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Non-invasive imaging cannot replace formal angiography in the diagnosis of renovascular hypertension
Agnes Trautmann1,2, Derek J Roebuck3, Clare A McLaren3
1Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
Insights
Digital subtraction angiography (DSA) is the gold standard for diagnosing renovascular disease (RVD) in children. Non-invasive methods like ultrasound, MRA, and CTA have limitations in sensitivity, making DSA essential for definitive diagnosis.
Area of Science:
- Pediatric Nephrology
- Diagnostic Imaging
- Cardiovascular Radiology
Background:
- Renovascular disease (RVD) is a significant cause of secondary hypertension in children, affecting approximately 10% of cases.
- Digital subtraction angiography (DSA) is the established gold standard for RVD diagnosis.
- Non-invasive imaging modalities, including Doppler ultrasound (US), magnetic resonance angiography (MRA), and computed tomography angiography (CTA), are increasingly utilized for RVD assessment.
Purpose of the Study:
- To evaluate and compare the diagnostic accuracy of US, MRA, and CTA against DSA in identifying RVD in pediatric patients.
- To determine the role of non-invasive imaging in the diagnostic pathway for childhood renovascular hypertension.
Main Methods:
- A retrospective review of 127 children with suspected renovascular hypertension, referred between 2006 and 2014.
- Comparison of diagnostic performance metrics (sensitivity and specificity) of US, MRA, and CTA against DSA.
- Analysis included patients with unilateral, bilateral, and intrarenal small vessel disease.
Main Results:
- Of 127 children, 99 (78%) were diagnosed with RVD; 80 underwent percutaneous transluminal angioplasty.
- US demonstrated a sensitivity of 63% and specificity of 95%.
- CTA (n=34) showed higher sensitivity (88%) and specificity (81%) than MRA (n=39) (80% sensitivity, 63% specificity).
Conclusions:
- The sensitivity of MRA and CTA is insufficient to reliably exclude RVD in pediatric patients with high clinical suspicion.
- DSA remains the definitive gold standard for diagnosing renovascular hypertension in children.
- DSA is recommended when clinical and laboratory findings strongly suggest RVD, even if non-invasive imaging is normal.
Objectives:
Renovascular disease (RVD) is found in about 10 % of secondary childhood hypertension. Digital subtraction angiography (DSA) is the gold standard to diagnose RVD. Non-invasive imaging methods like Doppler ultrasound (US), magnetic resonance angiography (MRA), and computed tomography angiography (CTA) are increasingly used. Our aim was to evaluate the role and accuracy of US, MRA, and CTA compared to DSA in diagnosing RVD in children.
Patients And Methods:
A retrospective review of 127 children with suspected renovascular hypertension was performed in children referred to Great Ormond Street Hospital between 2006 and 2014 due to clinical suspicion of renovascular hypertension and/or findings on US and/or MRA or CTA.
Results:
Ninety-nine of 127 children (78 %) were diagnosed with renovascular disease and 80 were treated with percutaneous transluminal angioplasty during the same procedure. The median age at presentation was 5.6 (range, 2.5-10.6) years. Thirty-six children had unilateral renal artery stenosis in major extraparenchymal vessels, 47 bilateral stenosis and 16 intrarenal small vessel disease. US had a sensitivity of 63 % and specificity of 95 %. MRA and CTA were performed in 39 and 34 children, respectively. CTA sensitivity was slightly higher than that of MRA, 88 vs. 80 %, and specificity 81 vs. 63 %.
Conclusions:
The sensitivity of MRA and CTA is still too low to reliably rule out renovascular disease in children with a strong suspicion of this diagnosis. DSA remains the gold standard to diagnose renovascular hypertension and is recommended when clinical and laboratory criteria are highly suggestive of renovascular disease even with normal radiological investigations from non-invasive methods.
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