jean-yves meuwly, md department of diagnostic …...doppler ultrasound of the abdominal vessels:...
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Doppler ultrasound of the abdominal vessels:
Pathological findings
Jean-Yves Meuwly, MD
Department of Diagnostic and Interventional
Radiology, CHUV-Lausanne, Switzerland
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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
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Abdominal aorta: normal findings
• 16-25 mm in diameter
• Flow velocities 70-140 cm/s
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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
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Double abdominal aorta
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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.
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Arteriosclerosis
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Aneurysm
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Aneurysm
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Aneurysm
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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
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Dissecting aneurysm
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Dissecting aneurysm
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Dissecting aneurysm
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Dissecting aneurysm
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Dissecting aneurysm
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Celiac trunk: normal findings
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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
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Stenosis of the celiac trunk
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Stenosis of the celiac trunk
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Stenosis of the celiac trunk
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Anomaly of the celiac trunk
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Anomaly of the celiac trunk
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Anomaly of the celiac trunk
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Anomaly of the celiac trunk
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Stenosis of the hepatic artery
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Normal celiac trunc
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Stenosis of the hepatic artery
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Superior mesenteric artery
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Stenosis of the SMA
• Systolic velocity > 300 ± 30 cm/s
• Diastolic velocity > 45 cm/s
• Aliasing with color Doppler
• Thrill
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Stenosis of the IMA
• Elevated maximum systolic velocity
• Increased end-diastolic flow velocity
• Quantitative measurements not available
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Stenosis of the IMA
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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
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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
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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
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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
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Angiography
• Gold standard
• Invasive
• Nephrotoxicity
• Irradiation
• Expensive
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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
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Normal Doppler spectrum
Origin of the arteries
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Normal Doppler spectrum
Intrarenal vessels
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Increase in flow velocity
Origin of the right renal artery
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« Tardus parvus » pattern
Intrarenal vessels
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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
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Arterioveinous fistula
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Arterioveinous fistula
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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 %
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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
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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
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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
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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
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Reversed flow in left gastric vein
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Reversed flow in left gastric vein
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Left gastric vein varices
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Left gastric vein varices
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Recanalized paraumbilical vein
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Recanalized paraumbilical vein
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Caput medusae
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Reversed portal flow
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Reversed flow in SMV
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Mesenteric collaterals
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Portal vein thrombosis
• Idiopathic (most frequently)
• Tumoral:– HCC
– Pancreatic tumor
– Metastasis
• Post-operative
• Blood dyscrasia
• Sepsis, pyelophlebitis
• Pancreatitis
• Cirrhosis, portal hypertension
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Portal vein thrombosis
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Portal vein thrombosis
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Portal vein thrombosis?
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Portal vein thrombosis: CEUS
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Cavernous transformation
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Cavernous transformation
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• 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)
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Spiegel veins
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Hepatic venous outflow obstruction
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Hepatic venous outflow obstruction
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Control after repermeabilization
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Surgical portosystemic shunts
• Portocaval
• Mesenterico-caval
• Splenorenal (Warren)
• Mesoatrial
• TIPS
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TIPSS
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TIPS Shunt patency
Cardiac modulation in the portal vein
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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
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Shunt compromise
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Shunt compromise
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Shunt compromise
HVPG 19 mmHg
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Dilatation of stenosis
HVPG 13 mmHg
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Double middle hepatic vein ?
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Pancreatic cyst?
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False aneurysm!
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Renal vein thrombosis
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Renal vein thrombosis
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Renal vein thrombosis
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Renal vein thrombosis
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Renal vein thrombosis
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Renal vein thrombosis