Hepatoportal Doppler

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Liver Doppler: Mastering the Maze

Liver Doppler: Mastering the Maze

Marsha M. Neumyer, BS, RVT, FSDMS, FSVU, FAIUM

Liver Doppler:Liver Doppler:Mastering the MazeMastering the Maze

Marsha M. Neumyer, BS, RVT, FSDMS, FSVU, FAIUMMarsha M. Neumyer, BS, RVT, FSDMS, FSVU, FAIUMInternational DirectorInternational Director

Vascular Diagnostic Educational ServicesVascular Diagnostic Educational ServicesVascular Resource AssociatesVascular Resource Associates

Harrisburg, PAHarrisburg, PA

•• Define the vascular Define the vascular

anatomy of the hepatoanatomy of the hepato--portal portal

systemsystem

•• Discuss the most common Discuss the most common

vascular hepatovascular hepato--portal portal

complicationscomplications

•• Describe the alterations in Describe the alterations in

blood flow patterns that occur blood flow patterns that occur

with hepatowith hepato--portal dysfunctionportal dysfunction

ObjectivesObjectivesObjectives

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Abdominal SonographyAbdominal Sonography

High resolution High resolution ultrasound systemultrasound system

22--5 MHz transducers5 MHz transducers

Color and power Color and power Doppler, compound, Doppler, compound, harmonic, and harmonic, and panoramic imagingpanoramic imaging

Abdominal SonographyAbdominal Sonography

TransducersTransducers

–– LinearLinear

–– CurvedCurved

–– PhasedPhased

12-5 MHz 7-4 MHz

5-2 MHz

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HepatoHepato--Portal DuplexPortal Duplex

Exam ObjectivesExam Objectives

Assessment of quality and direction of flowAssessment of quality and direction of flow

Identification of portal and/or hepatic vein thrombosisIdentification of portal and/or hepatic vein thrombosis

Documentation of portal vein diameterDocumentation of portal vein diameter

Evaluation of blood flow patterns in Evaluation of blood flow patterns in portoporto--systemic and systemic and splenospleno--renal shuntsrenal shunts

Confirmation of portal veinConfirmation of portal vein--hepatic vein fistulaehepatic vein fistulae

Examination GuidelinesExamination Guidelines

88--12 hour fast12 hour fast

Transducer frequency range 2.0 MHz Transducer frequency range 2.0 MHz –– 5 MHz5 MHz

Adjust the color imaging setAdjust the color imaging set--up for slow venous flowup for slow venous flow

Check the PRF (Velocity Scale) and wall filter settingsCheck the PRF (Velocity Scale) and wall filter settings

Confirm identification of all vessels with pulsed Confirm identification of all vessels with pulsed Doppler spectral waveformsDoppler spectral waveforms

Consistently optimize the size of the Doppler sample Consistently optimize the size of the Doppler sample volumevolume

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HepatoHepato--Portal SystemPortal System

Portal vein feed the Portal vein feed the liver; hepatic veins liver; hepatic veins drain this organdrain this organ

Portal vein carries Portal vein carries 70% of oxygenated 70% of oxygenated blood to the liverblood to the liver

Remaining 30% Remaining 30% carried by hepatic carried by hepatic arteryartery

Hepatic VeinsHepatic Veins

Hepatic Venous Flow PatternHepatic Venous Flow Pattern

BiBi--directional flowdirectional flow

Hepatofugal Hepatofugal directiondirection

Pulsatile due to Pulsatile due to cardiac influencecardiac influence

Flow toward the Flow toward the heart during heart during ventricular systoleventricular systole

Flow reversal during Flow reversal during atrial systoleatrial systole

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Normal ExaminationNormal Examination

No significant flow disturbance at the hepatoNo significant flow disturbance at the hepato--caval confluencecaval confluence

Flow throughout the right, middle, and left hepatic Flow throughout the right, middle, and left hepatic veinsveins

No evidence of extrinsic compressionNo evidence of extrinsic compression

No intraluminal echoesNo intraluminal echoes

Hepatic Vein ThrombosisHepatic Vein Thrombosis

BuddBudd--Chiari syndromeChiari syndrome–– Rare disorderRare disorder–– Obstruction of the hepatic veinsObstruction of the hepatic veins

DVT, Congenital web, trauma, malignancy, DVT, Congenital web, trauma, malignancy, hypercoagulable stateshypercoagulable states

Visualization of major veins does not exclude Visualization of major veins does not exclude thrombosisthrombosis–– Vein distension, wall thickening, collateralsVein distension, wall thickening, collaterals

Difficult ultrasound diagnosisDifficult ultrasound diagnosis

Hepatic Vein Stenosis/CompressionHepatic Vein Stenosis/Compression

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Abnormal ExaminationAbnormal Examination

Continuous, nonpulsatile flowContinuous, nonpulsatile flow

Hepatopetal or toHepatopetal or to--fro flow patternfro flow pattern

Significant flow disturbance at hepatoSignificant flow disturbance at hepato--caval confluencecaval confluence

Segmental absence or reduction of flowSegmental absence or reduction of flow

Extrinsic compression (Dense cirrhotic tissue, mass, etc.)Extrinsic compression (Dense cirrhotic tissue, mass, etc.)

Intraluminal echoesIntraluminal echoes

Confirmation of BuddConfirmation of Budd--ChiariChiari

Absence of flow in the hepatic veins; all veins Absence of flow in the hepatic veins; all veins may not be involvedmay not be involved

Identification of collateral vessels, particularly Identification of collateral vessels, particularly intrahepatic collateralsintrahepatic collaterals

Concurrent thrombosis of the portal vein (20% of Concurrent thrombosis of the portal vein (20% of cases) or IVCcases) or IVC

Extrinsic compression of veins from enlarged Extrinsic compression of veins from enlarged caudate lobe or hepatic mass.caudate lobe or hepatic mass.

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Portal VeinsPortal Veins

Main Portal VeinMain Portal VeinFlow is similar to Flow is similar to the lower extremity the lower extremity veinsveins

Nonpulsatile; Nonpulsatile; minimally phasicminimally phasic

Hepatopetal flow Hepatopetal flow directiondirection

Low velocityLow velocity

Portal VeinPortal Vein


Diameter < 13 mm at the level of the IVCDiameter < 13 mm at the level of the IVC

Nonpulsatile, minimally phasic flow in hepatopetal Nonpulsatile, minimally phasic flow in hepatopetal directiondirection

No significant flow disturbance in any segmentNo significant flow disturbance in any segment

No intraluminal echoesNo intraluminal echoes

No evidence of extrinsic compressionNo evidence of extrinsic compression

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Pulsatile Portal Venous FlowPulsatile Portal Venous Flow

Tricuspid Regurgitation, CHF, Fluid Overload


Normal-Hepatopetal Flow

Abnormal-Hepatofugal Flow

Portal Vein ThrombosisPortal Vein Thrombosis

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Abnormal ExaminationAbnormal ExaminationContinuous or markedly pulsatile flow Continuous or markedly pulsatile flow

Hepatofugal flow direction; diameter > 13 mmHepatofugal flow direction; diameter > 13 mm

Segmental absence of flowSegmental absence of flow

Significant flow disturbance in the main portal, at Significant flow disturbance in the main portal, at the confluence, or anastomosis (transplant)the confluence, or anastomosis (transplant)

Extrinsic compressionExtrinsic compression

Intraluminal echoes ( may be segmental Intraluminal echoes ( may be segmental thrombosis)thrombosis)

Portal HypertensionPortal Hypertension

Formation of varices due Formation of varices due to increased vascular to increased vascular resistanceresistance

HepatoHepato--fugal flow through fugal flow through collateral pathwayscollateral pathways

PortoPorto--systemic systemic anastomosesanastomoses

–– Flow seeks pathways Flow seeks pathways to inferior vena cavato inferior vena cava

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Gastroesophageal Gastroesophageal varicesvarices

Paraumbilical veinsParaumbilical veins

SplenoSpleno--renal shuntsrenal shunts

Retroperitoneal shuntsRetroperitoneal shunts



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Cavernous Transformation of the Portal VeinCavernous Transformation of the Portal Vein

Results from prior portal Results from prior portal vein thrombosisvein thrombosis

Formation of a complex Formation of a complex collateral network that collateral network that replaces the portal veinreplaces the portal vein

Mass of tortuous Mass of tortuous vessels in porta hepatisvessels in porta hepatis

Low velocity venous Low velocity venous signalssignals

Confirmation of Portal HypertensionConfirmation of Portal Hypertension

Hepatofugal portal venous flowHepatofugal portal venous flow

Portal vein diameter > 13 mmPortal vein diameter > 13 mm

No respiratory variation noted in portal veinNo respiratory variation noted in portal vein

Cavernous transformation of portal veinCavernous transformation of portal vein

Collateral veins imaged in the region of gallbladder, Collateral veins imaged in the region of gallbladder, porta hepatis, splenic hilumporta hepatis, splenic hilum

Paraumbilical vein imaged; collaterals in region of Paraumbilical vein imaged; collaterals in region of umbilicus; apparent coronary veinumbilicus; apparent coronary vein

Enlarged caudate lobe, > 8 cm in lengthEnlarged caudate lobe, > 8 cm in length

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Hepatic ArteryHepatic Artery

When portal When portal venous flow is venous flow is compromised, compromised, hepatic artery hepatic artery flow / velocity flow / velocity may increasemay increase

Rule out hepatic Rule out hepatic artery stenosisartery stenosis

Hepatic ArteryHepatic Artery


Low resistance waveformLow resistance waveform

Peak systolic velocity approximates 100 cm/sec; Peak systolic velocity approximates 100 cm/sec; may increase with portal vein thrombosis or portal may increase with portal vein thrombosis or portal hypertensionhypertension

Minimal spectral broadeningMinimal spectral broadening

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SplenoSpleno--renal Shuntrenal Shunt

Transjugular Intrahepatic Portosystemic ShuntTransjugular Intrahepatic Portosystemic Shunt

Relief of portal Relief of portal hypertensionhypertension

Expandable metal stentExpandable metal stent

Inserted via jugular vein Inserted via jugular vein through hepatic vein through hepatic vein into portal veininto portal vein-- drains drains through IVCthrough IVC

Diverts portal flow Diverts portal flow through hepatic veins through hepatic veins and IVCand IVC

Ultrasound is used to Ultrasound is used to monitor patency and monitor patency and assess complicationsassess complications

TIPSTIPS

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Normal TIPSNormal TIPS

Velocity ranges from 100Velocity ranges from 100--200 cm/sec200 cm/sec

Hepatofugal flow directionHepatofugal flow direction

Increased hepatic artery peak systolic velocity Increased hepatic artery peak systolic velocity ranges from 80ranges from 80--130 cm/sec130 cm/sec

Portal vein velocity ranges from 22Portal vein velocity ranges from 22--42 cm/sec42 cm/sec

FOSHAGER, AJR 1995; 165: 1FOSHAGER, AJR 1995; 165: 1--77

TIPSTIPS

TIPS DysfunctionTIPS DysfunctionMaximum peak systolic velocity less than Maximum peak systolic velocity less than 50 cm/sec50 cm/sec

Change in peak systolic velocity > 50 Change in peak systolic velocity > 50 cm/sec compared to baselinecm/sec compared to baseline

Focal stenosis with at least doubling of the Focal stenosis with at least doubling of the peak systolic velocitypeak systolic velocity

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Liver DopplerLiver DopplerSummarySummary

Know the anatomyKnow the anatomy

Know the pathologyKnow the pathology

Know the examination techniqueKnow the examination technique

Know the pitfallsKnow the pitfalls

Know the solutionsKnow the solutions

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Hepatoportal Doppler