Renal Artery Aneurysm Workup
- Author: Lindsay Gates, MD; Chief Editor: Vincent Lopez Rowe, MD more...
A complete blood count (CBC), chemistry panel, coagulation profile, and urinalysis should be performed prior to any surgical intervention for a renal artery aneurysm (RAA).
Special attention should be paid to the blood urea nitrogen (BUN) and creatinine levels because these values are indicative of renal function and can be followed to confirm that no renal damage exists if the decision is made to manage an RAA nonoperatively.
In a patient with hypertension, RAA, and no renal artery stenosis, studies should be ordered to exclude other endocrine sources of hypertension, including the following:
Pheochromocytoma - 24-hour urine collection for vanillylmandelic acid, metanephrine, and normetanephrine
Primary aldosteronism - Serum potassium
Cushing syndrome - Cortisol levels
Carcinoid - Urinary 5-hydroxyindoleacetic acid
Because most RAAs are asymptomatic and are found incidentally during a workup for other intra-abdominal pathology, imaging studies are required only for preintervention planning or longitudinal follow-up care.
Ultrasonography (US) with duplex examination is the least invasive imaging study. Two-dimensional (2D) US forms an anatomic picture based on the time delay of ultrasonic pulses reflected from structures. Vessel walls reflect ultrasound waves and appear white; blood absorbs and scatters ultrasound waves, appearing black. Normal vessels appear as dark-filled, white-walled structures.
Duplex studies use Doppler-shift measurement to detect the direction and velocity of blood flow. This can be useful in identifying renal artery stenosis. US can also be used in determining the how functional a kidney is by measuring its size. It should be kept in mind that the quality of imaging is highly operator-dependent and may be limited by the patient's body habitus.
Computed tomography (CT) is the most widely available and reproducible imaging modality. It is the test of choice for diagnosis and follow-up. Its anatomic resolution is superior to that of US (see the image below).
The advent of CT angiography (CTA) and three-dimensional (3D) reconstruction has facilitated accurate preinterventional planning. Because intravenous (IV) iodinated dye must be used, the only real limitation of this modality is in patients who have a life-threatening dye allergy or impaired renal function. Non–life-threatening dye allergies can be managed with premedication with diphenhydramine (histamine-1 receptor antagonist), cimetidine (histamine-2 receptor antagonist), and methylprednisolone sodium succinate (glucocorticoid).
Magnetic resonance angiography
Magnetic resonance angiography (MRA) with gadolinium enhancement and 3D reconstruction can produce images similar in quality to those obtained with arteriography (see the image below). However, this technology is not as readily available as US or CT, and it is more expensive.
Arteriography is the most invasive test but can be useful for helping define unclear anatomy seen on prior examinations (see the images below). For the most part, arteriography as a diagnostic test has been supplanted by CTA and MRA.
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