ANATOMY- ARTERIAL AO -Ascending AO: arises fr LV of the ♡ -Branches: Rt/Lt Coronary Art -AO Arch Branches: 1. Innominate (Brachiocephalic), 2. LT CCA, & 3. LT Subc A -Thoracic (Descending AO): fr the ♡ → AO opening (hiatus) of the diaphragm -Small branches feeding Pericardium, lung, esophagus & intercostal spaces are: -Pericardial branches, Esophageal A, Phrenic branches, Bronchial A, Mediastinal branches, POST Intercostal A ANATOMY- ARTERIAL  ABD AO -Fr the AORTIC opening in diaphragm to the Iliac Bif near level of the umbilicus -Ventral (ANT) aspect branches: 1. Celiac A 2. SMA 3. IMA -LAT aspect branches: 1. INF Phrenic A 2. Middle Suprarenal A 3. Renal A 4. Testicular or Ovarian A (Gonadal A) -Dorsal (POST) aspect branches: 1. Lumbar A=Collateral source for ABD & Viscera 2. Median Sacral A ANATOMY- ARTERIAL  Major Visceral Branches (Celiac A) -aka Celiac Trunk or Celiac Axis -1st major Ventral (ANT) branch of the ABD AO -Supplies Bl to stomach, Liver, Panc & Spleen -Divides into: 1. Splenic A: Coursing to the LT 2. LT Gastric A: Coursing to the LT 3. Common Hepatic A: Coursing to the RT a. Courses adj to the PV toward Porta Hepatis b. Gives rise to the GDA (Considered the Proper Hepatic A) -GDA courses INF, cont along POSTEROMEDIAL aspect of duodenum & toward ANTEROLAT surface of the Pancreatic head -Proper HA follows PV & CBD & divides→RT/LT HA w/in the liver -RT HA is located betw the CBD & PV ANATOMY- ARTERIAL  Major Visceral Branches (SMA) -2nd Ventral (ANT) branch off ABD AO arising approx 1 cm below Celiac Axis -Occasionally originates off the Celiac Axis -Courses INF, running Parallel to the ABD AO -Primarily supplies Bl to: -the Small intestine as well as the Pancreatic head, Cecum, Ascending Colon & a portion of the TRV Colon ANATOMY- ARTERIAL  Major Visceral Branches (Renal A-RT/LT) -Branches LATERALLY fr the AO, arising slightly INF (1-1.5 cm) to the SMA -RT RA courses POST to the IVC before entering the kidney. It is longer in length than the LT RA -LT RA enters dir→the hilum of the LT Kidney -Approx 20% of the population will have DUPLICATE RA (known as Accessory or Polar RA) -RA supply Bl to the Kidneys, Suprarenal glands & Ureters ANATOMY- ARTERIAL  Major Visceral Branches (Intrarenal Branches) 1. Segmental (Lobar) A 2. Interlobar A 3. Arcuate A 4. Interlobular A (Cortical branches) 5. Afferent/Efferent glomerular A (microscopic level) 6. Intertubular Capillary Plexuses (microscopic level) ANATOMY- ARTERIAL  Major Visceral Branches (IMA) -Arises fr ANTEROLAT position on the Mid-DIST LT side of the AO, DIST to the RA & approx 3-4cm SUP to the Iliac Bif -Smaller than the SMA & courses down to the LT Iliac fossa to become the Superior Hemorrhoidal A -Supplies Bl to the LT half of the TRV Colon, Descending Colon, Sigmoid Flexure & greater part of the Rectum ANATOMY- ARTERIAL  Major Visceral Branches (Gonadal A) -Testicular A: arise fr the ANT surface of the AO, pass thru the Inguinal ring to enter scrotum -Ovarian A: shorter than Testicular A & do NOT pass beyond the ABD cavity ANATOMY- ARTERIAL  Major Visceral Branches (ILIAC A) -RT & LT CIA: Arise fr the DIST AO @ the Iliac Bif -Each CIA Bif into the IIA (Hypogastric A) and the EIA ANATOMY- VENOUS Central Veins (SVC) -Formed by anastamosis of RT/LT Brachiocephalic (Innominate) Vns in the upper chest -Rcvs Bl fr UE & drains→RT Atrium of the ♡ -Venous flow is usually Pulsatile & Phasic in the SVC ANATOMY- VENOUS Central Veins (IVC) -Formed by union of the CIV in the pelvis & ascends to the RT of the AO -CIV: Formed fr union of the EIV & IIV -Rcvs Bl fr numerous ABD branches or tributaries before emptying→RA of the ♡ -Venous flow is usually Phasic in the IVC ANATOMY- VENOUS Visceral Veins (HV Rt/Middle/Lt) -Largest tributaries of the IVC -Drain Bl fr the Liver & empty→IVC (HEPATOFUGAL) -May enlarge in pts suffering fr CHF ANATOMY- VENOUS Visceral Veins (Renal Vns) -Return Bl fr Kidneys to the IVC -They anastamose on the LAT sides of the IVC, lying ANT to their respective RA -RT Renal V: -Has Dir route→the IVC & is SHORTER than the LT RV -RRV Rarely accepts branches=RT Adrenal & RT Gonadal Vns enter IVC Dir w/o comm to the RA -LT Renal V: -Courses fr the LT Kidney, ANT to the AO & POST to the SMA to enter the IVC on its LAT aspect -LRV Accepts Branches fr the LT Adrenal, LT Gonadal & Lumbar Vns b4 entering the IVC ANATOMY- VENOUS Visceral Veins (Gonadal Vns) -RT Gonadal Vns: drains Bl dir→the IVC -LT Gonadal Vns: drains Bl→LRV ANATOMY- VENOUS Portal Venous System -Venous branches that form the PV do NOT Dir join the IVC -Drains nutrient rich Bl fr the Intestines, Spleen, Stomach, GB & Panc -HEPATOPETAL: flow TOWARD liver -HEPATOFUGAL: flow AWAY fr liver -Normal Portal flow is HEPATOPETAL  ANATOMY- VENOUS Portal Venous System (4 Major Vessels) 1. PV or MPV 2. SPLENIC V 3. SMV 4. IMV ANATOMY- VENOUS Portal Venous System (PV or MPV) -Formed fr confluence of the SV & SMV -Collects Bl fr the SV, SMV & IMV -Divides→RT/LT Portal Branches w/in the Hepatic parenchyma ANATOMY- VENOUS Portal Venous System (Splenic V-SV) -Formed by tributaries of the Spleen=Short Gastric V, Pancreatic V, LT Gastro-epiploic V, IMV -Drains Bl fr Spleen, Panc, & Stomach -Joins w/ SMV to form the PV ANATOMY- VENOUS Portal Venous System (SMV) -Courses SUP fr intestines to join w/ the SV to form the MPV -Drains Bl fr Small Intestine, Cecum, Ascending/TRV Colon -Tributaries incl: RT Gastro-epiploic v, LT Gastric V, Pancreaticduodoneal V, RT Gastric V, Paraumbilical V & Cystic Vns ANATOMY- VENOUS Portal Venous System (IMV) -Drains Bl fr Colon -Travels SUP to join the SV POST to the PANC ABD/VISCERAL Common Congenital Anomalies 1. CA & SMA arise fr the AO as a common trunk 2. Common or RT HA may arise fr the SMA or dir off the AO 3. LT HA may arise fr LT Gastric A 4. IMV may terminate @ the junction w/ SMV & SV or → the SMV itself 5. Middle & LT HV may join to form a common trunk b4 entering the IVC 6. 1 of the 3 major HV (usually the RT HV) may be ABSENT 7. Duplication or transposition of IVC 8. Duplicate RA (Accessory or polar Art) 9. Duplicating LT RV=1 passing ANT & 1 passing POST to the AO 10. Duplicating RT RV= Both drain dir→IVC ABD/VISCERAL Risk Factors -ARTERIAL: 1. Diabetes 2. Smoking 3. Hypertension 4. Hyperlipidimia 5. Atrial Fibrillation (AF) -VENOUS: 1. Prior Thrombosis 2. Malignancy 3. Liver Disease MECHANISMS OF DISEASE  Renovascular Hypertension (HTN) -HTN caused by disease of the RA -Primary causes are: 1. Atherosclerosis 2. FMD of the main RA -Other causes incl: 1. Takayasu Arteritis 2. Post-irradiation Fibrosis 3. Neurofibromatosis 4. Thrombosis/embolism of the RA MECHANISMS OF DISEASE  Renovascular Hypertension (HTN) Diagnosis -↑ BP (HTN) -Stenosis/Occlusion of 1 or both RA -Renal Ischemia MECHANISMS OF DISEASE  Renovascular Hypertension (HTN) Treatment -Controlling BP is not the issue;  -Renal Failure secondary to RA Stenosis is a more Prevalent issue. Treatment includes: 1. Medical treatment 2. Surgical treatment a. Angioplasty & stenting, surgical revascularization, endarterectomy or bypass grafts MECHANISMS OF DISEASE  Mesenteric Angina/Ischemia -Caused by inability of Bl to reach intestines due to Stenosis or Occlusion of the SMA, CA or IMA -Criteria of diagnosis: a. Documentation of Critical Stenosis or Occlusion of @ least 2 of the 3 vessels -Sx incl ABD pain 15-30 mins postprandial (after eating) MECHANISMS OF DISEASE  Mesenteric Angina/Ischemia-Acute  -Usually caused by embolic occlusion fr a thrombus -Sx include: a. Severe abrupt onset of ABD pain b. ABD distention -Delayed diagnosis is a potential for catastrophic GI Ischemia & is considered a surgical ER MECHANISMS OF DISEASE  Mesenteric Angina/Ischemia-Chronic -Caused fr gradual progression of atherosclerosis, thrombus or embolism -Sx include: a. Postprandial pain b. Wt loss c. Diarrhea d. Aka 'fear of food syndrome' -Compensatory collateral circulation develops aiding the pt in tolerating the sx, making it difficult to diagnose MECHANISMS OF DISEASE  Portal HTN- Causes -↑ BP in PV resulting fr ↑ R to Bl flow -R is caused by: 1. Portal SV thrombosis/or tumor invasion 2. Cirrhosis 3. Trauma 4. Previous thrombus 5. Small Intrahepatic PV radicals 6. Budd-Chiari Syndrome (thrombosis of HV) MECHANISMS OF DISEASE  Portal HTN- Symptoms (Sx) 1. GI bleeding 2. Ascites 3. Hepatomegaly 4. Splenomegaly 5. Varices/bleeding @ various sites incl: a. Patent Ligamentum Teres (LT) b. Esophageal Varices c. Splenic Varices d. Subcapsular liver varices e. Hemorrhoids 6. Jaundice MECHANISMS OF DISEASE  Abdominal Aortic Aneurysm (AAA) -If Aortic internal lumen is >3 cm or if diameter of ART ≥ 1.5x the normal diameter -Occurs DIST to the RA & may extend→CIA MECHANISMS OF DISEASE  Abdominal Aortic Aneurysm (AAA)-Classification -Fusiform: Uniform, circumferential dilation of Aortic segment. Common in area of DIST ABD AO & Iliac Bif -Saccular: Focal outpouching on 1 side; NOT entire vessel circumference -Dissection: Longitudinal splitting of inner ART wall (betw intima & media) -Mycotic: Infection related aneurysm MECHANISMS OF DISEASE  Abdominal Aortic Aneurysm (AAA)-Etiology 1. Atherosclerosis 2. Aging 3. Infection/Inflammation 4. Trauma 5. Congenital Anomalies a. Ehler-Danlos Syndrome=Affect mfg of collagen w/c causes CT to be weak b. Marfan's Syndrome=CT defect causing weakness throughout the body incl ♡ & bl vessels 6. Medial Degeneration 7. Arteritis MECHANISMS OF DISEASE  Abdominal Aortic Aneurysm (AAA)- Signs & Sx 1. May be Asymptomatic (incidental finding) 2. ABD &/or back pain 3. Throbbing sensation in ABD='Pulsatile ABD mass' 4. DIST embolization causing 'blue toe syndrome' in the digital Art or occlusion of another small DIST Art MECHANISMS OF DISEASE  IVC Thrombosis -Development or existence of a Bl clot in IVC -Sx incl: 1. LE edema 2. Low back or pelvic pain 3. GI discomfort Non Invasive Test Procedures Direct-duplex/Color flow imaging-Capabilities -IDs AAA, AO stenosis &/or Occlusion -Eval patency & normalcy of flow in the SMA, CA & RA; detects Stenosis & Occlusion -Locates & IDs Venous thrombosis; determine patency of IVC, PV, HV, RV -Assess Portal HTN & Porto-caval shunts -IDs Vascular extrinsic compression syndrome Non Invasive Test Procedures Direct-duplex/Color flow imaging-Limitations -Pt cooperation, inability to hold breath or rapid breathing -Inability to eval vessels due to: a. Bony structures b. Bowel gas c. Scar tissue d. Recent surgery e. Excessive depth of vessels due to body habitus Non Invasive Test Procedures Direct-duplex/Color flow imaging-Pt Positioning -Supine w/ minimal head elevation -Decubitus=for access to flank areas, also helps to move bowel out of the way -Reverse Trendelenburg=for IVC studies Non Invasive Test Procedures Direct-duplex/Color flow imaging- Exam Protocol -Pt s/b fasting 6-8 hrs or overnight to minimize bowel gas formation -Low F Tx (2.5 or 3.5 MHz) A 5.0 Tx can be used for ANT vessels -ALL vessels s/b eval in SAG/TRV w/ 2-D, color & Doppler -Color/Doppler will determine: a. Presence/absence of flow b. Dir of flow c. Flow characteristics Non Invasive Test Procedures Imaging & Spectral Doppler Techniques-AO -Eval & meas the PROX, MID, DIST AO in AP & LAT diameter in the TRV plane -Check for Aneurysm=Note Loc, type & presence of thrombus. Meas RL if present -Check for Atherosclerotic plaque or dissection -Obtain Spectral waveforms PROX to the RA & meas PSV -Eval of Aortic Endograft placement a. Meas AAA residual b. Assess flow thru entire graft w/ color & Spectral Doppler to r/o stenosis or occlusion c. Eval periphery of graft & native AO for endograft leak d. Always perform ABI in conjunction for peripheral flow Non Invasive Test Procedures Direct-duplex/Color flow imaging- CA, SA, HA -Obtain Spectral waveforms fr Longitudinal plane & meas PSV/EDV -Look for flow disturbance and 'map' stenosis, if present -Visualization of CA, SA & HA is best in TRV a. Image resembles a 'seagull' or 'dove' w/ the HA coursing RT & Splenic A coursing Lt Non Invasive Test Procedures Direct-duplex/Color flow imaging-SMA -In TRV, it is seen MIDLINE as a Round, Anechoic structure w/ highly thick echogenic walls (layer of fat), ANT to the AO & POST to the SV -Obtain Doppler waveform fr a Longitudinal plane a. Map Stenosis if found b. Meas PSV/EDV c. Some protocols require an assessment while pt is fasting ff by a postprandial exam Non Invasive Test Procedures Direct-duplex/Color flow imaging-IMA -May be difficult to see due to overlying ABD bowel gas & its small caliber size -Best seen in SAG, originating fr the DIST LT ANTERO-LAT AO SUP to the Bif of the CIA Non Invasive Test Procedures Direct-duplex/Color flow imaging-Renal A (RAR) -Using Color & Spectral Doppler, eval origin of both RA @ the AO -If possible, eval entire lenght of RA to the kidneys -Calc the RENAL-TO-AORTIC Ratio (RAR) a. Divide highest RA PSV by PSV of the AO taken DIST to the SMA, but PROX to the RA origin -Image kidney in Longitudinal view; Meas length of kidney Non Invasive Test Procedures Direct-duplex/Color flow imaging-Renal A (RI & AT) -Obtain Doppler waveforms fr the Segmental RA; meas PSV & EDV (some labs meas AT or Rise Time) -Calc RI fr Segmental flow by Subtracting EDV fr PSV then dividing by the PSV -Another method of eval RA flow is to determine the AT/AI -AT is the time interval fr onset of systole to initial peak (msec) -AI is the slope of the Doppler Vel waveform. Calc as the the change in Vel betw onset of systole & systolic peak (cm/s) divided by AT Non Invasive Test Procedures Direct-duplex/Color flow imaging-IVC/HV -IVC: -Observe contraction & expansion of the vessel during respirations -Obtain Doppler waveforms in longitudinal -HV: -Best seen in TRV @ the level of the Xiphoid w/ Tx angled slightly Cephalic & to the RT -Look for outflow obstruction that may be caused by Hepatomegaly, Splenomegaly or Ascites Non Invasive Test Procedures Direct-duplex/Color flow imaging-PV, SV, MV 1. PV: -Assess w/ Color & Spectral Doppler; meas Diameter of main PV near the Porta Hepatis  2. SV: -Best seen in TRV midline, ANT to AO, SMA & IVC; forms the POST border of the Pancreatic body & tail 3. SMV: -Best seen in Longitudinal as a long tubular vessel ANT to the IVC Non Invasive Test Procedures Direct-duplex/Color flow imaging- RV -Eval fr the hilum of the kidney to the IVC -Obtain a Doppler sample close to the hilum of the kidney Non Invasive Test Procedures Interpretation (AO) -Normal 2-D appearance: a. SAG: Anechoic, tubular w/ echogenic walls, located LT of Midline; Courses INF, tapering in caliber DISTALLY b. TRV: Rounded appearance w/ anechoic lumen & echogenic walls -Meas: s/b <3 cm; dimensions in excess of this indicate aneurysm -Spectral Doppler/waveform: High R, Triphasic or Biphasic flow patterns Non Invasive Test Procedures Interpretation (AO) Endograft Eval -2-D assessment: -Compare sequential examinations, AAA s/b decreasing in size w/ time -An ↑ in size is evidence w/ Leak -Spectral Doppler: similar to peripheral grafts -≥ to 2x PSV fr just PROX=50% Stenosis -≥ to 4x PSV fr just PROX=75% Stenosis -Post placement complications: -Hematomas/Seromas -Pseudoaneurysms -Infection -Endoleak Non Invasive Test Procedures Interpretation (CA) -Normal 2-D appearance: -SAG: Small anechoic, tubular structure coursing INF fr the ANT surf of the AO -TRV: Best seen in this plane; 'Seagull' or 'dove' -Spectral Doppler/Waveform: -Normal flow is Low R w/ PSV fr 50-160 cm/s; EDV is usually <50 cm/s -PSV >200 cm/s w/ Post Stenotic Turbulence indicates a >70% stenosis -CA flow is not affected by fasting or eating Non Invasive Test Procedures Interpretation (HA) -Normal 2-D appearance: -Longitudinal view is most commonly visualized extending fr the CA origin & traveling to the RT -TRV view can be seen @ the Porta Hepatis in the liver -Spectral Doppler/Waveform:  -Low R w/ a large amt of continuous FWD flow throughout Diastole -Pts w/ Portal HTN, HA may be visibly enlarged w/ ↑ PSV/EDV flow -If CA is occluded, HA may be Retrograde flow Non Invasive Test Procedures Interpretation (Splenic A) -Normal 2-D appearance: -Tortuous, seen most commonly in TRV @ its origin w/ the CA -Spectral Doppler/Waveform: -Low R w/ ↑ Spectral Broadening due to turbulence fr tortuousity Non Invasive Test Procedures Interpretation (SMA) -Normal 2-D appearance: -SAG: 2nd ANT branch of the AO; Tubular appearance coursing INF -TRV: Seen Midline as a round, anechoic structure w/ highly thick echogenic walls, ANT to the AO & POST to the SV Non Invasive Test Procedures Interpretation (SMA) Spectral Doppler/Waveform analysis -Normal Vel: -Preprandial: High R=PSV 110-180 cm/s -Postprandial: Low R= broad PSV ranges -Abnormal Vel: <70% Stenosis -Preprandial: PSV<275 cm/s w/ Post stenotic Turbulence -Postprandial: Vel remains High R if obstruction is present Non Invasive Test Procedures Interpretation (IMA) -Normal 2-D appearance: -SAG: Small linear vessel coursing INF to the SMA, originating fr the DIST AO SUP & LT b4 the BIF of the CIA Non Invasive Test Procedures Interpretation (IMA) Spectral Doppler/Waveform analysis -Normal High R flow pattern fasting, changing to a Low R post prandial -Normal Vel: -PSV will vary fr 93-189 cm/s -Abnormal Vel: -PSV will vary depending on degree of collateral flow thru IMA in cases of occlusive dis of the ABD AO & other mesenteric vessels -PSV up to 190 cm/s were seen in pts w/ occlusion of the CA, SMA & CIA Non Invasive Test Procedures Interpretation (Renal A) -2-D appearance: Size & morphology 1. 10-12 cm length; ≤ to 8 cm=Chronic Renal Vascular disease 2. Examine the Renal Parenchyma for cysts, cortical thinning or other defects such as masses Non Invasive Test Procedures Interpretation (Renal A) Spectral Doppler/Waveform analysis -Low R flow pattern throughout the Renal & Intraparenchymal A; High R flow=Parenchymal Disease (Intrinsic Renovascular disease) -Tardus Parvus waveform (low Amplitude) pattern in Segmental RA & Rise time exceeding 0.7s suggests Main RA Stenosis or Occlusion -PSV in the main RA of >180 cm/s, PST & low flow Vel in the DIST RA are ABNORMAL Non Invasive Test Procedures Interpretation (RAR/RI) Spectral Doppler/Waveform analysis -RAR NORMAL: <3.5 -Abnormal: >3.5 indicates a >60% Diameter Stenosis -RI NORMAL: <0.7 -Abnormal: ≥ 0.7 -Renal allograft: -Rejection indicated if RI ≥ 0.7 but Specificity for Rejection is ↑ using an RI ≥ 0.9 Non Invasive Test Procedures Interpretation (IVC)  -Normal 2-D appearance: -SAG: Tubular appearance w/ varying AP meas -TRV: Oval or almond appearance lying to the RT & slightly ANT to the AO -Measurements: -Varies fr 5-30 mm during Quiet respirations & ↑ approx 10% during deep inspiration Non Invasive Test Procedures Interpretation (IVC) Spectral Doppler/Waveform analysis -Normal:  -PROX IVC will be pulsatile due to the RT Atrial ♡ pulsations; DIST will be Phasic, Spontaneous -Abnormal: -Continuous signal-suspect obstruction of a more PROX portion of the IVC; presence of tumor or thrombosis Non Invasive Test Procedures Interpretation (HV)  -Normal 2-D appearance: -Intrahepatic- do NOT have highly echogenic walls as the PV do -Measurement: -HV will ↑ in size as the approach the IVC & diaphragm Non Invasive Test Procedures Interpretation (HV) Spectral Doppler/Waveform analysis -Normal: -Flow s/b Hepatofugal -Signal s/b Phasic but somewhat Bi-dir & pulsatile due to the proximity to the IVC & RA of the ♡ -Abnormal: -Absence of spontaneous flow or lack of pulsatility; absence of Phasic flow Non Invasive Test Procedures Interpretation (PV) -Normal 2-D appearance: -Best seen @ the Porta Hepatis (PH) -Intrahepatic visualization shows echogenic walls as compared to the HV -Measurements: -Normal is <13mm or 1.3 cm during quiet respiration; size will ↑ w/ deep inspiration -Abnormal-Vn diameter >13mm @ the PH Non Invasive Test Procedures Interpretation (PV) Spectral Doppler/Waveform analysis -Normal: -Hepatopetal flow, NO Varices, Continuous flow pattern -Flow Vel of 20-40 cm/s -Abnormal: -Pulsatile flow=RT ♡ failure & Fl overload -Biphasic (to-fro) & Hepatofugal flow seen w/ Portal HTN -Absence of flow (Thrombosis) -Gastric Varices Non Invasive Test Procedures Interpretation (PV) Post-Interventional Assessment -TIPS=Transjugular Intrahepatic Portosystemic Shunt can be placed to reduce Portal Po -Most common location is placement of stent betw RT PV & RT HV -Doppler assessment should occur post placement for baseline Vel @ PROX to, AT & DIST to the anastamosis sites as well as w/in the stent itself -Vel s/b recorded & compared to subsequent examinations Non Invasive Test Procedures Interpretation (SV)  -Normal 2-D appearance: -SAG: Seen as a circular structure ANT to the CA -TRV: forms the POST border of the Pancreatic body & tail; Lies ANT to the AO, SMA & IVC Non Invasive Test Procedures Interpretation (SV) Spectral Doppler/Waveform analysis -Normal: -Hepatopetal flow -Abnormal: -Hepatofugal usually seen in cases of Portal HTN; Splenomegaly will usually be present Non Invasive Test Procedures Interpretation (SMV)  -2-D appearance: Long tubular vessel ANT to the IVC -Measurement: Diameter will ↑ 70-100% fr quiet respirations to deep inspiration -Spectral Doppler/Waveform -Abnormal: Doppler signal may be obliterated in pts w/ Portal HTN Non Invasive Test Procedures Interpretation (Renal V) -2-D appearance: Best seen in TRV plane running ANT to their respective Art -Spectral Doppler/Waveform -Phasic, Bidirectional & Pulsatile because they connect w/ the IVC Correlative &/or Prior Imaging Conventional Angiography/Digital Subtraction Arteriography-(Capabilities) -Can image vessels in Obese pts -Can image vessels in Post Surgical pt -Not limited by Vessel depth, bowel gas, or aberrant vascular anatomy Correlative &/or Prior Imaging Conventional Angiography/Digital Subtraction Arteriography-(Limitations) 1. Uncomfortable 2. Expensive 3. Radiation exposure 4. Invasive 5. Pt may experience allergic reactions to contrast agent 6. Can NOT be performed on pts experiencing Renal failure or Renal compromise Correlative &/or Prior Imaging Conventional Angiography/Digital Subtraction Arteriography-(Technique) -Contrast agent is injected via catheter→selected ART -Radiographic images of the contrast filling are obtained digitally -Filling defects & collateral flow pathways on the opacified images are noted -Digitally stored images may be manipulated to 'subtract' tissue interference Correlative &/or Prior Imaging Conventional Angiography/Digital Subtraction Arteriography-(Interpretation) -'Filling defects' or non-opacified regions w/in an ART may be measured & % stenosis calc -Lack of opacification indicates NO flow suggesting Total Occlusion -Collateral pathways are demonstrated & related to pathology in normal perfusion channels -Venous filling defects indicate thrombosis or extrinsic compression Correlative &/or Prior Imaging Computed Tomographic Arteriography (CTA) -LESS Invasive than conventional arteriography -Specialized radiologic procedure using contrast to examine Bl flow in the Art -Obtains images fr mult locations using many views & convert a 2-D to 3-D image -NOT for pts w/ sensitivity to contrast medium Correlative &/or Prior Imaging Magnetic Resonance Angiography (MRA) -Uses Radio waves in a strong magnetic field to produce 2-D & 3-D images of Bl vessels w/o use of contrast agents -NOT for pts w/ metal surgical clips, pacemakers or metal implants Treatment 1. Medical 2. Surgical 3. Endovascular Treatment- Medical -Anti-hypertensive: ↓ Po (force) exerted on endothelial cells of the vessel wall -Anticoagulants: Heparin or Lovenox (either thru IV or by subcutaneous inj), prevent Bl coagulation acts to prevent extension of thrombus, NOT to dissolve it -Warfarin: Taken orally after Heparin or thrombolytic therapy for pts w/: ART thrombosis, Graft Failures, Prosthetic ♡ valves, AF, Poor surgical candidates w/ cerebrovascular disease Treatment- Surgical -Bypass graft: Aortic bypass graft for aneurysm -Endarterectomy: a. ART is exposed & surgically opened in region of Atherosclerotic disease b. Intima, Media & plaque are removed -Transplantation  Treatment- Endovascular -Aortic endograft: covered stenting for ABD aneurysm -Angioplasty/Stent: 1. PTA for Stenosis 2. PTA w/ Stent placement -IVC interruption device (IVC Filter) may be inserted to avoid a thrombus fr becoming a PE -TIPS can be placed betw the Portal & HV to reduce & decompress Portal HTN