J Cardiol 2002 Jan; 39（1）: 59 – 62

Cardiovascular Imaging In-a-Month
A 68-Year-Old Man With Renal Artery Stenosis●Hisao

ITO, MD

Takayuki KANNO, MD＊ 1

Makoto MATSUMOTO, MD＊ 1
Tadashi

ISHIBASHI, MD＊ 2

CASE
A 68-year-old man was referred for investigation of a hepatic mass, which led tothe diagnosis of hemangioma. However, digital subtraction angiography（DSA）of theabdominal aorta performed during the investigation suggested left renal artery stenosis at 10 mm from the margin of the abdominal aortic lumen（Fig. 1）.
His blood pressure was 146/84 mmHg, and pulse rhythm was regular. Vascular
bruit at the upper back was unclear, and plasma renin activity was within the normallimits.

Fig. 1──────────────────────────────────────────────
宮城県立瀬峰病院 放射線科〔伊藤久雄〕，＊ 1 循環器科〔菅野孝幸，松本 誠〕: 〒 989−4501 宮城県栗原郡瀬峰町大里字富根，仙台
岸 55−2 ; ＊ 2 東北大学大学院医学系研究科 量子診断学〔石橋忠司〕
Departments of Diagnostic Radiology, and ＊ 1Cardiology, Miyagi Prefectural Semine Hospital, Miyagi ; ＊ 2Department of Radiology,
Graduate School of Medicine, Tohoku University, Sendai
Address for correspondence : ITO H, MD, Department of Diagnostic Radiology, Miyagi Prefectural Semine Hospital, Tominegishi
55−2, Osato, Semine-machi, Kurihara-gun, Miyagi 989−4501
Manuscript received July 30, 2001 ; revised August 20, 2001 ; accepted August 24, 2001

59

60Ito, Kanno, Matsumoto et al

Points for Diagnosis
DSA of the abdominal aorta（ Fig. 1）showed
severe left renal artery stenosis at about 10 mmfrom the margin of the aortic lumen. The locationof the stenosis suggested that the stenosis was notat the renal arterial ostium, but in the renal arterial
trunk.
Spiral computed tomography（CT）with contrast
medium showed outpouching of the aorta（infundibulum）and the distal renal artery stenosis（Fig. 2）. In addition, calcification was shown in
the infundibulum1）.
CT angiography of maximum intensity projection（Fig. 3）clearly showed high grade calcificationin the aortic infundibulum and the distal renalartery stenosis. Moreover, severe calcification wasshown in the lower abdominal aorta.
Virtual CT angioscopy visualized both the undulating inner surface of the abdominal aortic lumen（Fig. 4）, and a large nodular calcification at thewell-developed infundibulum followed by narrowing of the renal arterial lumen（Fig. 5）.
Cross-sectional CT imaging and three-dimensional representation suggested that the stenosis
was located at the transition of the infundibulum
and the correct origin of renal artery trunk. We considered that the renal artery stenosis was not situated in the renal artery trunk, but at the origin of therenal artery.
Our overall assessment is based on the previous
report of pseudotruncal renal artery stenosis2）,

Fig. 2

described as angiographic truncal stenosis locatedat more than 4 mm from the outer margin of theaortic lumen, because CT scan revealed that theaortic infundibulum was partly filled with calcification or thrombus and located proximal to the stenosis. CT was superior to DSA for visualizing theinfundibulum.
When the infundibulum is partially filled withcalcification or thrombus or both, the short tract
within the infundibulum mimics a normal proximal
segment of the renal artery. On the other hand,severe calcification in the aortic wall indicatesadvanced atherosclerosis, and the aortic infundibulum is usually associated with atherosclerotic renalartery stenosis2）.
Renal artery stenosis such as that in the present
patient should not be released immediately, because
the blood pressure and plasma renin activity are notelevated. However, the renal artery stenosis should
be resolved to improve hypertension in the presence of elevated blood pressure and plasma reninactivity.
Stent implantation is suitable for the treatment ofpseudotruncal ostial stenosis3）, but whether stentimplantation is useful in the present situation
remains unknown.
Diagnosis : Pseudotruncal ostial renal arterystenosis with large nodular calcification within thewell-developed aortic infundibulum.

Fig. 3J Cardiol 2002 Jan; 39（1）: 59 – 62

Cardiovascular Imaging In-a-Month6403）van den Ven PJ, Beutler JJ, Kaatee R, Beek FJ, Mali WP,Geyskes GG, Koomans HA : Transluminal vascular stentfor ostial atherosclerotic renal artery stenosis. Lancet 1995 ;
346 : 672−674

References1）Ito H : Two cases of renal artery stenosis : Utility of 3Dspiral CT. Nichidoku-iho 2000 ; 45 : 1582）Kaatee R, Beek FJ, Verschuyl EJ, van den Ven PJ, BeutlerJJ, van Schaik JP, Mali WP : Atherosclerotic renal arterystenosis : Ostial or truncal? Radiology 1996 ; 199 : 637−

Fig. 4Fig. 5J Cardiol 2002 Jan; 39（1）: 59 – 6261

62Ito, Kanno, Matsumoto et al

Fig. 1 Digital subtraction angiogram of the abdominal
aorta demonstrating narrowing of the left renalarterySevere left renal artery stenosis is located at 10 mmfrom the margin of the aortic lumen, and is followed
by a post-stenotic dilatation.
Fig. 2 Cross-sectional computed tomographic imaging
with contrast medium showing the infundibulum（arrows）
which is partially filled with calcificationand followed by severe stenosis
Calcification is also seen at the opposite site of theinfundibulum.
Fig. 3 Maximum intensity projection imaging demonstrating that most of the infundibulum（arrows）
isfilled with calcification and followed by renalartery stenosis
Severe calcification is demonstrated in the lower
abdominal aorta.
Fig. 4 Virtual computed tomographic angioscopy（left）
and scheme（ right）
of the abdominal aorta fromhead to foot projection demonstrating the undulat-

ing inner surface and mural calcification of theaorta
Left : Threshold levels of the computed tomography
value of the inner surface and mural calcification are
100 HU and 330 HU, respectively.
Right : White segments show the inner surface of theaortic lumen, and dark segments show the severe
mural calcification. The infundibulum of the aorticwall（arrows）and nodular calcification（arrowheads）
are visible.
Fig. 5 Virtual computed tomographic angioscopy（left）
and scheme（right）
approaching the infundibulum
Left : The nodular calcification has higher computed
tomography values than the enhanced aortic lumen,
and therefore the nodular calcification in this image issimilar to the real nodule.
Right : Dark segments at the infundibulum（largearrows）show the nodular calcification（arrowheads）,
and the narrowing of the lumen（small arrows）at theorigin of left renal artery located behind the nodular
calcification.

J Cardiol 2002 Jan; 39（1）: 59 – 62