RVS PART IV

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Author:
marie78
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304603
Filename:
RVS PART IV
Updated:
2015-07-01 22:29:27
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ABDOMINAL VISCERAL
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RVS
Description:
VASCULAR EXAM
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  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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)
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. ANATOMY- VENOUS
    Visceral Veins (Gonadal Vns)
    • -RT Gonadal Vns: drains Bl dir→the IVC
    • -LT Gonadal Vns: drains Bl→LRV
  15. 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 
  16. ANATOMY- VENOUS
    Portal Venous System (4 Major Vessels)
    • 1. PV or MPV
    • 2. SPLENIC V
    • 3. SMV
    • 4. IMV
  17. 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
  18. 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
  19. 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
  20. ANATOMY- VENOUS
    Portal Venous System (IMV)
    • -Drains Bl fr Colon
    • -Travels SUP to join the SV POST to the PANC
  21. 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
  22. 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
  23. 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
  24. MECHANISMS OF DISEASE 
    Renovascular Hypertension (HTN) Diagnosis
    • -↑ BP (HTN)
    • -Stenosis/Occlusion of 1 or both RA
    • -Renal Ischemia
  25. 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
  26. 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)
  27. 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
  28. 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
  29. 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)
  30. 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
  31. 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
  32. 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
  33. 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
  34. 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
  35. 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
  36. 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
  37. 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
  38. 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
  39. 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
  40. 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
  41. 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
  42. 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
  43. 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
  44. 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
  45. 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
  46. 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
  47. 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
  48. 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
  49. 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
  50. 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
  51. 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
  52. 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
  53. 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
  54. 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
  55. 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
  56. 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
  57. 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
  58. 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
  59. 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
  60. 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
  61. 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
  62. 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
  63. 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
  64. 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
  65. 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
  66. 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
  67. 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
  68. 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
  69. 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
  70. 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
  71. 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
  72. 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
  73. 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
  74. 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
  75. 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
  76. 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
  77. 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
  78. Treatment
    • 1. Medical
    • 2. Surgical
    • 3. Endovascular
  79. 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
  80. 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 
  81. 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

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