Abdominal Doppler 2013

7/23/2019 Abdominal Doppler 2013

1/117

Dr.Randhawa's Institute Of Ultrasound Training,New Delhi

Indicn. Of Abdominal Vas. Studies

1.Liver Disorders: Cirrhosis, Diffuse malig.infiltern.

2.Portal Hypertension(e.g.:Hepatic disorders,Portal Vein thrombosis)

3.Hypertension due to renal disorders


2/117

Dr.Randhawa's Institute Of UltrasoundTraining,New Delhi

4.Abdominal aortic aneurysm Leriches syndr.(Occlusion of Aorta at level of iliac bifurcation)

5.IVC outflow obstrucn. e.g :IVC thrombosis.

Cardiac ds: CHF ,Tricuspid regurgn.


3/117


Identification of Vessels

Probe placed transversely just beneathxiphoid. Aorta seen in T.S. & slight superior

angulation will show Celiac trunk arising fromAorta and branching into common hepatic A.(Which moves to rt.) and splenic artery (whichmoves to lt.)


4/117


Sup. Mesentric Artery

Identification:Slight tilting inferiorly fromceliac artery will show the SMA. Next ,probe

is moved longitudinally to see the SMA asit moves almost parallel to aorta

Both celiac & SMA art. arise from ant. part ofaorta & at times may have common origin.


5/117


SMA & AORTA


6/117


Probe kept transversely with very light pressure

to locate left renal vein as it passes b/w aorta&SMA .

From this position probe angulation done slightsuperiorly & towards rt. to locate rt. Renal art.Probe further rotated to trace the rt. Renal art.as it passes post. to IVC.

Lt.Renal vein again brought into view in T.S.& slight probe tilt to lt .will show the lt.renal artery.


7/117


IDENTIFICATION OF VENOUS SYS.

IVC Runs parallel to aorta on rt. Side

Superiorly it recieves hepatic veins which havehepatofugal flow

Near umbilicus IVC divides into two commoniliac veins

Lt .Common iliac v passes behind Rt. Commoniliac a.(Thus thrombosis of lt. iv more commondue to compression )


8/117


Spectral Doppler Of IVC IVC near heart shows waveformhaving cardiac influence

Spectrum is complex with doublepeak which may be followed by flow

reversal due to atrial systole.


9/117


Sampling of IVC near Rt.atrium

Slight flow reversal due to atrial systole


10/117


Spectral(Contd.) IVC in mid & lower part has typicalvenous waveform with phasic

variation due to resp.


11/117


IVC can also be distended by liftingthe legs or by squeezing the thigh

muscles


12/117


Cardiac pathology effecting IVC flowe.g. : CHF ,Tricuspid regurgitation leadto decreased flow towards the heart &

there may be even flow reversal duringsystole.


13/117


IVC Obstruction due to thrombosis

IVC may appear distended

Non compressible

Thrombus may be seen

Flow may be absent or monophasic


14/117


Absence of response to Valsalva

Normal response to valsalva----During

Valsalva Intrathoracic pressure

increases thus IVC distends. Onrelease of pressure IVC collapses due

to flow towards heart.


15/117


HEPATIC VEINS

Three hepatic veins having flowaway from liver & towards IVC.

Waveform very much similar to IVCbecause of cardiac influence.


16/117


With thrombosis: Veins may distend

Normal pulsatile waveform may be

replaced by monophasic flow or there

may be no flow .

Course may be atypical withthickening of venous walls.


17/117


FLOW PATTERN OF HEPATIC VEIN

Antegrade flow (i.e. towards the rt.atrium) has twocomponents a larger systolic wave and a slightlysmaller diastolic wave.

Between these two antegradeflow patterns, at endsystole a small retrograde flow pattern may be seen.

Another retrograde flow pattern is seen during atrialsystole.


18/117


Hepatic vein flow shows increased flow velocity(systolic component) during inspiration and decreasedvelocity during expiration.

Hepatic vein flow velocity will change with change ofRt. atrial pressure. Diseases causing increased Rt.

Atrial pressure e.g: TR will reduce or replace antegradesystolic flow with retrograde wave.


19/117


Pulmonary hypertension will cause

prominent flow reversal duringatrial systole.

In atrial fibrillation velocity ofantegrade flow in systole andretrograde flow of atrial systole is

reduced.


20/117


Hepatic vein

Waveform very similar to that of IVC near heart


21/117


Hepatic vein


22/117


Monophasic due to cirrhosis


23/117


Blunted due to fatty liver


24/117


Blunted due to valsalva


25/117


Variations of normal flow pattern

Alhough all 3 hepatic veins have similar flow patternin normal case but variations do occur.

Variations can be due to the phase in whichsampling is taken, inspiration,expiration or valsalva.

It can also be due to any focal fat infiltration ormalignant mass.


26/117


Top hepatic vein shows dampaned pattern

Middle one shows nearly monophasic

Bottom one is normal triphasic


27/117


Severe TR will cause reduction in Swave velocity and later flow in systole

will stop

Much later S wave will reverse.


28/117


TR-- S wave smaller than AGrade 1


29/117


S wave is absent

TR grade 2


30/117


S wave reversal

TR grade 3


31/117


Biphasic wave-- when A , S and V wave are allretrograde , they may fuse and form a single wavewith flow in one direction.

D wave comprises flow in other direction leading tobiphasic wave.

Usually seen when significant TR is seen with rtsided failure.


32/117


Biphasic


33/117


34/117


Hepatic veinAbn. waveform

Spectral Doppler shows lack of normalpulsatility due to partial obstruction

distal to this area.


35/117


36/117


SCANNING TECH.3-3.5 mhz probe usedLt.Portal vein scanned thru sub xiphoidregion as a smaller Doppler angle is obtd bydoing so.Rt Portal vein scanned in its horizontal portion

thru intercostal spaces in lateral direction

App. Doppler angle essential in scanning rt.

Portal vein because at angles >60No flow may be seen.


37/117


PORTAL VEIN Has a undulating waveform due toeffect of abdominal resp pressure.

With exp the flow increases & withinsp. It decreases.

On holding breath in expiration the

undulations decrease & thus thismanoever helps to see thedirection of the flow.


38/117


Waveform---Portal Vein


39/117


Portal vein Normal velocities The maximum portal vein velocity varies from 15-30

cm/s.

The minimum velocity varies from 5-20 cm/s

The difference between maximum and minimum

velocity ranges from 5-15 cm/s. Difference willincrease with increase pulsatility.


40/117


Reduced velocity,Increased pulsatility

PATHOLOGY


41/117


PATHOLOGY Hepatic disorders or Portal vein thrombosis

Foll. Changes may be seen:

1.Flow may be away from liver

2.Flow may be monophasic having lost the resp.variation.

3.It may be triphasic at times eg. CHF,TR


42/117


4.Flow may be variable (sometimes towards &

sometimes away from liver)

5.No flow at times

6.With portal hypertension collaterals may be

seen

F f l h i


43/117


Features of portal hypertension

Dilated Portal, splenic& sup.mesentric vein.

Portal vein diam. >13mm

Splenomegaly

Ascites


44/117


45/117


Determination of direction of blood flow in portal

vein helps in planning surgical tt optionsHepatofugal flow----portocaval or mesocaval shuntHepatopedal-----splenorenal shunt

Measurement of portal vein vel. Has prognosticvalue in pts with portal hypertensionLow flow vel.---advanced disease.


46/117


Portal vein----Abn. waveform

Waveform has marked variations of flow withreversal(biphasic) due to congestive liver(a

sequel of CHF / TR resulting in increased res.to flow)


47/117


Prestenotic velocity is usually normal with

normal resistive pattern of the waveform.

However in marked stenosis (>50%) the res mayLower when collaterals have dev.

In the absence of collaterals vascular res.may in fact increase

In complete stenosis prestenotic vel may be verylow with little or no diastolic flow.(High res. Pattern


48/117


Portal vein stenosis

(A)At the site of stenosisPeak vel. is very high

(B)Distal to stenosis vel. islower & turbulence is seenby flow above & below the

baseline


49/117


Sites for collaterals In the umbilical area supf. beneath the skin

At the splenic hilum

Along lesser sac


50/117


Collaterals in S/C tissue(umb. Reg.)

----7.5 mhz


51/117


Gastric varices----lesser sac


52/117


Splenic varices----Spectral waveform displayed above & below the baseline due to

turbulence seen in variceal flow


53/117


AVERNOUS TRANSFORMN- PORT. V

Seen in chronic venous obstruc.(more than 1 year).

Hence likely to be seen in pts with benign disease

Portal venous landmarks not visualized in theirnormal positions.


54/117


Extrahepatic portal vein not seen

Fibrosis produces high level echoes

Periportal venous collaterals seen in the

region of porta hepatis as multiple tubularstruc having flow pattern similar to portal

vein.

Hepatic artery shows increased size & flow.


55/117


Caput medusae -- engorged veins of

abd wall


56/117


SEV. SUP EPIGASTRIC VEIN

IEV INF EPIGASTRIC VEIN

SRV. SUP RECTAL VEIN

IRV. INF RECTAL VEIN

IMV. INF MESENTERIC VEIN

LGV. LT GASTRIC VEIN

SV. SPLENIC VEIN

PV. PORTAL VEIN

PUV. PARAUMBILICAL VEIN


57/117


Dark tubular area within falciform ligament is seen inhealthy persons without any flow on color doppler.

This is normal.

When flow is seen it is enlarged paraumbilical veinseen in cases of portal hypertension.


58/117


Patent para-umbilical vein


59/117


60/117


Inferiorly paraumbilical vein may drain via superficialvein , superficial epigastric vein , into femoral vein.

Via deeper inf. epigastric vein it may drain into

external iliac vein.


61/117


When paraumbilical vein drains via superficial veinslike lateral thoracic veins or sup. epigastric vein,caput medusae may be seen.


62/117


Reason for preferential drainage through superficialor deep route is unknown.


63/117


Paraumbilical vein may prolapse into thesubcutaneous fat of abdominal wall causingherniation.


64/117



65/117


Hernia of paraumbilical v prolapsing


66/117


Helical flow is spiral flow where there is

1---alternating red and blue color

Or

2-- both red and blue color in same part.


67/117


Normal flow


68/117


Normal laminar flow


69/117


Spiral flow


70/117


Spiral flow


71/117


72/117


73/117



74/117


ABDOMINAL AORTAFlow above the celiac axis is of low res.biphasic type since celiac artery & supmesentric art. supply visceral organs which

have low res.

Flow distal to SMA is triphasic since suppliesto pelvis & lower extremities (high res. Areas)


75/117


76/117


Waveform---Upper Aorta


77/117


COELIAC ARTERY IT HAS COMMON HEPATIC A. AND SPLENIC A. ASMAIN BR.

THEY SUPPLY LIVER AND SPLEEN RESP. WHICHARE LOW RES. ORGANS


78/117


THUS FLOW IN THESE VS. IS LOW RES.(LIKEINTERNAL CAROTID)

FORWARD FLOW IS SEEN BOTH PRE- MEAL ANDPOST MEAL


79/117


Coeliac Artery(low res.)


80/117


Coeliac artery---branches


81/117

Dr.Randhawa's Institute Of Ultrasound

Training,New Delhi

COELIAC ARTERY-Branches


82/117


Training,New Delhi

SUPERIOR MESENTERIC A IT SUPPLIES INTESTINE ,STOMACH ANDCOLON WHICH ARE OF HIGHER RES.

THUS FLOW IN SMA UNLIKE COELIAC ANDITS BR. IS OF HIGH RES(eg.ext.carotid)

HOWEVER AFTER MEAL RES. DECREASES

AND FLOW IS CONSTANTLY FORWARD


83/117


Training,New Delhi

WaveformSMA(High res.)


84/117


Training,New Delhi

Blood flow change with meal

Before meal SMA shows high res. Patterndiastolic flow is very low.

After meal res. to flow decreases thus diastolicflow increases


85/117


Training,New Delhi

Preprandial flow Post Prandial flow


86/117


87/117


88/117


Training,New Delhi

CHRONIC THROMBUSFeatures 1-hyperechoic

2-irregular borders

3-well attached

4-contracted vein


89/117

THROMBOSIS


90/117


Training,New Delhi

Flow void in color duplex image

Acute venous thrombosis(less than 10 days) veindistended to twice the size of acc. Artery

Inability to compress the venous lumencompletely


91/117


Training,New Delhi

Valsalva increases intra-abd pressure and thuspost valsalva flow in lower limb increases

Upper ext. Flow inc. On inspiration

RENAL VEIN


92/117


Training,New Delhi

RENAL VEINNORMAL WAVEFORM SHOWS RESPIRATORY

PHASCITY TYPICAL OF PERIPHERAL VEIN

OBSTRUCTED VEIN MAY SHOW

1 NON PHASIC FLOW

2 DILATION OF VEIN

3ECHOGENIC THROMBUS IN LUMEN

4 POOR OR NO RESPONSE TO VALSALVA


93/117


94/117


95/117


Training,New Delhi

Metastases are poorly vascularand only 30% show flow.

Hemangiomas also are similar and

only 30% are vascular.


96/117


97/117


Training,New Delhi

Focal nodular hyperplasia has flow inform of radiating pattern or multiple

tubular strands.


98/117

A-Gray scale image shows a subtleisoechoic mass

B Doppler sho s star like arterial


99/117


Training,New Delhi

B-Doppler shows star like arterialpattern suggesting FNH

C-Lesion appearing like focal sparing infatty liver

D-Doppler shows hypervascular mass

with star like appearance.Classicfinding of FNH

E-Subtle mass in rt.lobe of liver

F-Doppler shows it to be hypervascularwith vascular pattern typical of FNH


100/117


101/117


Training,New Delhi

Focal Spared Area


102/117


103/117


104/117


Training,New Delhi

Dampened waveform in hepatic vein


105/117


Training,New Delhi

IVC waveform proximal to thrombus

showing dampening


106/117


107/117


Training,New Delhi

Reduced velocity


108/117


109/117


110/117


Training,New Delhi

Pseudoaneurysm with spectrum


111/117


Training,New Delhi

Pseudoaneurysm


112/117


113/117


114/117


Training,New Delhi

Volvulus


115/117


Training,New Delhi

PW Doppler image of the right ICA shows spectral

broadening (turbulence) with an elevated PSV. These results

may be due to a high degree of stenosis immediatelyproximal to the point of sampling; therefore, further

investigation with another imaging modality is required.

Intrastenotic


116/117


Training,New Delhi

PW Doppler image of the proximal right ICA shows a tardus-

parvus waveform(a prolonged systolic acceleration time

with low PSV) A severe proximal stenosis behind theshadowing plaque is suspected; therefore, evaluation with

another imaging modality is required.

Post stenotic


117/117

E-FAR DISTAL THE VELOCITIES ARE LOWER

AND WAVES ARE SPACED FAR APART

Documents

Abdominal Doppler 2013