Doppler ultrasound of lower limb arteries
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Doppler ultrasound of lower limb arteries
Samir Haffar M.D.
Assistant Professor of internal medicine
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Doppler US of lower limb arteries
Anatomy of lower limb arteries
Normal Doppler US of lower limbs arteries
Duplex US criteria for arterial evaluation
Causes of lower limb arterial diseases
Doppler US of bypass graft
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Anatomy of abdominal aorta & its branches
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
• Lies to left of midline
• Inferior vena cava to its right
• Extends from L1 to L4
• Gives visceral branches
• Gives phrenic & lumbar branches
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Anatomy of iliac artery
CIA (4 – 5 cm long)
From L4 to sacroiliac joint
Divides into IIA & EIA
Left to corresponding CIV
EIA (twice long of CIA)
Superficial to corresponding vein
Gives inferior epigastric artery
Becomes CFA at inguinal ligament
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
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Anatomy of femoral & popliteal arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Common femoral artery (4-6 cm long)
Lies superficially in the groin
Divides to SFA & PFA
Superficial femoral artery
Extends down medial thigh
Passes deep through adductor hiatus
Popliteal artery
Commences below adductor hiatus
Passes vertically through popliteal fossa
Divides to tibio-peroneal trunk & ATA
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Anatomy of crural arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
There are several interconnection
So that each artery can supply all regions
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Normal diameter of lower limb artery
• Sub-diaphragmatic aorta 21 – 24 mm
• Infra-diaphragmatic aorta17 – 20 mm
• Common iliac artery 10 – 12 mm
• External iliac artery 8 – 10 mm
• Common femoral artery 7 – 9 mm
• Superficial femoral artery 6 – 8 mm
• Popliteal artery 4 – 6 mm
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
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Anatomical variations of lower limb arteries
May be occasionally encountered
Artery Variation
Aorta Duplication (very rare – duplication image artifact)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
ATA High origin across knee joint
May be small or hypoplastic (2%)
Peroneal artery Origin from ATA rather than tibio-peroneal trunk
CFA bifurcation Bifurcation can sometimes be very high
EIA Aplasia with blood supply to leg via strong IIA
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Duplicated aorta or duplication artifact
Meuwly JY et al. Ultraschall Med 2011 ; 32 : 233 – 236.
Duplication image artifact frequent in lower abdomen:
False cases of twin pregnancies
Double intra-uterine devices
Gray-scale US
Duplicated aorta
Color Doppler US
2 aortic lumen filled with color
Tiny sliding probe to right
Only one lumen filled with color
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Doppler US of lower limbs arteries
Anatomy of lower limb arteries
Normal Doppler US of lower limbs arteries
Duplex US criteria for arterial evaluation
Causes of lower limb arterial diseases
Doppler US of bypass graft
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Arteries scanned in Doppler US of lower limbs
• Tibio-peroneal trunk
• Posterior tibial artery
• Anterior tibial artery
• Peroneal artery
• Dorsalis pedis artery
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Aorta & the following arteries on both sides
• Common iliac artery
• External iliac artery
• Common femoral artery
• Profunda femoris artery
• Superficial femoral artery
• Popliteal artery
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Normal wall of the artery3 layers
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Transducer positions for scanning AA
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005 .
Sagittal or
longitudinal
Transverse
Coronal
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Normal aortic bifurcation
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Normal external iliac vessels
Transverse scan
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Region of the groin
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Normal SFA & PFA
Transverse view Longitudinal view
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Region of adductor canal & popliteal fossa
Region of adductor canal is difficult to evaluate
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Region of adductor canal & popliteal fossa
Distal superficial femoral vessels Normal popliteal vessels
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Insonation of leg arteries
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Posterior tibial artery
Peroneal artery
Medial approach
Anterior tibial artery
Anterolateral approach
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Proximal
Normal anterior tibial artery
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Normal posterior tibial vessels
Proximal Distal
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Normal peroneal vessels
Longitudinal view Transverse view
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Normal triphasic waveform of peripheral arteriesArterial high resistance flow
Narrow frequency band
Steep systolic increase
Quick drop
Early diastolic reverse flow ( of systolic flow amplitude)⅕
Late diastolic short forward flow
ABPI: Ankle Brachial Pressure Index
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
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Normal PSV of lower limb arteries
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Pulsatility index
Most commonly used of all indices
S: Systolic
D: Minimum diastolic
M: Mean
PI: S – D / M
Normal PI: 4 – 13 (average 6.7)
Depending on location of peripheral arteries
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Factors influencing pulsed Doppler waveform Complicate evaluation
• Cardiac pump function Cardiac insufficiency
• Aortic valve function Aortic stenosis/insufficiency
• Course of vessel Tortuosity
• Vessel branching
• Peripheral vascular resistance Peripheral inflammation
Polyneuropathy
Warm or cold extremity
Vaso-spastic disordersStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
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Arterial monophasic flow
• Hyperemic (normal PSV& normal RT*)
Exercise
Fever
Downstream infection
Temporary arterial occlusion by blood pressure cuff
• Tardus-Parvus waveform (low PSV & longer RT)
Distal to severe stenosis or occlusion
*Rise time: Time between beginning of systole & peak systole
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Hyperemic monophasic flowFollowing exercise
Normal triphasic waveform
Normal DPA at rest
Monophasic hyperemic flow
Following exercise
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Hyperemic flowPhlegmon of foot
Monophasic waveform
Normal PSV
Normal rise time
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Doppler US of lower limbs arteries
Anatomy of lower limb arteries
Normal Doppler US of lower limbs arteries
Duplex US criteria for arterial evaluation
Causes of lower limb arterial diseases
Doppler US of bypass graft
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Duplex US criteria for arterial evaluation
Anatomy (course, variants) Vessel contour (aneurysm, stenosis) Wall structures (calcification, plaque, cyst) Pulsation (axial, longitudinal) Perivascular structures (hematoma, abscess, tumor, muscle)
B-mode
Demonstration of flow Flow direction Flow pattern (laminar, turbulent) Flow profile (monophasic, triphasic) Flow velocity
Doppler
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
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Doppler US of lower limbs arteries
Anatomy of lower limb arteries
Normal Doppler US of lower limbs arteries
Duplex US criteria for arterial evaluation
Causes of lower limb arterial diseases
Doppler US of bypass graft
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Causes of arterial diseases
Atherosclerosis
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
Most common cause
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Peripheral arterial diseaseFontaine & Leriche classification
Stage Complains
I Asymptomatic
II aII b
Mild claudication Moderate to severe claudication
III Ishemic rest pain
IV Ulcer or gangrene
Underdiagnosed & therefore undertreated disease
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Ankle Brachial Pressure Index (ABPI)Continuous wave Doppler (takes 10 - 15 min)
Posterior
tibial artery
Dorsalis
pedis artery
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Peroneal artery
Highest ankle pressure / highest brachial pressure
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Grading arterial disease using ABPI
ABPI Comment
> 1.3 Falsely high value (suspicion of medial sclerosis)
0.9 – 1.3 Normal finding
0.75 – 0.9
Mild PAD
0.4 – 0.75
Moderate PAD
< 0.4
Severe PAD
ABPI: Ankle Brachial Pressure Index
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
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ABPI in diabetics
Calcification of vessel walls
Beaded appearance of color flow
Ankle pressure 280 mmHg
Brachial pressure 120 mmHg
ABPI 2.3
Falsely elevated recordings in diabetic patients
Calcified & rigid arterial walls
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Direct & indirect signs of stenosis
Proximal to stenosis
At site of stenosis
Distal to stenosis
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Grading of lower limb artery stenosis Flow pattern proximal to lesion
High resistance, low volume waveform
Characteristic shoulder on systolic downstroke
Due to pulse wave reflection from distal disease
Shoulder
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Grading of lower limb artery stenosis PSV at site of stenosis
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Grading of lower limb artery stenosis
PSV ratio
Robbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.
Proximal: 2 cm proximal to stenosis
At stenosis : Same Doppler angle if possible
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Grading of lower limb artery stenosis
PSV ratio
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Grading of lower limb artery stenosisRanke scale
Left vertical line: Pre-stenotic PSV
Right vertical line: Intra-stenotic PSV
Middle vertical line: Degree of stenosis in %
Ranke C et al. Ultrasound Med & Biol 1992 ; 18 : 433 – 440.
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Grading of lower limb artery stenosisEffect of collaterals
Excellent collaterals
Poor collaterals
Absence of collaterals
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Grading of lower limb artery stenosis Flow pattern distal to lesion
Tardus: Longer rise time
Parvus: Low PSV
Severe stenosis or occlusion
Tardus-Parvus waveformDamping waveform
Increased systolic rise time
Loss of pulsatility
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Lower limb arterial stenosesMost common sites
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Aorto-iliac: 25 %
Femoro-popliteal: 65%
Infra-popliteal: 10%
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Stenosis of PFA / Aliasing
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Grading of arterial stenosis
SFA:
PSV of A 69 cm/sec
PSV of B 349 cm/sec
B / A 349 / 69 = 5
> 80% diameter stenosis
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
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Two severe stenosis of SFA
2 severe stenoses demonstrated in SFA
Areas of color flow disturbance & aliasing (arrows)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
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Calcified atheroma in SFA
Drop-out of color flow signal in parts of lumen
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
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Occlusion of the CIA
Occlusion in CIA
Reversed flow in IIA (blue) to supply flow to EIA (red)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005 .
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Arterial occlusion & collaterals
Short occlusion of mid-SFA (large arrow)
Large collateral at both ends of occlusion (small arrows)
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
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Diagnostic reliability of peripheral arterial diseaseSystematic review – DSA as gold standard
Collins R et al. BMJ 2007 ; 334 : 1257 – 1266.
MRA CTA CDUS
No of studies 6 5 7
SensibilityMedian (range)
94%(85 – 100)
97%(89 – 100)
90%(74 – 94)
SpecificityMedian (range)
99.2%(97 – 99.8)
99.6%(99 – 100)
99%(96 – 100)
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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FA lumen filled with hypoechoic thrombus or embolus
Good delineation of vessel wall without signs of plaque
Normal flow in adjacent FV
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Thrombosis or embolism / Femoral artery
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Compression syndrome (entrapment syndrome)
Cystic adventitial disease
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Definition of aneurysm & ectasia
Aneurysm
Diameter increase > 50% of normal expected diameter
Ectasia
Diameter increase < 50% of normal expected diameter
Considerable variability in normal diameter of arteries
Depends on physical size, sex, & age
Johnston K W et al. J Vasc Surg 1991; 13:452 – 458.
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Types of aneurysmTrue aneurysm
False aneurysm
Dissecting aneurysm
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Common sites for lower limbs aneurysms
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
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Abdominal Aortic Aneurysm (AAA)
• Normal size of abdominal aorta 1.5 – 2.5 cm
• Ectatic aorta 2.5 – 3 cm
• Aortic aneurysm > 3 cm
• Annual growth rate of aneurysms 0.33 cm/year
measuring between 4 & 5.5 cm
* Bhatt S et al. Ultrasound Clin 2008 ; 3 : 83 – 91.
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Classification of abdominal aortic aneurysms
Classification Categories
By location
Suprarenal: Above origin of renal areteries (very rare) Juxtarenal: Where renal arteries originate Infrarenal: Below origin of RA (most common)
Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.
By morphology Fusiform (most common) Hourglass Saccular
By etiology Atherosclerotic (most common) Inflammatory (5% – 10%) Mycotic (1%): saccular, salmonella & SA, high mortality
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Measurement of widest part
Measurement technique of aneurysm
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004 .
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Measuring diameter of AAAIncorrect measurement Correct measurement
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin, 2nd edition, 2011.
Correct diameter measured by rotating transducer clockwise
until round image of aorta comes into view
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Shapes of aneurysm
Fusiform Saccular
Most frequent
Double aneurysm
Hourglass aorta
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Abdominal aortic aneurysm / Fusiform
Transverse image
Anteroposterior diameter
from outer wall to outer wall
Sagittal image
Diameter measured in transverse
image larger due to obliquity
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
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Abdominal aortic aneurysm / Hourglass
Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.
Two discontinuous focal segments of aneurysmal dilatation
Aortic diameter in between is normal in caliber
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Abdominal aortic aneurysm / Saccular
Saccular or mycotic aneurysm
Thrombus seen as low-level echoes within aneurysm
Sagittal image of abdominal aorta
Abraham D et al. Emergency medicine sonography: Pocket guide.
Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.
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Battaglia S et al. J Ultrasound 2010 : 13 : 107 – 117.
Abdominal aortic aneurysm / Swirling flow
Pseudo ‘‘yin-yang sign’’
Similarity in appearance to pseudo-aneurysm finding
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Suprarenal aortic aneurysm
Schuster H et al. Ultraschall Med 2009 ; 30 : 528 – 543.
Cross section viewLongitudinal section view
Inclusion of visceral & renal
arteries
Perfused lumen
& narrow circular thrombus
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Infrarenal aortic aneurysm Distance between RA & upper limit of aneurysm
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
SMA
LRV
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Abdominal aortic aneurysm / Rupture High mortality rate (90%)
AAA with peripheral thrombus
Small hypoechoic area (wall rupture)
Hypoechoic structure at upper end
Presence of active bleeding
No further imaging confirmation
Taken directly to OR Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.
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Abdominal aortic aneurysm / Dissection
B-mode image Color flow imaging
True l
umen
Fals
e lum
en
Dissection into thrombus & vessel wall has occurred
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
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Abdominal aortic aneurysm / Thrombus liquefaction
Area of thrombus liquefaction may be confused with dissection
Large thrombus separate area of liquefaction from lumen
Thrombus
Lumen
Liquefacti
on
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
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Diameter of aneurysm (indication for surgery) Shape of aneurysm (Fusiform, hourglass, sacular) Partial thrombosis Infra-renal or supra-renal Involvement of iliac arteries: common, internal
Additional criteria if endovascular treatment
Distance of proximal end of aneurysm to renal artery Degree of angulation in case of elongation of infra-renal aorta Conic neck of aneurysm Lumen of CFA (large enough for stent insertion)
Relevant color duplex findings in AAA
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin, 2nd edition, 2011.
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Stent-graft expands to make firm
circumferential contact with
‘neck’ of relatively normal aorta
between RA & upper end of AAA
each CIA below aneurysm
Endovascular aortic aneurysm repair (EVAR)First performed by Parodi from Argentina in 1990 1
1 Parodi JC et al. Ann Vasc Surg 1991 ; 5 : 491 – 499.2 Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Stent-graft
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Endoleak after EVARPersistence flow in aneurysm lumen after procedure
• Increase in aneurysmal diameter with risk of rupture
• 20 – 40% at any time after graft placement1
• Lifelong surveillance 1st month, 6th month, yearly2
• Modalities CTA: gold standard
CDUS/CEUS: acceptable alternative
MRA – DSA
1 Demirpolat G et al. J Clin Ultrasound 2011; 39 : 263–269.2 Stavropoulos SW et al. Radiology 2007;243:641.
Determination of endoleak & aneurysmal size
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Type IVPorosity of graft material (resolved in 1 month)
Type IIIPerforation & tear in graft material (rare)
Type I Failure of proximal or distal attachment sites
Type IIFlow through aortic or iliac branches (common)
Endoleak following EVAR
White GH et al. J Endovasc Surg 1996 ; 3 : 124 – 5.
Carrafiello G et al. Cardiovasc Intervent Radiol 2006 ; 29 : 969 – 974.
Type VSource not identified (controversial)
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EVAR / Mirror artifact
Demirpolat G et al. J Clin Ultrasound 2011 ; 39 : 263 – 269.
Synchronous pulsatility with flow in patent graft
Changing position while examining from different aspects
Spectral analysis aids in reducing false positive
Mirror image behind patent limbs of stent graft
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EVAR / Poorly organized thrombus
Aneurysmal sac contains mix of echoes
Large anechoic area (A) which could represent an endoleak
No flow detected (region of poorly organized thrombus)
Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.
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Types of endoleakType I: Distal attachment site
Type II: Patent lumbar artery
Thrush A et al. Peripheral vascular ultrasound. Elsevier, London, 2nd edition, 2005.Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.
Type II: Inferior mesenteric artery
Type I: Proximal attachment site
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Selective screening for AAA
• Selective screening
3 important risk factors Males
Age > 65 years
History of smoking
• Effectiveness of screening
4 RCTs including more than 125,000 men
Reported results for up to 5 – 10 years of follow-up
Reduction in mortality from 68% to 21%
Lederle FA. Ann Intern Med 2003 ; 139 : 516 – 22.
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Popliteal artery aneurysm / Partial thrombosis
Transverse CDUS Sagittal pulsed & CDUS
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Most common peripheral aneurysm
70% of peripheral aneurysms
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Popliteal artery aneurysm / Complete thrombosis
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Thrombosed popliteal aneurysm occluding PA
Patency of popliteal vein clearly demonstrated
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Differential diagnosis of pain in popliteal fossa
• Arterial aneurysm or pseudoaneurysm• Arterial dissection• Venous aneurysm • Adventitial cystic disease• Baker’s cyst• Enlarged lymph nodes• Hematoma, seroma, abscess • Muscle tears• Muscle tumors
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Popliteal vein aneurysm / Rare
1 MacDevitt DT et al. Ann Vasc Surg 1993 ; 7 : 282 – 286.2 Graham RN et al. Am J Surg 2010 ; 199 : e5 – e6.
Dilatation twice or 3 times of normal vein diameter 1
PE (70-80% ) – Post-thrombotic syndrome – Swelling in popliteal fossa
Longitudinal US Transverse US Color Doppler US
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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Intimal dissection of abdominal aorta
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Change in color coding due to
position of re-entry site
Color Doppler USLongitudinal & transverse scan
Gray-scale USLongitudinal & transverse scan
Intimal flap seen if sound beam
strikes at perpendicular angle
Search for involvement of visceral & iliac arteries
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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Pseudo-aneurysm
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
To-and-fro flow
Typical triphasic flow
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Pseudo-aneurysm / “to-and-fro” flow
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
During systole “to”
Flow enters PA via the neck
Pseudo-aneurysm lumen enlarges
During diastole “fro”
Flow exits PA via the neck
Pseudo-aneurysm lumen contracts
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Pseudo-aneurysm / CFA2 – 4% of cases after catheter intervention
Large perivascular
fluid collection
Color Doppler: swirling pattern “yin-yang” pattern
Pulsed Doppler: “to-and-fro” flow classic pattern
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Pseudoaneurysm / Variations in ‘‘to-and-fro’’ flow
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Limited systolic flow More pronounced diastolic flow
Diastolic flow decreases progressively
Diastolic flow increases progressively
Diastolic flow relatively limited
Two distinct phases of diastolic flow
Variations in duration & velocities of systolic & diastolic flow due to arrhythmia
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Pseudo-aneurysm / Multiloculated type Not uncommon
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Mistake made by inexperienced examiners:
Recognize most superficial lobe correctly
Confuse deeper lobe with femoral artery
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Pseudo-aneurysm / Differential diagnosis
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Arborizing flow in enlarged inguinal LN mistaken for PS
Low-resistance arterial flow with continuous diastolic flow
Venous flow below baseline
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Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.
Inguinal LN from melanoma
Vessels at base of LN different from pattern seen in PA
“to and fro’’ pattern near base of LN
Pseudo-aneurysm / Differential diagnosis
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Pseudo-aneurysm / US-guided compression 3 steps
Franklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.
Preparation Compression Following repair
Duration of compression: 10 – 15 minutes
Success rate: 75 – 85%
Complications: PA rupture, distal embolization, & venous thrombosis
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Pseudo-aneurysm / US-guided compression
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005 .
Marked perivascular tissue
vibration associated with arterial jet
US guided
compression
Pseudoaneurysm
successfully thrombosed
ThrombosisPA of CFA
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Pseudo-aneurysm / US-guided thrombin injection
Replaced compression as technique of choice
Needle advanced into superficial aspect of PA to avoid neck
100 – 300 units of human thrombin
Avoid fast injection
Success rate 97% according to several studies
Franklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.
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Pseudo-aneurysm / US-guided thrombin injection
Second injectionComplete thrombosis
CFA pseudoaneurysmSurrounded by hematoma
Thrombin injectionunder US guidance
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Success rate 97% according to several studies
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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Arterio-venous fistulaLeft external iliac artery
Right external iliac artery
Low resistance arterial flow
Right external iliac vein
Arterialized venous flow
Left external iliac vein
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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Arteritis / “macaroni or halo sign”
Higher-level echo
Lumen intima interface
Surrounded by
Concentric homogeneous hypoechoic structure
Intima media complex
Schäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd edition, 2011.
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Transverse scan Longitudinal scan
Giant cell arteritis / Abdominal aorta“Macaroni sign”
Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Aortic wall thickening (typical finding)
IMA at its origin pierces thickened wall directly
without first coursing close to aortic wall as in fibrosis
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Moussavian B & Horrow MM. Ultrasound Quarterly 2009 ; 25 : 89 – 91.
Retroperitoneal fibrosis / Ormond’s disease Hypoechoic cap-like structure anterior to aorta & IVC
Involvement of IVC important for differential diagnosis
Infra-renal abdominal aorta
Sagittal view
Infra-renal abdominal aorta & IVC
Transverse view
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Retroperitoneal fibrosis / Ormond’s disease
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
IMA arising from left lateral aspect of aorta
Pushed against aortic wall before piercing hypoechoic layer
Aorta at origin of IMA
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Inflammatory aortic aneurysmTypical appearance
Schäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd edition, 2011.
Atherosclerotic wall change
Circumferential hypoechoic layer around aneurysm confirms
the inflammatory origin of aneurysm
Transverse scan Longitudinal scan
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Thrombangiitis obliterans / Buerger diseaseMale – Smoker – Young (34 years)
• Location Distal lower leg & foot
• Occlusion material Hypoechoic
• Vascular wall Hypoechoic without calcification
• Occlusion length alternating normal/abnormal seg
• Collaterals “corkscrew vessels”
• Vein Phlebitis migrans
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
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Thrombangiitis obliterans / Buerger disease
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
37-year-old smoker – Rest pain in forefoot for 14 days
PTA
Occlusion without IMT Inflamed venous wall thickening
Superficial vein
35-year-old smoker – 3-year history of Buerger – Necrosis of toes
Typical corkscrew arteries
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Buerger’s Disease / Corkscrew Collaterals
Fujii et Y. J Am Col Cardiol 2011 ; 57 : 2539.
Type I: Large snake sign
> 5 mm
Type II: Small snake sign
3 – 5 mm
Type IV: Small dot sign
< 1 mm
Type III: Dot sign
1 – 3 mm
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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Vascular complications of entrapment syndrome
Post-stenotic aneurysm
Mural thrombi
Thrombotic occlusion
Method of choice for diagnosis & evaluation:
Duplex US with provocation tests
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
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Popliteal entrapment syndrome / Provocation tests Examaging PA just below knee joint space
Plantar flexion of foot
against hand of examiner
Standing on tip toe
Stretching of knee
while patient lies prone
Stiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
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Popliteal artery entrapment syndrome (PAES)Plantar flexion test
Progressive compression of popliteal artery by GCM
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
Asymptomatic compression of PA by provocation tests in > 50%
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Popliteal aretery entrapment syndrome (PAES)
Isolated popliteal artery occlusion
Transverse section
AS Soleus arteryVS Soleus vein
Longitudinal section
AS Soleus arteryVS Soleus vein
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
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Causes of arterial diseases
Atherosclerosis (most common cause)
Thrombosis or embolism
Aneurysm
Intimal dissection
Pseudo-aneurysm
Arterio-venous fistula
Arteritis
Entrapment syndrome
Cystic adventitial disease
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Cystic adventitial disease of PACyst involving long popliteal segment
Transverse view Longitudinal view
Difficult to differentiate from dissection with thrombosis of false lumen
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
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Cystic adventitial disease of PA
Transverse view Longitudinal view Pulsed Doppler
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
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Doppler US of lower limb arteries
Anatomy of lower limb arteries
Normal Doppler US of lower limbs arteries
Duplex US criteria for arterial evaluation
Causes of lower limb arterial diseases
Doppler US of bypass graft
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Bypass graft
Sonography is the recommended non-invasive
technique for the postoperative monitoring
of bypass graft patency
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Types of graft
• Synthetic graft
PTFE* Above knee
• Autologous vein
Reversed vein Removal – reversal – anastomosis
In situ vein Leaves vein in its bed – anastomosis
In all cases Removal of valves in vein graft
Perforating veins tied off
* PTFE: Polytetrafluoroethylene
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Aorto-bi-femoral graft Femoral-to-femoral artery bypass graft
Peripheral arterial bypass graft – 1
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Peripheral arterial bypass graft – 2
Femoro-Popliteal Above Knee
Femoro-Popliteal Below Knee
Femoro-Tibial Below Knee
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Bypass graft / Normal US
Composite PTFE & vein graft
Slightly dilated area
corresponding to valve site
In situ vein graft
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Bypass graft / Normal flow pattern
Hyperemic flow often seen
in early postoperative period
Hyperemic monopahasic flow Pulsatile flow
Over time, flow normally
assumes a pulsatile flow
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Bypass graft / Normal PSV
Average PSV
from 3 – 4 sites
without stenosis
Graft flow velocity
Normal PSV: 45 – 180 cm/s
AbuRahma AF et al. Noninvasive peripheral arterial diagnosis.
Springer-Verlag, London Limited, 1st edition, 2010.
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Bypass graft / Causes of graft failure
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004 .
Atherosclerosis
Graft degeneration
Neointimal hyperplasia
Technical faults
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Bypass graft / Sampling velocities in stenosis
Ratio 2.0 = 50% stenosis
Ratio 4.0 = 75% stenosis
Proximal anastomotic stenosis
Graft conduit stenosis
Distal anastomotic stenosis
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Bypass graft / Severe stenosis
Stenosis
PSV of A 16.4 cm/sec
PSV of B 319 cm/sec
Spectral broadening
B / A 19 times
A
Proximal to stenosis
A
B
At stenosis
B
Critical stenosis
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Hemodynamic criteria & management of graft stenosis
Category
Risk PSVcm/sec
PSV ratio
Graftvelocity
Management
I Maximum > 300 > 3.5 < 45 AnticoagulationImmediate intervention
Wixon CL et al. J Vasc Surg 2000 ; 32 : 1 – 12.
II High > 300 > 3.5 > 45 Elective interventionin 15 days
III Moderate < 300 > 2 > 45 ObservationCorrection if progression
IV Low < 180 < 2 > 45 Observation
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Bypass graft / Entrapment
Graft running between two
muscles causing moderate stenosis
Vein graft in lower tight
Graft compressed between two
muscles causing virtual occlusion
Leg flexion
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Bypass graft / Occlusion
Extremely low volume flow recorded from in situ
vein graft indicates imminent graft occlusion
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Bypass graft / Fibro-intimal hyperplasia
Large area of intimal hyperplasia in a vein graft
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Bypass graft / Aneurysmal area in vein graft
Aneurysmal area in vein graft corresponding to valve site
Area of hyperplasia or thrombus in area of dilation
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Bypass graft / False aneurysm
GFA
False aneurysm at distal end of femorofemoral graft
due to failure of anastomosis
Note corrugated appearance of Dacron material
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Bypass graft / Seroma
Fluid-filled seroma
adjacent to vein graft
Differential diagnosis:
– Seroma
– Hematoma
– Lymphocele
– Abscess
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Bypass graft / Infection
G
Echo region tracking from PTFE graft to skin surface
Pus discharging from skin surface at this point
I
G
I
PTFE (transverse view) PTFE (longitudinal view)
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References
Arnold – 2004 Elsevier – 2005 Springer-Verlag – 2011
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