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Ultraschalldiagnostik von Nierenarterienstenosen

Stenosekriterien, CEUS, In-Stent-Rezidivstenose

Ultrasound diagnostics of renal artery stenosis

Stenosis criteria, CEUS and recurrent in-stent stenosis

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Zusammenfassung

Hintergrund und Fragestellung

Als nicht invasive, nebenwirkungsfreie und kostengünstige Methode ist die Sonographie für die Diagnostik der Nierenarterienstenose die Methode der Wahl. Insgesamt vier verschiedene Methoden, zwei direkte (peak systolic velocity = PSV, renal aortic ratio = RAR) und zwei indirekte Kriterien (resistance index = RI, Akzelerationszeit) zur Messung relevanter Nierenarterienstenosen werden beschrieben, jeweils mit sehr unterschiedlichen Treffsicherheiten in verschiedenen Studien. Weiterhin wird kontrovers diskutiert, ab welchem Grad die Stenose therapierelevant ist und welche sonographische Grenzgeschwindigkeit (PSV) in der Graduierung diagnostisch relevant ist.

Methode

Kritisches Review basierend auf einer selektiven Literaturrecherche zu Messmethodik und Validität der Sonographie bei Nierenarterienstenose. Kritische Methodenevaluation und Darstellung von Messprinzipien zur möglichst exakten Messung verglichen mit dem Goldstandard Angiographie sowie Bewertung des Stellenwerts von CT-Angiographie und MR-Angiograpie.

Ergebnisse und Schlussfolgerungen

Die PSV bietet als direkte Messmethode in der Stenosedetektion und Graduierung die höchste Sensitivität und Spezifität. Die meisten Studien ermitteln in ROC-Kurven bei einer PSV > 180–200 cm/s Sensitivitäten und Spezifitäten von 85–90 % für > 50 %igen Stenosen. Andere Methoden wie der Quotient aus PSV in Aorta und Nierenarterie (RAR) oder indirekte Kriterien wie der Widerstandsindex im Seitenvergleich (dRI) oder die Akzelerationszeit können ergänzend zu Verbesserung der Treffsicherheit herangezogen werden. Die Kontrastmittelsonographie (CEUS) verbessert durch die Echokontrastverstärkung die Treffsicherheit.

Früher wurden erst höhergradige Stenosen als therapierelevant angesehen, andererseits wird inzwischen schon der Druckabfall von > 20 mmHg bei > 50 %igen Stenosen (PSV 180 cm/s) als relevant für einen Reninanstieg bewertet. Stenosen bei fibromuskulären Dysplasien können sonographisch nach dem Kontinuitätsgesetz zuverlässig graduiert werden. Die Studienlage in der Graduierung von In-Stent-Rezidivstenosen ist kontrovers, tendenziell höhere Cut-off-Werte für PSV und RAR sind jedoch anzunehmen. MRA und CTA zeigen zwar Treffsicherheiten von > 90 %, jedoch mit möglichen Nebenwirkungen für Patienten, insbesondere bei vorbestehendem Nierenparenchymschaden.

Abstract

Background and objectives

Sonography is a non-invasive and economic method with no side effects and is the method of choice for the diagnostics of renal artery stenosis. A total of four different methods, including two direct criteria, i.e. peak systolic velocity (PSV) and renal aortic ratio (RAR) and two indirect criteria, i.e. resistance index (RI) and acceleration time for measurement of relevant renal artery stenoses are described, each with very different accuracies in various studies. Furthermore, it is controversially discussed what grade of stenosis is therapy relevant and which sonographic PSV is diagnostically relevant in grading.

Methods

This article presents a critical review based on a selective literature search of measurement methods and validity of sonography for renal artery stenosis. A critical evaluation of the methods and presentation of the measurement principles for an exact as possible measurement compared to the gold standard of angiography is followed by an assessment of the importance of computed tomography angiography (CTA) and magnetic resonance angiography (MRA).

Results and conclusion

As a direct measurement method PSV provides the highest sensitivity and specificity in the detection and grading of stenoses. Most studies reported a sensitivity and specificity of 85–90 % for > 50 % stenoses in receiver operating characteristic (ROC) curves with a PSV > 180–200 cm/s. Other methods, such as the ratio of PSV in RAR or indirect criteria, such as RI in a side to side comparison (dRI) and acceleration time can be used as additional methods to improve the accuracy. Contrast-enhanced ultrasound (CEUS) improves the accuracy due to echo contrast enhancement. Previously, only higher grade stenoses were considered to be therapy relevant but now even a drop in pressure of > 20 mmHg for > 50 % stenoses (PSV 180 cm/s) is considered to be relevant for an increase in renin. Stenoses in fibromuscular dysplasia can be reliably graded sonographically according to the law of continuity. The study situation in grading of recurrent in-stent stenoses is controversial; however, tendentially higher cut-off values for PSV and RAR are assumed. Both MRA and CTA have an accuracy > 90 % but with possible side effects for patients especially with pre-existing renal parenchymal damage.

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Correspondence to Dr. W. Schäberle.

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W. Schäberle, L. Leyerer, W. Schierling und K. Pfister geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Appendices

Detaillierte Beschreibung der Videos

Videoclip 1

Stenose von 50–60 % im mittleren Drittel der linken Nierenarterie durch eine fibromuskuläre Dysplasie. Stenosegraduierung nach dem Kontinuitätsgesetz: PSV-Ratio mit PSV intrastenotisch/PSV prästenotisch (Nierenarterie am Abgang) = 220 cm/s/80 cm/s = 2,7.

Der Videoclip zeigt die Ableitung der intrastenotischen PSV (im mittleren Drittel der Nierenarterie) und der prästenotischen PSV (proximales Drittel der Nierenarterie). Atemverschieblichkeit der Arterie erschwert die Messung.

Videoclip 2

Hochgradige Nierenarterienrezidivstenose nach PTA und Stent mit PSV > 5 m/s. Sowohl in konventioneller Duplexsonographie (im B-Bild bessere Visualisierung des Stentverlaufs) als auch farbduplexsonographisch ist der Untersuchungsablauf dargestellt, mit dem Versuch den Stenosejet optimal zu treffen, um die maximale PSV abzuleiten und somit die Rezidivstenose adäquat zu graduieren. Die Atemverschieblichkeit der Arterie erschwert die Messung (das „sample volume“ wird atemabhängig aus dem Gefäßlumen/Stent herausbewegt). Der Stent (echoreich, Maschendrahtmuster) ragt etwas in das Aortenlumen.

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Schäberle, W., Leyerer, L., Schierling, W. et al. Ultraschalldiagnostik von Nierenarterienstenosen. Gefässchirurgie 20, 102–111 (2015) doi:10.1007/s00772-015-0013-x

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Schlüsselwörter

  • Farbduplexsonographie
  • Nierenarterienstenose
  • Stenosekriterien
  • In-Stent-Rezidivstenose
  • Ceus

Keywords

  • Color duplex sonography
  • Renal artery stenosis
  • Stenosis criteria
  • Recurrent in-stent stenosis
  • Contrast enhanced ultrasonography