-
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
|
|
