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Introduction and Objectives | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Introduction and Objectives | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017AVIRcompleteddiagnosticforumHypertensionimaginginterventionaljacklicensurepediatricprinciplesradiologicradiologyrenaltalktechnologisttreatmentuniversityvascularwisconsin
RVH -  Delayed Perfusion Demonstrated on Angiogram | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
RVH - Delayed Perfusion Demonstrated on Angiogram | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017arteryAVIRbloodchapterdelayedflowfull videohormonehoseHypertensionimpairsinhibitorskidneykinknarrowingperfusedperfusionphysiologicpressurerenalreninstenosisvasculature
Renal Artery Stenosis - Syndromes Leading to RAS | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Renal Artery Stenosis - Syndromes Leading to RAS | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017AVIRbloodchapterdiseasediseasesdysplasiafibromuscularfull videoinvolvemusclesyndromestumorsvascularvessels
Other causes of RVH - Alterations to Blood Flow | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Other causes of RVH - Alterations to Blood Flow | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017altersaneurysmsarteryAVIRbloodchapterFistulaflowfull videokidneymalformationpathperfusionpressureresistancestenosisvenous
FMD | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
FMD | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angiogramappearanceAVIRbranchchapterclassicdelayeddysplasiaenhanceenhancementfiberfull videoimageinvolvingperfusionsecondarystenosis
Evaluation of Children with Suspected RVH | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Evaluation of Children with Suspected RVH | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angioAVIRchaptercreatininediagnosticekgelectrolytesevaluationfull videoHypertensioninterventionalorgansphysicalrenovascularspectralstudiesworkup
Imaging of Children Suspected of RVH - Non Invasive Imaging Modalities | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Imaging of Children Suspected of RVH - Non Invasive Imaging Modalities | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angiogramAVIRchapteretiologyfull videoimaginginternetkidneylimitationsmassmodalitiessecondarystenosisstrengthstechniquestumorultrasound
Multiple UTIs and Chronic HTN | 16  | Female | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Multiple UTIs and Chronic HTN | 16 | Female | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angiogramarteryAVIRbloodchapterchronicdopplerfull videohoseHypertensionintrarenalkidneylimitingperfusionpressurerefluxrenalrenal arteryscarringsegmentalspraystenosistractultrasoundurinaryvasculaturevelocityvesselwaveform
CT - False Positive and Negative CT | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
CT - False Positive and Negative CT | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angiogramarteryAVIRbilaterallychaptercoronalfull videoimagesionizingkidneylimitationsnarrowednormalradiationradiologistreproduciblestenosisvesselvessels
MRI MRA and Limitations  | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
MRI MRA and Limitations | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017arteryartifactAVIRchapterfull videohydrateimagingionizingminimallyMRImultiplanarresolutionstenosis
Captopril Scintigraphy and Examples | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Captopril Scintigraphy and Examples | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017anatomicalanatomyarteryAVIRchapterfull videoimagedinhibitorkidneykidneysperfusedperfusionphysiologicpolerenalscintigraphysimultaneouslystenosisupper
Direct Renal Vein Renin Sampling in Children - Treatment Options | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Direct Renal Vein Renin Sampling in Children - Treatment Options | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017aldosteroneAVIRchapterfull videohormonesHypertensionmedicinemedicinesnephrectomypercutaneousrenalrevascularizationvein
Renal Artery Interventions in Children - Angiography and PTA | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Renal Artery Interventions in Children - Angiography and PTA | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angiogramangiographyangioplastyAVIRbloodchapterchildrencuredecreasedysfunctionfull videogoalgoalsmedicationmedicationsorganpercentilepressurestudiesworse
Algorithm for Suspected RVH - Flush Aortagram and Selective Catheterization with PTA | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Algorithm for Suspected RVH - Flush Aortagram and Selective Catheterization with PTA | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017accessoryangiogramangioplastyaortaarrowarteriesarteryAVIRballoonbranchcatheterchaptercomplicationsdecreasedeasyflushfull videohybridnarrowingnoticeoriginsperfusionpreparedrenalrenal arteryrisksrupturesecondaryspasmstenosisvesselvesselswire
Percutaneous Transluminal Angioplasty  | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Percutaneous Transluminal Angioplasty | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017angiogramangioplastyarteryAVIRballoonchaptercomplicationsfull videonitroglycerinpostpreparedrecoilrisksrupturestenttechniquestpavasospasmwire
Renal Examples - Transplant with Pre and Post Doppler | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
Renal Examples - Transplant with Pre and Post Doppler | The Role of Interventional Radiology in the Diagnosis and Management of Children with Renal Vascular Hypertention
2017accessoryanesthesiaangioplastyanticoagulationarrowarteryAVIRbloodbranchchapterchildrenetiologyfull videogrowhematomahematomashypertensivehypotensionkidneymedicationsnarrowingnormalizationpostpressurerenalstenosisstentingvasculaturevelocityvessel
Transcript

we are going to talk to or have seacoast dr jack ville dr. Jack fo completed his medical training at the University of Wisconsin he then completed his radiology residency at the University of Tennessee's he finished his vascular and interventional fellowship at the

University of Washington dr. de veau currently resides as an associate professor and division chief of pediatric radiology with Children's Hospital Wisconsin uniquely prior to dr. Vose medical training he worked as the

charge radiologic technologist at home Memorial Hospital Newport Beach California she understands the importance of educating his team with an interventional radiology and has given lectures to technologist for the local a

dr chapter in wisconsin please welcome dr. Jack bow to the podium I really want to suck my gratitude and appreciation for being invited to speak in this forum educated I was an x-ray tech before my previous life and it was until recently

that I actually gave up my RT a licensure realizing that this career in medicine is probably going to work out a little bit not on the chief radiology but but I held out alright so what I'm going to do is I'm going to talk about

the role of interventional radiology in the treatment of renal that's for hypertension and children but more importantly as opposed to the specific discussion of that I want to talk about the principles in general and that's

where I think a lot of information can be garnered 22 in this forum about general principles not necessarily of the one thing but you can translate it into other skills that are that you guys perform on a daily basis at your home

interventional radiology lab I have no financial disclosures no one's willing to give me extra money all right so what we'll do today is discuss some imaging as well as in a bachelor treatment options for children with renal vascular

hypertension right we'll talk about non-invasive diagnostic imaging techniques first and then we'll talk about the endo bachelor diagnostic diagnostic as well as the intravascular treatment options

whether there'd be the indications or why we do it the various limitations as well as the procedural aspects all right

so hypertension and children there's two major categories of hypertension primary hypertension right which is a diagnosis

of exclusion meaning that there is a specific reason why the child has high blood pressure right increasing on far up there's not a specific diagnosis why the child has opportunity charges has hypertension we don't know why all right

there's an increasing number of children in recent years much like an adult that are becoming diagnosed with hypertension and why is that is it because of obesity particularly lead over children that's what I suspect right and then setting

their hypertension unlike in adults adults in this room eighteen ninety percent of us who have high blood pressure we do not know why we just went on an old age it's the mirror opposite and children if a child has high blood

pressure there's an underlying ideologies up to us to find out what the underlying etiology or causes why because if you can find out the cause hopefully you can treat it so what is

the prevalence of hypertension and

children right or real master hypertension so we know bounce or hypertension is approximately ten percent of children with high blood pressure have an underlying vascular cause coming coming from their kidneys

particularly the younger they are infants and young children the older they are whether they start getting towards teenagers or towards a near adult size age then it starts becoming more likely to the obesity or the

essential hypertension or primary physician you don't know what might be their genetics women on the parents right so renal artery stenosis is the third most common condition after renal scarring or Okla marrow disease meaning

that the king is damaged as a cause of hypertension so we'll talk about why the kidneys are so important in hypertension in a few moments okay so go here so cream el bachelor

hypertension right it's hypertension

resulting from a lesion or lesions that impairs blood flow to part or all the kidney I use a perfect example here you take a hose right you turn on us you turn on the faucet the hose coming out the water's coming up line with the

pressure what happens if you kink the hose right the water pressure on one side decreases dramatically alright and then at the spicket its arse polishing out right so if the water pressure is decreasing on that one side that's the

kidney that's the key to saying hey I don't have enough blood pressure so it sends back hormone thing hey increase the blood pressure that's hypertension so very similar to a wee largeness if you have a real arsonist it blocks the

blood flow to the kidney therefore the kidney feels less pressure it sends out hormones and hey tompa blood pressure to help increase the blood flow to my kidding right so the cause can be a result of the narrowing of the renal

artery itself or it might be something outside doing arts is pushing on or compressing on it right so as a result when there's narrowing of the renal artery it sends back a hormone called renin-angiotensin so we might have heard

some of these medicines called r in angiotensin inhibitors or ace inhibitors those permits the formation of the renin alright so here's a nice example alright so there we go and here's smart so here's a

real ing brown where we select up the left kidney and you notice that that deep vasculature is pretty well pacified but right here we do not see it well and pacified there's a stenosis right there so it's getting delayed perfusion so

there's some delayed perfusion and that part of the kidney is sending back hormone saying hey I'm not getting perfused stuff and that's because of the kink upstream so you can Clues you that there's perfusion delay and that's the

physiologic are chiral response that's forming right so what are some potential

causes of real artist message there are various syndromes and diseases that can cause it and I'll briefly go through those fibromuscular dysplasia is a

disease of the muscle muscle itself right and these are various other syndromes sorry that can just lead to the various diseases within the blood wall I won't fit into those specific but we can just understand those when you

start hearing these syndrome so their underlying vasculopathy so what's the term vasculopathy means fast vascular supply goes on top athenians disease of the vessels just generic so anything that can involve or involve the boys

that so itself can alter the way blood flow is sent to the kidneys and there is other vascular disease and then there's these external compression masses or tumors can push up on these blood vessels and cause narrowing so other

causes or rear allows for opportunities anything that alters blood flow in this case it might be something that beats too too much blood flow right so in this case right here we see that there's here's the renal artery it's being

filled and then we see this artur venous malformation or AV fistula so it's big deal with an AV fistula over here we see we see the artery filling and then we see the vein and then there's IDC so what happens is if there's increased

flow through there it's police resistance notice that we're not getting much perfusion to the upper pole of the kidney so that's leading to steal syndrome so its path of least resistance so if there's a bridge that's open and

there's a one-way there's a road right there's there's a freeway and another side road it's going to take the freeway because it's a path of least resistance and therefore divert flow from part of the kidney and that part of the kidney

feels d please pressure so saying I'm not get enough blood flow so I'm going to send back some hormone angiotensin in order to increase the blood pressure so anything that can affect the blood perfusion or flow to the kidneys can

send back those hormones so it's not only stenosis but anything that alters the perfusion pressure aneurysms can do the tip can do the same thing right and so to any of those typically associated with various syndromes that we're

talking about and then in this case the AV official or AV malformation that we

so let's go to the things that you guys are more familiar with all right let's go to renal artery stenosis all right so

5 a monster dysplasia and children are otherwise healthy most common cause in children in Western society right so we live in the West so this is a fiber monster dysplasia is the most common gut unlike in africa in

eastern Asia or sub-saharan or Latin America what happens is the most common cause is probably going to be tuberculosis we don't have to get have that many children would spur closes in our in our Western civilization but

tuberculosis Kings really affect the renal print and therefore in the vast majority of the world outside of our Western civilization it's going to be tuberculosis where's in the Western civilization civilization it's going to

be fiber monster dysplasia where is the disease of the process itself that leads gnosis and thus the patients will come to our intervention radiology suites in the adults where the vast majority has work it could be a so sporadic disease

all right so what's the appearance of fiber monster dysplasia seriously classic and shit around the class and gram it shows it has a beaded appearance the classic interim it shows it has a very beaded appearance so each one of

those beads is actually high areas of high grade stenosis so it's really beaded and the CT shows areas of stenosis as well although the overall enhancements noticed here during the CT when we do the seat the kidney seems

that enhance all right because we image the CT after seven or 80 seconds contrast as well got in there it doesn't the CT has not has sensitive in detecting perfusion abnormality because it's a static point in time where the

angiogram gives us time and Anatomy that's why you can't see the perfusion on this you can see that there's delayed perfusion if we had a cycle so here's a classic fiber much legislation and noticing children it's involving this is

a classic is that it's involving the main renal artery in the adults but until it can happen anywhere and I'll show you a much more example of where it happens in the secondary or tertiary branches which is

a lot harder to identify because of the resolution so you know it's in this case right here we have an angiogram we have a selective and camp and we have stenosis of an upper pole Brent so this is the primary bed which is a secondary

branch up here we have a secondary branch here the main we order and a secondary branch in this case we have a second area branch notice that there's a perfusion difference down there just like we talked about in general

invincible again you kink the hose you decreased perfusion pressure so there's delayed enhancement there's a hydrous notice right there and this was delayed enhancement there right because they ain't gon give a temporal resolution it

gives us time but if we were taking image later on this would eventually enhance so that's and that's why CT is insensitive because it would image it later but here we see if there's a hybrid stenosis and we'll talk about

treatment of that in a few moments right

so how do we evaluate children what's the spectrum of answer hypertension child has hypertension do they go straight to the angio lab that would be nice but it's a little bit more invasive

than we would like so we have to screen them somehow right so we have to be able to distinguish which children are appropriate to go to interventional radiology in order to be to have a diagnostic ranch ramp with the

presumption of treatment we'll talk about that in just a few moments but we'll talk about the diagnostic evaluation first so evaluation of children with spectral renovascular hypertension unexplained hypertension

after a complete medical workup we had to make sure they don't have an underlying a different cause right so the history in a physical examination they describe their onset of hypertension do a physical exam on them

double America's their monitor their blood pressure over 24 hours or right they'll check the lab work to include a creatinine renan's electrolytes and do various other EKG studies as well as you know

studies to make sure they don't have other end organ diseases how long have they have the hypertension has it already been affected other organs because with chronic hypertension you can affect other organs and that's a

significantly higher level of concern so

some factors of increased likelihood of finding a stenosis by angiography so if the patient has a very high blood pressure greater than the 90th percentile for that for the child's age

sex and wait you already have a sixty percent chance of finding our notice without even do an angiogram so if they have if they're in the 99th percentile we're probably just going to go ahead and do an angiogram anyways right but

other things that you could compound to that to make it even a higher percentage is do they have secondary symptoms or complications of high blood pressure such as cardio no cardiomyopathy right do they need two or more medications

right if you know on a single blood pressure medication is controlling you know not much better that we can do that right alright and or if they have a diagnosis of a syndrome with a high association with bachelor / Mallory's

whether it be one of those vasculopathy czar sinful that we talked about earlier

alright so imaging and children with Spector renal mass properties will start off with some non-invasive imaging techniques at first at this time

unfortunately there's no real non-invasive reliable way to really exclude it because when we do the various imaging studies just because we can't see it doesn't mean it doesn't exist we might not just be able to find

it because it might be in a secondary or tertiary branch right but the purpose of these nominations of the imaging techniques is worthwhile as a screening test because to make sure the child doesn't have a kidney tumor or other

abdominal mass that could be the potential etiology because if it's a tumor that's a lot of different pathway that we should do we don't want to diagnose a kidney tumor by angiogram we can usually do that with a non-invasive

imaging technique whether it be ultrasound or CT so the purpose is as a screen and survey of the oven for other secondary causes but if we do identify arena or stenosis it decreases the length of time in which we have to

operate during the internet or radiology procedure so it helps us with our planning and identification and prep work so one of the various non-invasive imaging modalities ultrasound CT MRI the nucleus

integrity so we'll go through each one of those briefly the strengths of them as well as the limitations they all have strengths they all have the limitations so ultrasound advantages it's pretty cheap and easily performed most places

have ultrasound available so it's readily available like it's non-invasive it doesn't require any ionizing radiation so there's low risk it's relatively inexpensive as well alright so very good so here's a 16 year old

girl with a history of multiple urinary tract infections as a child she has chronic hypertension and increasing a medication requirement so we do a renal ultrasound and it shows that the right kidney is a certain size and the left

kidney is extremely small so here there's a right kidney biopsy on its measured at the left kids extremely small with the child with chronic was a chronic urinary tract infection it's probably scarring of that left kidney

due to reflux disease as her underlying legal pathology and probably explains why she has hypertension as opposed to us having to do an angiogram she's not likely to have renal artery stenosis she has another explanation for her

hypertension so we go through the various concerned about that so we go through the various other imaging test techniques right there sorry about that and so what are the other findings that we might see what we know our census in

that case we have an alternate diagnosis but when we're looking for renal artery stenosis what are we looking for in when we use an ultrasound we also used abarth interrogate the vasculature right so one of the things that we look for with a

vasculature when we use ultrasound is is what happens you notice when you have that hose example gift right you have that hose what happens when you put your finger over the end of the spigot it's our shoot mount right because what

happens is increases the pressure it narrows tube and then forward the water has to come out faster and sprays out that's why we put our finger of it over the end of the hose in order to make a spray faster off

spray further same thing happens by Doppler ultrasound when there's a narrowing there's an increased velocity and that's what we can detect BIOS and Appa so here we do a Doppler of the main reorder and shows increase velocity

right there so there's certain velocity there but like that kinkos we saw all right what happened on the other end it decreases the pressure on the other end post so that's what we call it harvest tardis waveform so it has a blunted

waveform so the blood pressure on that side is lower so the things that we look for in da plural nouns are going to be an increase in velocity in the area stenosis behind the service we're going to have decreased perfusion or flow

which is a parvis TARDIS and therefore we have an altered renal a hora ratio the velocity in the arena artery compared to the aorta which is a standard will be markedly increased so that so that way we can use Doppler

potentially identify ring our noses but that's pretty hard it's hard to find our sensors in adult with cooperative in a child even more challenging not only because they're of their cooperation level because it can out it more

frequently happens in a blood vessel fee on the main artery which makes it even smaller so you're looking for a needle in a haystack virtually so the limiting Badgers like we talked about earlier is operator dependent it can be time to

them take up the upwards of an hour and a negative study does not exclude potential for the intrarenal causes it might be in a branch vessel that we just can't see so limiting factors of old stump twenty percent of the exams are

technically unsatisfactory even in the adults so it's significantly higher in children right and stenosis of an accessory or small segmental renal artery may not be identifiable right so that's not uncommon so I've done ang

grounds before to where we've seen the real our noses and we've asked us to another verdict on it I'm telling you exactly where it is right there's no guessing and they still can't find it it's hard because there are hundreds of

vessels inside the blood vessel all

right how about CT next advantage of CT it's pretty minimally invasive I just put in the perf IV it's really available most hospitals have CT scan or FL all right it can be performed pretty rapidly

and allow for us to do a speech 3d reconstructed images right it's also able to diagnose these alternative diagnoses right is there a mass in the belly is there a shrunken kidney are there some other respects ed ologies for

there for the hypertension so here's a nice example of a CT that shows R&R stenosis here we have a beautiful 3d we can strengthen image right so here we have our CT and it shows with the radiologist arrow sign an area of we are

stenosis right there and post dynamic dilation here's our normal right Maori and this is a lot so there we have our marine artist who knows that's right there the correlation correlating coronal images alright so here's another

example beautiful example of the abdominal aorta being markedly narrowed also affecting the Queen orders bilaterally so here's when we take out everything in the background you clewis ed radar stenosis so CT is a beautiful

method rapid reliable and reproducible its limitations are the ionizing radiation right if it wasn't for the ionizing radiation we'd all be gettin CT scans every day all right it also has limited resolution it's unable to show

the small vessels beyond the main Reem artery right and again a normal CT does not preclude the possibility of an abnormal vessel of enterprise so again the CT has limitations as well as it's mainly serving as a screening tool but

that being said if you could finally large doses fantastic information helps guide us where we need to go in a shorter amount of time and it lets us plan better right so here's a positive CT right I do the CT we see that there's

no slowly left kidney or so I can't see a blood vessels left kidney there must be something going on right again I see the right I see the blood vessels the right Kenya I don't see a bug that sort of left kidney

here's the right renal artery I don't see left and must be narrowed which is an angiogram and it looks perfectly normal so the CT just over called it and that's not unusual all right do a sub selection so it's a false positive and

here's the false negative the CT was done we can't see any abnormality but when we do the angiogram there's a high grades gnosis developing a branch vessel right there there's a high-grade stenosis involved in that branch doesn't

write that that ultra don't got no chance of finding that CT can't find it so but the angiogram is much more

sensitive so a nine-year-old girl with hypertension symmetrical anal enhancement by CT it looks perfectly

normal right hmm the ancient RAM shows there's no there's no main renal artery on the right the right way martyr is completely obstructed and we subselect alphab renal artery on the right and it's all these collateral

supplying bypass route again why is that how can that be well what happens when you go in our for you it and there's a major accident right it shuts down the freeway so what do cars do they all get off on the side roads and go around seem

to make sense right or you can see it in traffic all day to do for the reality's not going to open up the traffic angle so all this car starts gathering around be the obstruction anything happens with blood vessels close down about that so

what does we'll find a way around it thankfully and then it may not work as efficiently but it will get there eventually just like getting home in traffic so again this angiogram is just old eventually the kidney does profuse

albeit not as efficiently but it does perfuse the CT just couldn't show us that it shows that the kidney profuse fine 70 seconds later MRI very similar

to CT in its resolution it has no ionizing radiation is minimally invasive

right allows us to multiplanar imaging and 3ds right it doesn't even require I've made contrast but the problem with it shows us beautiful images nice hydrate stenosis main renal artery high-grade see noses are mainly more

artery looks good no problem all right where's are some limitations try choosing an MRI and a child keeping them there still for an hour so it's very challenging right it's acceptable to artifact a little breathing little

motion we're really be a detriment to the imaging resolution right and again a normal study does not preclude the possibility of certain mental level stenosis all right and then there's

capable students igra fee right which is

a nuclear medicine study it's not very good for anatomy but it's really good for physiology all right so it uses an ACE inhibitor all right to where they'll do an imaging of the kidneys first and you don't see what the what the kidneys

perfused and then give the ACE inhibitor right when you dial eight out the renal artery after you give them an ACE inhibitor the perfusion to the kidney is decreased so therefore they'll be asymmetric

enhancement of the kidney and that and the function of the keating lastly decrease the advantages is minimally invasive it provides functional or physiologic evaluation the kidney but it doesn't really give us any anatomical a

information it can't show me the stenosis or anything like that right in addition it's the child has bilateral renal disease or renal artery noses then you really can't tell the difference it's really relying on the difference of

activity of the kidneys and chiefly it's limited anatomical detail as we talked about so here's some examples right here's both kidneys enhance simultaneously both kidneys have simultaneously all right so it's being

imaged from the back right I really can't see it all right but there's a subtle delay perfusion to the right upper pole kidney apparently and that's because in the anatomy it's if we see that there's a we have our status of the

upper pole branch upper pole price notices so this eucla scintigraphy it's just not sensitive enough to show us the

anatomy and hears it so it was a false positive for the nucleus in theory on this one this is a false positive look

at this again a nine-year-old with hypertension the kidneys seem to enhance differently so there must be a real are stenosis there must be a real our noses but the kidneys enhanced differently this left kidney enhances earlier but

when we do the Instagram I can't there's a reason why that kidney enhanced it was delay in an answer is because there was no mean we already slow I suppose completely occluded so again there's no limit anatomical detail offered by the

nuclear medicine says so

let's move on to the gold standard and geography remains the gold standard it gives us high resolution right we're able to directly identify the rarest roses but more important what what's the

utility of diagnosing something if you can't do anything about it so really its utility is that when we see it we have an intent-to-treat so where we can perform an angioplasty it also allows us flow dynamics as well as its resolution

is superior allows us to see the second third and fourth level branches so some limitations of angiography the main one is that it's invasive that's the main limitation of our specialty unfortunately I are is that it's

quote-unquote invasive invasiveness is all relative okay so I'm doing a Perkins puncture is invasive compared to doing nothing but certainly much less invasive and opening up the abdomen so we always have to put things in perspective right

so what's the yield right the yield of a positive angiography of finding an abnormality is at least fifty percent when those various factors are identified with what we talked about

okay so in addition we also can do renal

vein sandpoint right so remember what I talked about when there's a that narrowing it turns out hormones to the kidney the kidneys will send out hormones or aldosterone we can also measure those in the renal vein to see

if there's differences in them and help isolate one side to the other just in case the Renard nose is too small and we can't see but mainly we want to do the Instagram so we can treat alright so there's different forms of treatment of

renal a hypertension and children one is medical management just given medicine it's not on the single medicine you can't get much better than that you know and it's it controlled unfortunately I like an adult we get hypertension at the

age of 60 and if we have to take medicines for the next 20 years or probably I diet with it you know if a child is at nine years old they have to take medicine we don't know what's the effects of taking medicines for the next

60 or 70 years are going to be so it's imperative that we at least try to diagnose why they have hypertension you can do surgical revascularization or a nephrectomy which is much more in days and or in our case in our profession

percutaneous catheter and SRAM so the

search we know studies in children I show some utility and relatively say most more relatively small but we can see dating back to well in the early 90s midnight numerous studies show that

angiogram as well as angioplasty is safe and effective in children all right study from London study from Italy various studies from around the country 2008 and create and my experience most recently in Philadelphia so this is not

an unheard of or unproven a method to treat you a little high blood pressure okay so angiography and and an angioplasty where the goals the goals Jim is to improve blood pressure right so I I do not want to set myself up for

failure with family so whenever I talk to families I give as well as clinicians we talk about multiple goals whether the goal right is if the goal is only cure right we're setting a pretty lofty uh you know in and we're probably going to

come up short right so I have different stages of goals that we talked to them and family about once the goal is is to stop your thoughts are from getting worse you know I think that's at the wind if we can stop their blood pressure

from getting worse number two if we can decrease them in other medications they take I think that's a win and number three if we cure them that's great right so there are different levels of success so we have to speak with the family

about realistic goals you know I don't want to sell them the Golden Gate Bridge is I and we're going to cure you we may not cure well but it doesn't mean we didn't succeed all right so who and why children with stage two hypertension

meaning that children who have high blood pressure above the 95th percentile should get an angiogram right children that have evidence of end organ dysfunction whether it be enlarged heart neurological changes or various other

things organ should should have an angiogram right if they're increasing medication requirements let me just start off with one I've one medication the last two years and all of a sudden the child is needing to

medications something is getting worse we should you an inch rim right and something happens when when children turn teenage years right they take the medication they take the medications right they're doing well somewhere on

junior high they start the buffer service ignores the blood pressure medication that we're giving them doesn't work is it big and it may be because of non-compliance they're not taking it right they developed

independent thoughts right and if they're not gonna take the medications we got to do something about it right as well as the desire to decrease the number of medications as well as preserve renal function if thats no

sustains around long run it will eventually lead to kidney disease

alright so the algorithm for spectrum about hypertension sorrowful in medical management right if you control with one blood pressure medication all right I'll

keep following them until something changes right until it escalates right if they need two medications or greater or there's an acute change we will do a non-invasive imaging technique one of the studies that we talked about

typically an ultrasound or CPR mi to make sure they don't an alternative diagnosis right and if they don't see anything there then we'll go straight to Catherine or angiogram right and when we do is a catheter in each graph we're not

doing it as a diagnostic tool solely we're doing as it and should diagnose the engine with intent to treat they always plan to treat right so what do we do we start with a fleshy order one you always start with the flush a autograph

because as we know right arteries are extremely finicky these put a catheter more a wire arm it can do spasm right so we do not want to falsely identify spasm as we know our students because spasm goes away she notices well not so I

always start off with a renal engine to show me that the main renal arteries are nice and clear we always start with a slushy over them to make sure that we don't screw with the origins of the renal arteries in this case the origins

are a wide open but there's a renal artery stenosis involving the lower pole the right kidney lower pole for like Sydney there's that narrowly right there see that blood vessels as big as that so after you do the flush aorta Graham

will do a selective angiogram because this will give us greater detail of the interproximal notice here we have a hybrid snows notice that look there's decreased perfusion at this point in time to the right upper kitty so

sometimes it's really hard to identify the Renard noses it's easy when I put an arrow to it right but it's hard when we're all scrubbed in we don't season so frequently I'm not looking for the regards to the nose itself i'm looking

for a secondary science so are these secondary science but their signs are that i can see real change is like there's delays in perfusion of that part the kid you can see that as that cartoon a lot easier than finding dispensers

that we work our way backwards there's delays perfusion so let's work our way backwards there's the late perfusion so let's work our way backwards so that's a principle whenever we do angiography it's not what you see is what you don't

see when they're stenosis we don't see it enhance as well that's easy that's everything that all those you'll see alright it's hard to find the stenosis in this jumbled mess if I took if I took away the arrow right but it's it's

easier for us to detect the difference there's decreased perfusion oh right and then what do we do after that easy its standard principle get a wire across doing anju plasti get out of Dodge all right so it sounds all relatively simple

right and these are common techniques we have right these are common techniques that we perform right carefully dilate and it's critical that we appropriate size because what are the risks right we tell them that everything goes well

until it doesn't go well alright so we have to understand what are our risks the risks whenever we put a wire or Catherine ran chest and she bout to blow into the lane artery is that a late rupture it all right we can cause

thrombosis right Arleen cause of vasospasm things that nature so we want to be effective and efficient when we work all right we do not want to keep the wire in there but the captain there and all right we'll just take our time

the renal artery is extremely finicky right so post dilation angiogram it shows pre high-grade snelfus post nice and open per inch brown Tigers noses post everything nice and open refuses nicely right so evaluate for

complications will look for dissection rupture recoil maybe the angioplasty balloon wasn't big enough when we have to go larger that's fine as well we address potential complications by having being prepared for them or

thankful that's not your time nothing that that happens but we have to be prepared so with this rhombus what do we need to be prepared with nitroglycerin to relax the vessel TPA to get rid of the class right be prepared to

re-inflate the angioplasty balloon and or place a stent if we rupture the vessels so these are things but we have to think about what's next it's easy it's beautiful when everything goes right but we have to be prepared for

what's next here's another example of mainly Rory it's pretty striking hired census as fancy wide open narrowing and wide open and we'll go to example of an accessory learning artery you notice here there's this small we know artery

branch there's stenosis in a branch vessel on the mainland artery and aorta injured Esther's accessory renal artery it's socius small branch and some secondary so we take branch of a branch right so when we select out the renal

artery we can see a little bit better there's either it's notice as the arrow would indicate I'm sorry I have to play ping-pong back and forth my apologies so hybrid stenosis with the arrow and a branch of a wrench we had the size it

appropriately before and after angioplasty right there so it looks a little better looks a little better right looks a little better and you might say hey that narrowing after Angela the vessel behind

it is still bigger you don't have to make the angioplasty the same size is a vessel afterwards we just have to make it what it's normal should be equivalent to its branches so not all goes all goes

then what do we do after that easy its standard principle get a wire across doing anju plasti get out of Dodge all right so it sounds all relatively simple

right and these are common techniques we have right these are common techniques that we perform right carefully dilate and it's critical that we appropriate size because what are the risks right we tell them that everything goes well

until it doesn't go well alright so we have to understand what are our risks the risks whenever we put a wire or Catherine ran chest and she bout to blow into the lane artery is that a late rupture it all right we can cause

thrombosis right Arleen cause of vasospasm things that nature so we want to be effective and efficient when we work all right we do not want to keep the wire in there but the captain there and all right we'll just take our time

the renal artery is extremely finicky right so post dilation angiogram it shows pre high-grade snelfus post nice and open per inch brown Tigers noses post everything nice and open refuses nicely right so evaluate for

complications will look for dissection rupture recoil maybe the angioplasty balloon wasn't big enough when we have to go larger that's fine as well we address potential complications by having being prepared for them or

thankful that's not your time nothing that that happens but we have to be prepared so with this rhombus what do we need to be prepared with nitroglycerin to relax the vessel TPA to get rid of the class right be prepared to

re-inflate the angioplasty balloon and or place a stent if we rupture the vessels so these are things but we have to think about what's next it's easy it's beautiful when everything goes right but we have to be prepared for

what's next here's another example of mainly Rory it's pretty striking hired census as fancy wide open narrowing and wide open and we'll go to example of an accessory learning artery you notice here there's this small we know artery

branch there's stenosis in a branch vessel on the mainland artery and aorta injured Esther's accessory renal artery it's socius small branch and some secondary so we take branch of a branch right so when we select out the renal

artery we can see a little bit better there's either it's notice as the arrow would indicate I'm sorry I have to play ping-pong back and forth my apologies so hybrid stenosis with the arrow and a branch of a wrench we had the size it

appropriately before and after angioplasty right there so it looks a little better looks a little better right looks a little better and you might say hey that narrowing after Angela the vessel behind

it is still bigger you don't have to make the angioplasty the same size is a vessel afterwards we just have to make it what it's normal should be equivalent to its branches so not all goes all goes well all right all fair in love and war

so here's a patient with a transplant high-grade stenosis high-grade stenosis seems pretty simple I spread the origin just give by do an energy policy check everything is all good right we do the angioplasty everything looks good right

so that's perfectly fine everything looks great and then post enough before we have high velocity post we have students we have harvest artists after the angioplasty normalization and normalization so everything went really

well three trans a pre intraclass see the velocity was are really high harvest artists behind it where the puzzle behind the stenosis was really dampened but after the angioplasty nice normalization right so I'll show nice

easy way to follow it up that's fine and dandy huh alright so here's another example one things don't go quite as well again hikers two noses at the nasty Moses high-grade snows and snaps bonuses everyone looks pretty straightforward we

get across with you an angioplasty and then afterwards huh we've dissected the blood vessel right so at this point the kidney is going ischaemic so we have to be repaired weeds so so we have to deter what do we

do well then we just prepared lay your head down so it's not ideal we don't prefer to live in telling children why because the children grow right unlike an adult you can lay it down all right the patients find that I grow much

anymore or the shelf I want to put the skin right size for that child at this point in time the younger there doesn't grow and that it may not be quite big enough in the future so is really stenting in children really is meant for

Salvage as opposed to a primary right so post PTA care right they've been on hyper David hypertensive for quite some time they've been on multiple medications so post PTA care I put them in the ICU and take away all the bugs

are three medications why because if they take the blood pressure medication the problem might be hypotension because we take them away the etiology for that high blood pressure so we so we'll take away all the blood pressure medications

see how many we have to put back into play because hypotension can be an issue right and then we have the anti quiet them overnight because after we do an angioplasty it's very irritating to the vasculature so the platelets want to

aggregate so we had to put them on heparin or hold on overnight and it will monitor for complications right so when we put the cut when we put them on anticoagulation what's the risk at the puncture site right hematomas right so

we're fighting ourselves right I'm actually keeping something that's going to increase the risk of hematoma at the groin site so what do we do well I'd rather have a hematoma the growing sites and then for our boats off their kidney

so in children I don't know if these other people talked about ice creaking where we use an NGO seal or an arterial closer assistive ice I know there's some debate about that why should we do it you know holding pressure is perfectly

good but in children when we do these under and under anesthesia right using engine field device think has a couple hundred dollars by keeping a child under sedation for a couple hours cuff more than a couple hundred dollars so i

think it's a more than worthwhile and there have been studies that we've published that says NGO CEO is perfectly acceptable performing children and safe

and so for the courtesy of time I know what happy hour is coming up you know

i'll close this up soon and i just want to we'll just i'll just go through that right alright so conclusion renovascular hypertension is a common cause of hypertension and children okay anything that alters flow will cause can lead to

reno master hypertension right non-invasive imaging techniques may not identify the cause but it doesn't mean they're not useful they'll help identify all potential alternatives or say everything looks normal and we have to

go to the edge ground right Catherine our engine on with intent to treat is safe and effective and shouldn't be shied away from all right and thank you and this is a picture of my daughter again you know I had to say if you'll

indulge me with an extra 30 seconds here I really really appreciate being offered the opportunity to equal it with it what the team here is because I know how valuable you know the collaborators the partners in in the IR sweetest no one

can do it alone it's important that the technologists and the nurses are engaged you know I know the motives are technologists near if not all of you that are technologists but it's critical that we are engaged to the team in order

to function seamlessly because everything goes when everything goes well it's all dandy it's when things fault is that we really need everyone on the same page and understanding and appreciative of what's going on it's

unacceptable to have you know members of our team off in the corner doing something else and not understand the appreciation and I know it's interventional technologies you guys are side by side with us engage with the

equipment so I'm very appreciative not only because of my history because I know what dedication you guys have the professionalism that you guys have you know you guys are showing up here I know that you know we all rather be spending

time with our family but this is a dedicated thing that you guys are doing I'm so proud of that all right thank you [Applause]

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