Jean-Yves Meuwly, MD Department of Diagnostic …...Doppler ultrasound of the abdominal vessels:...
Transcript of Jean-Yves Meuwly, MD Department of Diagnostic …...Doppler ultrasound of the abdominal vessels:...
Doppler ultrasound of the abdominal vessels:
Pathological findings
Jean-Yves Meuwly, MD
Department of Diagnostic and Interventional
Radiology, CHUV-Lausanne, Switzerland
Abdominal vessels• Arteries
– Abdominal aorta
– Celiac trunk• Common hepatic artery
• Splenic artery
• Left gastric artery
– Superior mesenteric artery
– Inferior mesenteric artery
– Renal arteries
• Veins– Inferior vena cava
– Hepatic veins
– Portal vein
– Splenic vein
– Mesenteric veins
– Renal veins
Abdominal aorta: normal findings
• 16-25 mm in diameter
• Flow velocities 70-140 cm/s
Abdominal aorta: pathology
• Arteriosclerosis
• Aneurysm– True aneurysm: diameter > 3.0 cm or 1.5 x proximal
aorta
– Dissecting aneurysm: two lumina with asymmetrical blood flow
– False aneurysm: rare and usually traumatic
• Stenosis: maximum systolic velocity > 200 cm/s
• Prostheses
Double abdominal aorta
Refraction artifact
Meuwly, J. Y., A. S. Knopfli, et al. (2011). "Duplication of abdominal aorta: a very rare congenital anomaly but a commonultrasound artifact." Ultraschall Med 32(3): 233-236.
Arteriosclerosis
Aneurysm
Aneurysm
Aneurysm
Aneurysm
• Measurement in the anterioposterior diameter, in transverse scan plane
• Location of the upper and lower margins
• Additional aneurysm in other vascular segment of the peripheral arteries
• Risk of leakage:– > 5 cm
– Annual growth > 1 cm
Dissecting aneurysm
Dissecting aneurysm
Dissecting aneurysm
Dissecting aneurysm
Dissecting aneurysm
Celiac trunk: normal findings
Stenosis of the celiac trunk
• Maximum systolic velocity > 250 - 300 cm/s
• Aliasing with color Doppler
• Thrill
• Tardus parvus waveform in hepatic artery
• Low resistance in the periphery
• Sensibility 100%
• Specificity 88%
Harward T, J Vasc Surg 1993
Stenosis of the celiac trunk
Stenosis of the celiac trunk
Stenosis of the celiac trunk
Anomaly of the celiac trunk
Anomaly of the celiac trunk
Anomaly of the celiac trunk
Anomaly of the celiac trunk
Stenosis of the hepatic artery
Normal celiac trunc
Stenosis of the hepatic artery
Superior mesenteric artery
Stenosis of the SMA
• Systolic velocity > 300 ± 30 cm/s
• Diastolic velocity > 45 cm/s
• Aliasing with color Doppler
• Thrill
Stenosis of the IMA
• Elevated maximum systolic velocity
• Increased end-diastolic flow velocity
• Quantitative measurements not available
Stenosis of the IMA
Investigation of intestinal ischemia
• Demonstration of stenosis of two of the three splanchnic arteries is strongly suggestive of diagnosis
• Possible multiple collaterals
• 18% of patients over 60 years without symptoms of mesenteric ischemia have been shown to have significant disease on Doppler
Roobottom CA, AJR 1993
Indications for renal Doppler
• To confirm renal perfusion
• Diagnosis of renal vein thrombosis
• Renal obstruction
• Renal tumor
• Renal artery stenosis– Screening
– Follow-up
• Arterioveinous anomalies
• Aortic aneurysm and aortic dissection
Renal artery stenosis
• Morphological renal artery stenosis– Angiography
– Doppler
– Spiral CT
– MR Angiography
• Functional renal artery stenosis– Scintigraphy
– Doppler sensibilised with Captopril
– MRI sensibilised with Captopril
Morphological stenosis
• Arterial narrowing >50% leads to a
significant reduction in renal blood flow
– Atheroma (75%)
– Dysplasia (25%)
No information on the relationship between stenosis and HTA
Angiography
• Gold standard
• Invasive
• Nephrotoxicity
• Irradiation
• Expensive
Doppler ultrasound• Morphologic and hemodynamic criteria• Assessment of renal arteries
– Origins and course of both renal arteries– Increase in flow velocity with spectral broadening– PSV 200 cm/s, RAR 2.5
• Assessment of intrarenal vessels– Tardus parvus pattern– Reduced resistance index < 0.5
• Sensitivity 92 - 98%• Specificity 81 - 98%
de Haan, M. W., A. A. Kroon, et al. (2002). "Renovascular disease in patients with hypertension: detection with duplex ultrasound." J Hum Hypertens 16(7): 501-7.
Staub, D, Canevascini, R, Huegli R. W., et al. Best Duplex-Sonographic criteria for the assessment of renal artera stenosis – Correlation with intra-arterial pressure gradient. (2007) Ultraschall in Med 28: 45-51
Normal Doppler spectrum
Origin of the arteries
Normal Doppler spectrum
Intrarenal vessels
Increase in flow velocity
Origin of the right renal artery
« Tardus parvus » pattern
Intrarenal vessels
Comparison of techniques
Vasbinder JBC, Nelemans PJ, Kessels AGH, et al. Diagnostic tests for renal stenosis in patients suspected of having renovascular hypertension: A meta-analysis. Ann Intern Med 2001; 135:401-411
Arterioveinous fistula
Arterioveinous fistula
Portal vein
• 70% of incoming blood volume to the liver
• Oval lumen, 7-15 mm maximum diameter
• Hepatopetal flow
• Average flow velocity 15 ± 3 cm/s
• Flow of «PLUG» type
• Postprandially:– Increased velocity of 25-50 %
– Increased flow of 180-200 %
Portal hypertension• Prehepatic
– Portal thrombosis
– Portal vein compression
– Arterio-venous fistula
– Schistosomiasis (most frequent origin throughout the world)
• Intrahepatic– Toxic, drugs or viral induced hepatopathy
– Veno-occlusive disease of bone morrow transplantation
– Cirrhosis
– Hepatocarcinoma, metastases, lymphoproliferative disease
• Posthepatic– Budd-Chiari syndrome (HVOO)
– Cardiac disease
Portal hypertension
• Elevation in portal vein pressure by 5 mmHg
• Development of collateral pathways– Short gastric, left gastric and coronary veins varices
– Paraumbilical veins
– Splenorenal-mesenteric collaterals
– Pericholecystic varices
– Haemorrhoideal collaterals
• Haemorrhagic risk when pressure rises to 12 mmHg
Portal hypertension
• Extrahepatic dilatation of the portal vein
• Rounded cross-section
• Decreased respiratory modulation
• Decreased flow in the portal vein
• Dilated splenic vein (>10 mm)
• Splenomegaly
• Collateral circulation
• Ascites
• Pathological findings in the liver parenchyma
Portal hypertension: collaterals
1. Paraombilical vein:
Caput medusae
2. Left gastric and
coronary veins
3. Right gastric veins
4. Splenorenal veins
5. Mesenteric et rectal
veins
1
23
4
5
Reversed flow in left gastric vein
Reversed flow in left gastric vein
Left gastric vein varices
Left gastric vein varices
Recanalized paraumbilical vein
Recanalized paraumbilical vein
Caput medusae
Reversed portal flow
Reversed flow in SMV
Mesenteric collaterals
Portal vein thrombosis
• Idiopathic (most frequently)
• Tumoral:– HCC
– Pancreatic tumor
– Metastasis
• Post-operative
• Blood dyscrasia
• Sepsis, pyelophlebitis
• Pancreatitis
• Cirrhosis, portal hypertension
Portal vein thrombosis
Portal vein thrombosis
Portal vein thrombosis?
Portal vein thrombosis: CEUS
Cavernous transformation
Cavernous transformation
• Occlusion (BCS) or stenosis of hepatic vein(s)
• May be associated with IVC thrombosis or stenosis
• Primary:– Membranous obstruction – fibrous web (major cause in South Africa and Asia)
• Secondary:– Hypercoagulation disorders
– Trauma
– Cancer
– Toxic
– Pregnancy
– Oral contraceptives
• Idiopathic (70%)
Budd-Chiari syndrome (HVOO)
Spiegel veins
Hepatic venous outflow obstruction
Hepatic venous outflow obstruction
Control after repermeabilization
Surgical portosystemic shunts
• Portocaval
• Mesenterico-caval
• Splenorenal (Warren)
• Mesoatrial
• TIPS
TIPSS
TIPS Shunt patency
Cardiac modulation in the portal vein
Shunt compromise • Intimal hyperplasia
• Focal stenosis
• Portal flow < 50 cm/s– Chong WK et al, Radiology 1993
• Flow < 50 cm/s in the shunt– Feldstein VA et al, Radiology 1996
• Increase or decrease in shunt velocity of > 50 cm/s compared with initial value– Dodd GD III, Gastroenterology 1992
• Hepatopetal flow in portal vein branches
• Hepatofugal flow in main portal vein
Shunt compromise
Shunt compromise
Shunt compromise
HVPG 19 mmHg
Dilatation of stenosis
HVPG 13 mmHg
Double middle hepatic vein ?
Pancreatic cyst?
False aneurysm!
Renal vein thrombosis
Renal vein thrombosis
Renal vein thrombosis
Renal vein thrombosis
Renal vein thrombosis
Renal vein thrombosis