Evaluarea Doppler a Evaluarea Doppler a AA membrului AA membrului

superiorsuperior

Alexandru AndritoiuESC, Artery Research (Cambridge)

Background

Anatomie vasculara• Topografie• Raporturi AA-VV

• Doppler• Color• Spectral (PWD)• Power-angio• B-flow• Contrast (CEUS)

ANATOMIEANATOMIE

Common upper extremity arterial anatomy: Common upper extremity arterial anatomy: The ulnar artery supplies the superficial palmar arch, The ulnar artery supplies the superficial palmar arch,

the major source of blood flow to the digitsthe major source of blood flow to the digits

Stepansky F et al. Radiographics 2008;28:e28-e28

Fig.  Common upper extremity arterial anatomy: The ulnar artery supplies the superficial palmar arch, the major source of blood flow to the digits. The radial artery supplies the deep palmar arch, which in turn supplies the dorsal arches of the hand.

  The superficial palmar arch is formed mainly by the ulnar The superficial palmar arch is formed mainly by the ulnar artery and is completed by the superficial branch of the artery and is completed by the superficial branch of the

radial artery.radial artery.

Stepansky F et al. Radiographics 2008;28:e28-e28

Fig.  The superficial palmar arch is formed mainly by the ulnar artery and is completed by the superficial branch of the radial artery. A complete arch is not always present. The superficial palmar arch provides the arterial supply to the digits via the digital palmar arteries.

B-modeB-mode

• Perete fin-ecogen• Calibru normal• Pulstatilitate

Elementele de semiologie patologica

• placi• stenoza• tromboza• ocluzie• anevrism

Doppler colorDoppler color

• Permebilitate• Calibru normal• Directia de curgere• Velocitatea • Amplitudinea

Elemente patologice• Flux turbulent• Absenta fluxului• Fistula AA-VV• Stenoza/ocluzie• Disectie

VELOCIMETRIEVELOCIMETRIE

• AA de rezistenta• Profil trifazic• Difera topografic

Elemente patologiceElemente patologice• Cuantificarea stenozei• Ocluzie• HemodinamiceHemodinamice• Incarcarea din colaterale• Amonte/aval de stenoza• Sdr. Furt S-V (sten. AS)• Sdr. defileului toracic

INDICATIIINDICATII

• Stenoza TBC• Stenoza AS• Cateterizarea AB• Ocluzia AB• Embolie distala (Fi A, • Sdr. Defileului toracic• Evaluarea Fct. Endoteliale• Arterite (TAO, B. Raynaud)• Fistule AA-VV (dializa)• By-pass (patenta/stenoza graftului)

TBCTBC

• Crosa Ao• ACC dr-AS dr• Rar: stenoza

semnificativa

A SubclavieA Subclavie

• Abord: spatiul supra/subclavicular

• Raporturi cu V Subclavie

• Flux pulsatil

• Sediul stenozei ATS

• Consecinte hemodinamice aval/amonte

ATENTIE: AS ABERANTA IN CAZURI PEDIATRICE Se asociaza cu sdr. compresiv al cailor aeriene

Stenoza ASStenoza AS

• Prevalenta: 2-7%• Diferenta TAS >15 mm

dr/stg

CAUZE:• ATS – placa• B. Takayasu• Dispazia fibromusculara• Radioterapie

Relatia cu:• Fumatul, • HDL-C • ATS (BCI, stenoza ACI,

BOAP, stroke)

Shadman R et al. J Am Coll Cardiol, 2004; 44:618-623 Gutierrez GR et al. Angiology. 2001;52:189–194English JA et al.Cathet Cardiovasc Intervent. 2001;54:8–11

• CAD – 0.5-4%

• PAD – 18.7%

Stenoza AS - DiagnosticStenoza AS - Diagnostic

• Clinic:

difer TAS dr/stg >15-20 mmHg

claudicatia bratului• FRCV

ImagisticaImagistica• US US • Angio CT/RMNAngio CT/RMN• Angio-standardAngio-standard

Angiografie Angio-CT

HemodinamicaHemodinamica

• In relatie cu localizarea/severitatea stenozei

• Local: V max S ampla • Amonte: sdr. Furt S-V• Aval: flux redus:• A axilara• A brahiala• A mamara interna

Stenoza ASStenoza AS

Flux distal: tardut et parvus

Subclavian steal Subclavian steal syndromesyndrome

• Stenoza/ocluzia AS ipsilaterala cu devierea retrograda a fluxului in AV

• Stenoza situata proximal de originea AV

• Asimptomatic

• Simptome neurologie (ischemie cerebrala)

Contorni, 1960;Fisher, 1961;Parrott, 1964

UNILATERAL/BILATERAL DOBANDIT/CONGENITAL

Subclavian steal syndromeSubclavian steal syndrome

Stepansky F et al. Radiographics 2008;28:e28-e28

Fig.  Subclavian steal syndrome. (a) TOF sequence with a saturation band above the section demonstrates absence of signal in the left vertebral artery (arrow). (b) TOF sequence with a saturation band below the section demonstrates signal corresponding to retrograde flow in the left vertebral artery (arrow). (c) Coronal maximum intensity projection (MIP) image from contrast-enhanced MR angiographic study demonstrates occlusion of the proximal subclavian artery (arrow), with reconstitution distal to the origin of a patent left vertebral artery.

Modificari precoce ale anvelopei Modificari precoce ale anvelopei spectrale a spectrale a

AV in furtul S-VAV in furtul S-V

• Tipul I (20%)

• Tipul II (40%)

Kliewer MA et al. Am J Radiol 2000;174:815-819

• Tipul III (12.5%)

• Tipul IV (27.5%)

Kliewer MA et al. Am J Radiol 2000;174:815-819

Furt S-V patent (total)Furt S-V patent (total)

Flux inversat (retrograd)

TratamentTratament

InterventionalInterventional• angioplastie

ChirurgicalChirurgical• By-pass Car-AS• By-pass AS-AS• By-pass axilo-axilar

Angioplastie cu balonasAngioplastie cu balonas

By-passBy-pass

Rolul USRolul US

• DiagnosticDiagnostic – necesita confirmare Angio!• Supraveghere post-interventionalaSupraveghere post-interventionala• Restenoza post-stentare• Tromboza graftului

Kablak-Ziembicka A et al. Cardiovasc Intervent Radiol 2007;30:894-900

Tromboza ASTromboza AS

Cauze:Cauze:

• Lezarea endoteliului

• Stari protrombotice

• Efort fizic (compresie musculara)

• Sdr. de defileu toracic

AS in defileul toracicAS in defileul toracic

Coronary-Subclavian steal Coronary-Subclavian steal syndromesyndrome

DefinitieDefinitie

Sdr. coronarian (anginos) aparut la pacientii revascularizati prin by-pass cu a. mamara interna la care se dezvolta stenoza proximala de AS

HemodinamicaHemodinamica

• Flux retrograd in A. mamara interna stg.

• Ischemie miocardica in zona revascularizata

TratamentTratament

• Interventional

• Angioplastie-dilatarea stenozei AS + stentare

• By-pass:

• Transpozitie-sunt Car-Subcl distala

Proteza vascularaProteza vasculara

• Perete ecogen• Material sintetic• Lumen• Tipuri diferite

US – metoda ideala de supraveghere a evolutiei post-operatorii (permeabilitatea/ocluzia trombotica)

Hematom periproteticHematom periprotetic

Artera BrahialaArtera Brahiala

AB – Doppler colorAB – Doppler color

AB – anvelopa spectralaAB – anvelopa spectrala

IndicatiiIndicatii

TrombozaTromboza CercetareCercetare• Remodelare arteriala• Evaluarea fct. endoteliale

Tromboza ABTromboza AB

CAUZE

• Lezarea endoteliului• Cateterizarea AB

• Conditii protrombotice:• Trombofilie• Anticonceptionale orale

Tromboza ABTromboza AB(post-angiografie)

Doppler color - Power-angio lipsa semnal vascular

Anevrism de a. brahialaAnevrism de a. brahiala