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

• 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

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

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

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

Left gastric vein varices

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: CEUS

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

Control after repermeabilization

Surgical portosystemic shunts

• Portocaval

• Mesenterico-caval

• Splenorenal (Warren)

• Mesoatrial

• TIPS

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

HVPG 19 mmHg

Dilatation of stenosis

HVPG 13 mmHg

Double middle hepatic vein ?

Pancreatic cyst?

False aneurysm!

Renal vein thrombosis

Jean-Yves Meuwly, MD Department of Diagnostic …...Doppler ultrasound of the abdominal vessels:...

Documents

Transcript of Jean-Yves Meuwly, MD Department of Diagnostic …...Doppler ultrasound of the abdominal vessels:...