Renal and Mesenteric Pathologies
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Northwell Health, Uniondale, New York
On Sunday afternoon at ISET 2025, John S. Pellerito, MD, vice chair of radiology at the Zucker School of Medicine, Northwell Health, delivered an in-depth presentation on renal and mesenteric vascular pathologies. The session focused on the diagnostic approaches and clinical considerations for evaluating and managing these conditions, emphasizing the importance of Doppler ultrasound and other imaging modalities.
Dr. Pellerito’s presentation covered both common and rare vascular disorders affecting the renal and mesenteric arteries and veins. His discussion included criteria for identifying stenosis, occlusion, aneurysms, pseudoaneurysms, dissections, and venous thrombosis, with insights into their clinical implications and diagnostic techniques.
A critical aspect of the presentation was the importance of using proper patient positioning and acoustic windows for optimal imaging. Dr. Pellerito recommended using the liver and kidney as acoustic windows; lateral decubitus positioning for left renal artery evaluation; an oblique liver approach for the right renal artery; and a sagittal approach for the abdominal aorta and mesenteric arteries.
Dr. Pellerito outlined the key Doppler ultrasound criteria for diagnosing renal artery stenosis:
- Peak systolic velocity (PSV) >200 cm/sec
- Renal-aortic ratio >3.5
- Abnormal segmental artery waveforms, including tardus-parvus waveforms characterized by a delayed systolic upstroke and absence of an early systolic peak.
Chronic mesenteric ischemia is associated with significant stenosis of 2 or more mesenteric arteries. Doppler ultrasound criteria for mesenteric stenosis include:
- PSV >200 cm/sec in the celiac artery and inferior mesenteric artery
- PSV >275 cm/sec in the superior mesenteric artery
- Mesenteric-to-aortic ratio >3:1 with post-stenotic turbulence.
Although spontaneous dissections are uncommon, Dr Pellerito noted, they can occur due to conditions such as atherosclerosis, hypertension, fibromuscular dysplasia, and trauma. Computed tomography imaging remains the primary diagnostic tool, with findings including an intimal flap, mural thrombus, and infarcts in renal, hepatic, or splenic tissues.
Renal artery aneurysms, though rare (0.3–1% incidence), predominantly occur in middle-aged women and are often extrarenal, he said. Surgical intervention is recommended for aneurysms between 1.5 and 3 cm. Visceral artery aneurysms and pseudoaneurysms are also uncommon but potentially life-threatening, with 22% presenting as emergencies. Renal vein thrombosis can arise from hypercoagulable states, trauma, tumors (eg, renal cell carcinoma), nephrotic syndrome, and compression syndromes such as nutcracker syndrome. Mesenteric vein thrombosis, although seen in a younger population, carries a mortality rate of 20-50%, necessitating early detection and intervention.
Dr. Pellerito’s presentation underscored the advancements in vascular imaging and the importance of integrating patient history with imaging findings to improve diagnostic accuracy and patient outcomes.
