider or under the provider’s direction. The accompanying clinicalinformation should be provided by a physician or other appropriate health care provider famil-iar with the patient’s clinical situation and should be consistent with relevant legal and localhealth care facility requirements.

V. Specifications of the Examination

The study is generally performed for both kidneys. If not, the report should state the reason fora unilateral study (eg, evaluation of a renal stent or known solitary kidney).

The study consists of grayscale imaging of the kidneys with spectral and color Doppler imagingof the extrarenal and intrarenal vessels.

A. Grayscale Imaging

The longest renal length should be measured and reported. In patients who have not hadrecent cross-sectional imaging of the kidneys, a complete renal ultrasound examinationmay be considered. See the AIUM Practice Parameter for the Performance of an UltrasoundExamination of the Abdomen and/or Retroperitoneum.

B. Spectral and Color Doppler Evaluation

Analysis of main renal artery and intrarenal arterial waveforms should be used to evaluatefor renal artery stenosis.

Careful attention to technique is important to ensure accurate examination results, includ-ing selecting a transducer that is appropriate for the patient’s body habitus, optimizingcolor Doppler parameters, using an appropriate sample volume, optimizing the velocityscale for the size of the waveform to avoid aliasing (this may require adjusting the scale,baseline, or frequency or selecting a lower-frequency transducer), and using the lowestfeasible angle of insonation. Angle correction is essential for determining blood flow veloc-ity. The angle between the direction of flowing blood and the applied Doppler ultrasoundsignal should not exceed 60°.


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1. Main Renal Artery EvaluationThe entire main renal artery should be scanned along its long axis using optimizedcolor Doppler guidelines. Occasionally, power Doppler or grayscale imaging may benecessary to localize a portion of the artery. Inability to visualize the entire or part(especially the origin) of the main renal artery should be reported.Spectral Doppler imaging should be performed along the vessel’s length from the originto the hilum at the lowest feasible angle of insonation.The greatest peak systolic velocities should be recorded at the origin/proximal portion,at the mid aspect, and near the hilum.3–18 A peak systolic velocity should also be record-ed at any site of color aliasing or suspected stenosis. If there is significant stenosis, aDoppler waveform should be recorded within the stenosis and distal to the stenosis.An effort should also be made to search for accessory renal arteries.19 When visualized,peak systolic velocities should be recorded as described above.An appropriate angle-corrected spectral waveform from the abdominal aorta at thelevel of the renal arteries should be recorded. The aortic peak systolic velocity is usedto calculate the ratio of the peak systolic velocity in the renal artery to the aorta.Renal artery stent evaluation should include recording a peak systolic velocity in theproximal renal artery (if possible), within the stent, and distal to the stent (if possible).20

In infants who have developed an aortic thrombus after catheterization, the relation-ship of the clot to the renal arterial orifices and the flow around the thrombus shouldbe documented. If the thrombus is located near a renal artery orifice, renal arterial andintraparenchymal waveforms should be obtained to assess renal perfusion.

2. Intrarenal EvaluationSpectral waveforms should be recorded from segmental arteries in the upper andlower poles and the interpolar region (midportion) of each kidney. It is important touse a fast sweep speed and optimize the velocity scale to ensure accurate results. If acceleration index measurements are used in the assessment, angle correction isneeded; the angle of insonation should be as low as possible, usually 20° or less.Intrarenal analysis consists of quantitative and/or qualitative evaluation of the Dopplerwaveforms. Quantitative evaluation may include acceleration times, accelerationindices,21,22 or resistive indices.23–25 For qualitative analysis, the morphology of the wave-form should be assessed for a normal systolic upstroke or tardus parvus changes.21,22


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VI. Documentation

Adequate documentation is essential for high-quality patient care. There should be a perma-nent record of the ultrasound examination and its interpretation. Images of all appropriateareas, both normal and abnormal, should be recorded. Variations from normal size should beaccompanied by measurements. Images should be labeled with the patient identification, facil-ity identification, examination date, and side (right or left) of the anatomic site imaged. An offi-cial interpretation (final report) of the ultrasound findings should be included in the patient’smedical record. Retention of the ultrasound examination should be consistent both with clin-ical needs and with relevant legal and local health care facility requirements.

Reporting should be in accordance with the AIUM Practice Parameter for Documentation of anUltrasound Examination.

VII. Equipment Specifications

Duplex and color Doppler sonography of the renal arteries should be performed in real timeusing transducer frequencies based on body habitus. For adults, mean frequencies between 2and 5 MHz are most commonly used. In neonates, frequencies of 7 to 15 MHz are typicallyused.

VIII. Quality Control and Improvement, Safety, Infection Control, and Patient Education

Policies and procedures related to quality control, patient education, infection control, andsafety should be developed and implemented in accordance with the AIUM Standards andGuidelines for the Accreditation of Ultrasound Practices.

Equipment performance monitoring should be in accordance with the AIUM Standards andGuidelines for the Accreditation of Ultrasound Practices.

IX. ALARA Principle

The potential benefits and risks of each examination should be considered. The ALARA (as low as reasonably achievable) principle should be observed when adjusting controls thataffect the acoustic output and by considering transducer dwell times. Further details onALARA may be found in the AIUM publication Medical Ultrasound Safety, Third Edition.


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Acknowledgments

This parameter was revised by the AIUM in collaboration with the American College ofRadiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologistsin Ultrasound (SRU) according to the process described in the AIUM Clinical StandardsCommittee Manual.

Collaborative CommitteesMembers represent their societies in the initial and final revision of this parameter.

ACRSharlene A. Teefey, MD, ChairBrian D. Coley, MDKristin Crisci, MDMaryellen R. M. Sun, MDJason M. Wagner, MD

AIUMEdward Bluth, MD Laurence Needleman, MDJohn S. Pellerito, MD

SPRLynn A. Fordham, MDMartha M. Munden, MDCicero T. Silva, MD

SRUMark E. Lockhart, MD, MPHMichelle L. Robbin, MDDeborah J. Rubens, MD


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AIUM Clinical Standards CommitteeLeslie Scoutt, MD, ChairJoseph Wax, MD, Vice ChairBryann Bromley, MDLin Diacon, MD, RDMS, RPVIJ. Christian Fox, MD, RDMSPat Fulgham, MDCharlotte Henningsen, MS, RT, RDMS, RVTAdam Hiett, MD, RDMSLars Jensen, MDAlexander Levitov, MDVicki Noble, MD, RDMSAnthony Odibo, MD, MSCEDeborah Rubens, MDKhaled Sakhel, MDShia Salem, MDJay Smith, MDLami Yeo, MD

Original copyright 2008; revised 2013Renamed 2015


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Documents

AIUM Practice Parameter for the Performance of Native ... · Native Renal Artery Duplex Sonography ... See the AIUM Practice Parameter for the Performance of an Ultrasound Examination