Abdominal Vasculature SONO 131 – Lecture #4. Vascular Anatomy Arterioles Artery Heart Capillaries...
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Transcript of Abdominal Vasculature SONO 131 – Lecture #4. Vascular Anatomy Arterioles Artery Heart Capillaries...
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Abdominal Vasculature
SONO 131 – Lecture #4
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Vascular Anatomy
Arterioles
Artery
Heart
Capillaries Venules
Vein
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Vascular Anatomy
Vessel Walls– Tunica intima– Tunica media– Tunica adventitia– Vasa vasorum
Arteries Veins
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Circulatory Anatomy
Aorta– Ascending– Arch– Descending– Thoracic– Abdominal
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Anterior Branches Abdominal Aorta
Celiac Trunk [Axis]– Common hepatic
Hepatic– Right and Left Hepatic
Gastroduodenal– Left Gastric– Splenic
Left gastroepiploic Short gastric artery Several smaller splenic arteries Great pancreatic artery
Hepatic– Left and right hepatic
SMA– Inferior pancreatic– Duodenal– Colic– Ileocolic– intestinal
IMA– Left colic– Sigmoid– Superior rectal
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Celiac Trunk
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Mesenteric Arteries
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Lateral & Dorsal Branches
Lateral– Phrenic
Paired arteries
– Renal Right & Left
– Gonadal
Dorsal– Lumbar
4 on each side of aorta
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Renal Arteries
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Sonographic Appearance - Arteries
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Sonographic Appearance - Arteries
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Sonographic Appearance - Arteries
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Abdominal Artery Summary
Abdominal aorta– Celiac Axis
Splenic artery Hepatic artery Left gastric artery
– SMA Inferior pancreatioduatenal Branches to the colon
– Renal Arteries Level L1 – 2
– IMA– Aortic bifurcation
Right & Left Common Iliac arteries
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Abdominal Venous System
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Inferior Vena Cava
IVC = union of common iliac veins
Tributaries to IVC– 3 anterior hepatic veins– 3 lateral
Right suprarenal veins Renal veins Right testicular or ovarian vein
– 5 lateral abdominal wall veins inferior phrenic + lumbar
– 3 veins of origin common iliac + median sacral
Drains – Abdominal organs – Abdominal structures– Lower extremities
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Lateral Abdominal Veins
Suprarenal Veins– Right & Left
Renal Veins– Right & Left
Gonadal Veins– Testicular or Ovarian
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Anterior Abdominal Veins
Hepatic Veins– Right– Middle– Left
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Portal Venous System
Portal Vein
Splenic Vein
Superior Mesenteric Vein
Inferior Mesenteric Vein
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Sonographic Appearance - Veins
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Abdominal Vein - Summary
IVC– Right and left
common iliac veins– Renal veins– Hepatic veins
Portal vein– Splenic & SMV– Right & left portal vein– Porta hepatis– Hepatopetal flow
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Clinical Indications Abdominal Vasculature Imaging
Arterial– Suspect aortic aneurysm– Possible ateriovenous fistula– Possible mesenteric ischemia
Venous– Leg swelling– Portal hypertension
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Arterial Abnormalities
Atherosclerosis - altering of intimal lining of artery by focal accumulation of lipids, complex carbohydrates, blood and blood products, fibrous tissue and or calcium deposits
– Cause – No known cause, but progression linked hyperlipidemia, hypertension, cigarette smoking and diabetes mellitus
– Signs, Symptoms – None until significant stenosis
– Sonographic Appearance – Luminal irregularities, tortuosity, vessel wall calcification
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Aorta Aneurysm
True Dilation of artery due to wall weakness Lined by all 3 components of artery wall
– Fusiform– Saccular
False Lined by outer layers of aortic wall or clot
– Dissecting– Pseudoaneurysm
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Aneurysm - Patient Presentation
Causes– Atherosclerosis– Trauma– Syphilis– Marfan’s syndrome– Mycotic (Infective)
Clinical Features– Abdominal or back pain– Abdominal bruit– Pulsatile abdominal mass– Impaired distal arterial
flow
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Dissecting Aortic Aneurysm
Type I– Ascending Aorta– Aortic Arch– Most dangerous [spiral]
Type II– Marfan’s Syndrome– Ascending Aorta– Aortic Arch
Type III– Descending Aorta– Abdominal Aorta
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Aortic Aneurysm
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Ultrasound Presentation
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Endovascular Stent Graft
Medtronic Aneurx Cook Zentih Gore Excluder
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Stent Graft Therapy
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Stent Graft Therapy
Completed Deployment
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Stent Graft Therapy
Pre – Stent Placement Post – Stent Placement
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Stent Graft Therapy
Pre – Stent PlacementPost – Stent Placement
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Aortic Rupture Risk Factors
Diameter Rapid expansion > 0.6 cm / year Family history Hypertension COPD, Current Smoking Shape:
Eccentric > Saccular> Fusiform
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Inflammatory Aneurysms
Aneurysm enveloped by a dense fibrotic reaction
Uncommon – 5 to 20% of aneurysms Uncertain cause Clinically like other aneurysms
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Branch Vessel Aneurysm
Splenic– Most common– Usually multiple & occur in main splenic trunk– Life threatening
Hepatic– 2nd most common– Right hepatic arterial branch – Common cause – systemic infection,
arteriosclerosis, blunt trauma– Silent or asymptomatic
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Branch Vessel Aneurysm
SMA– Rarest [1 in 12,000]– Cause - cystic medial necrosis (mycotic aneurysm)– Intestinal angina & postprandial abdominal pain– General abdominal pain, fever
Renal Artery– Low incidence – approximately 20%– Symptoms – palpable mass, hypertension, blood in
urine, flank pain
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Vascular Stenosis
Vessel lumen narrowed Post stenotic dilatation Increased velocities in area of stenosis Down stream changes
– Turbulence– Decreased velocities– Slowed acceleration during systole– Relative elevation of diastolic velocities
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Abdominal Artery Evaluation
Doppler flow patterns [Angle corrected @ 60]– Aorta
Proximal – high systolic / low diastolic flow Distal – triphasic flow
– Celiac Axis Spectral broadening Unchanged after meals
– Hepatic Artery Spectral broadening
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Arterial Flow Characteristics
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Renal Artery Stenosis
– Associated with uncontrollable hypertension Up to 6% of all hypertensive patients have renal artery
stenosis as underlying cause
– Decreased glomerular filtration rate– Ischemic renal damage– Atherosclerotic plaque within first 2 cm– Fibromuscular dysplasia – lesions in distal 2/3 of
renal artery
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Renal Artery Stenosis
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Mesentery Artery Stenosis
Lack of adequate blood supply due to underlying vascular compromise
– Mesenteric atherosclerotic disease– Embolic phenomenon
Individuals at risk:– Smoking, coronary disease, PAD, chronic renal disease,
diabetes mellitus Symptoms:
– Progressive postprandial pain, weight loss, change in bowel habits, epigastrc bruit
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Venous Flow Characteristics
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Venous Abnormalities
Vena Caval Obstruction
Tumors of the IVC
Portal Venous Thrombosis
Portal Venous Hypertension
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Vena Caval Obstruction
IVC site of clot or tumor Greenfield filter
– Reduce risk of clot embolizing
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Renal Vein Thrombosis
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Hepatic Venous Abnormalities
Budd-Chiari Syndrome– Occlusion of some or all
of the hepatic veins or occlusion of IVC
– Clinically – Ascites, right upper quadrant pain, hepatomegaly
– Sonographically – sluggish flow in IVC & hepatic veins
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Portal Venous Abnormalities
Thrombosis Hypertension
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Portosystemic Shunts
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Portosystemic Shunts
Surgical end-to-side or side-to-side anastomosis of portal vein and IVC or TIPS
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TIPS [Transjugular Interhepatic Portosystemic Shunts]
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Abdominal Vasculature Review