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bining PSV and RAR yielded sensitivities and specificities of approximately 90 % [8, 24, 42] using a PSV of > 180 cm/s or 200 cm/s and an RAR of 3.5. Abu Rahma [1] described the combination of a PSV of

> 285 cm/s and an RAR of > 3.5 as a vi-able criterion in renal artery diagnostics with a sensitivity of only 60 % but a spec-ificity of 94 %, whereby this comparison was made with an angiographic stenosis

of over 60 %. According to the ROC curve in the same study, a lower cut-off and the combination of a PSV of > 285 cm/s and an RAR of > 3.5 inevitably resulted in a significantly better sensitivity of 73 % but a worse specificity of 81 % (. Table 1); how-ever, the use of several stenosis criteria in the clinical routine is overly complex and time-consuming. For this reason, stenosis detection should be performed primarily by determining PSV and should only be complemented by RAR and dRI in doubt-ful situations or borderline findings.

The use of CCDS with PSV, as well as the other criteria, shows greater accura-cy for the detection of high-grade steno-sis. It has hitherto been assumed that only stenosis > 70 % causes a relevant postste-notic pressure drop and increased renin release as a counterregulatory action via the renin-angiotensin system. Thus, on-ly high-grade RAS are considered as re-quiring treatment [15, 26, 28, 48]. It is im-portant to reliably identify these RAS for a treatment-oriented diagnosis. The dis-cussion on the PSV cut-off at 50 % steno-sis is more academic in nature than any-thing else; however, even at > 50 % RSA on angiography (Grosse et al. 2001) [42] measurements of the intra-arterial systol-ic pressure gradient show a mean pres-sure gradient of > 22 mm Hg. In Staub’s study [42] a PSV of > 200 cm/s (correlat-ing with 50 % stenosis on angiography) showed a mean systolic pressure gradient of 23 mmHg and, hence, hemodynami-cally relevant stenosis accompanied by a regulatory counteraction [9]; however, it should be pointed out that poststenotic pressure was measured with the catheter lying across the stenosis (additional lumi-nal narrowing).

The method for determining the pres-sure drop, as validated using the PSV in il-iac stenosis [45] across the stenosis using the simplified Bernoulli equation (drop in pressure dP = 4 × intrastenotic PSV2) is only reliable in high-grade stenosis, as the prestenotic PSV is considered negligi-ble in this context. In the case of renal ar-tery branch stenosis, the prestenotic PSV in the aorta cannot be used. The postste-notic PSV [dP = 4 × (intrastenotic PSV2– poststenotic PSV2)] occasionally used in-stead [46] of the prestenotic PSV (in the Bernoulli equation) is inaccurate and ne-

Fig. 5 8 Poststenotic change in the Doppler frequency spectrum. a Comparison between postste-notic changes right and left. b Comparison of the Doppler frequency spectrum and RI before and af-ter stenosis caused by fibromuscular dysplasia in the middle third (e.g. in the case of poor visualization of the middle third). c The increasing drop in the Pourcelot resistive index (RI = systolic PSV—end-dia-stolic PSV/systolic PSV) and the increase in acceleration time (AT) with increasing stenosis grade (right normal, middle moderate to high-grade stenosis, right > 90 % stenosis) [38]

Fig. 4 8 Fibromuscular dysplasia with 50–60 % stenosis in the middle third (predilection site). PSV ratio = 2.7 (see also video clip), PSV at the origin of the renal artery 80 cm/s and intrastenotic PSV 220 cm/s (stenosis grading according to the continuity equation)

S8 | Gefässchirurgie Suppl 1 · 2016

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bining PSV and RAR yielded sensitivities and specificities of approximately 90 % [8, 24, 42] using a PSV of > 180 cm/s or 200 cm/s and an RAR of 3.5. Abu Rahma [1] described the combination of a PSV of

> 285 cm/s and an RAR of > 3.5 as a vi-able criterion in renal artery diagnostics with a sensitivity of only 60 % but a spec-ificity of 94 %, whereby this comparison was made with an angiographic stenosis

of over 60 %. According to the ROC curve in the same study, a lower cut-off and the combination of a PSV of > 285 cm/s and an RAR of > 3.5 inevitably resulted in a significantly better sensitivity of 73 % but a worse specificity of 81 % (. Table 1); how-ever, the use of several stenosis criteria in the clinical routine is overly complex and time-consuming. For this reason, stenosis detection should be performed primarily by determining PSV and should only be complemented by RAR and dRI in doubt-ful situations or borderline findings.

The use of CCDS with PSV, as well as the other criteria, shows greater accura-cy for the detection of high-grade steno-sis. It has hitherto been assumed that only stenosis > 70 % causes a relevant postste-notic pressure drop and increased renin release as a counterregulatory action via the renin-angiotensin system. Thus, on-ly high-grade RAS are considered as re-quiring treatment [15, 26, 28, 48]. It is im-portant to reliably identify these RAS for a treatment-oriented diagnosis. The dis-cussion on the PSV cut-off at 50 % steno-sis is more academic in nature than any-thing else; however, even at > 50 % RSA on angiography (Grosse et al. 2001) [42] measurements of the intra-arterial systol-ic pressure gradient show a mean pres-sure gradient of > 22 mm Hg. In Staub’s study [42] a PSV of > 200 cm/s (correlat-ing with 50 % stenosis on angiography) showed a mean systolic pressure gradient of 23 mmHg and, hence, hemodynami-cally relevant stenosis accompanied by a regulatory counteraction [9]; however, it should be pointed out that poststenotic pressure was measured with the catheter lying across the stenosis (additional lumi-nal narrowing).

The method for determining the pres-sure drop, as validated using the PSV in il-iac stenosis [45] across the stenosis using the simplified Bernoulli equation (drop in pressure dP = 4 × intrastenotic PSV2) is only reliable in high-grade stenosis, as the prestenotic PSV is considered negligi-ble in this context. In the case of renal ar-tery branch stenosis, the prestenotic PSV in the aorta cannot be used. The postste-notic PSV [dP = 4 × (intrastenotic PSV2– poststenotic PSV2)] occasionally used in-stead [46] of the prestenotic PSV (in the Bernoulli equation) is inaccurate and ne-

Fig. 5 8 Poststenotic change in the Doppler frequency spectrum. a Comparison between postste-notic changes right and left. b Comparison of the Doppler frequency spectrum and RI before and af-ter stenosis caused by fibromuscular dysplasia in the middle third (e.g. in the case of poor visualization of the middle third). c The increasing drop in the Pourcelot resistive index (RI = systolic PSV—end-dia-stolic PSV/systolic PSV) and the increase in acceleration time (AT) with increasing stenosis grade (right normal, middle moderate to high-grade stenosis, right > 90 % stenosis) [38]

Fig. 4 8 Fibromuscular dysplasia with 50–60 % stenosis in the middle third (predilection site). PSV ratio = 2.7 (see also video clip), PSV at the origin of the renal artery 80 cm/s and intrastenotic PSV 220 cm/s (stenosis grading according to the continuity equation)

S8 | Gefässchirurgie Suppl 1 · 2016

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