Jean-Yves Meuwly, MD Department of Diagnostic and Interventional Radiology, CHUV-Lausanne, Switzerland Doppler ultrasound of the abdominal vessels:

Pathological findings Abdominal vessels

• – Abdominal aorta – Celiac trunk • Common hepatic • Splenic artery • Left gastric artery – Superior mesenteric artery – Inferior mesenteric artery – Renal arteries • – Inferior vena cava – Hepatic veins – Portal – Splenic vein – Mesenteric veins – Renal veins Abdominal aorta: normal findings • 16-25 mm in diameter • Flow velocities 70-140 cm/s Abdominal aorta: pathology • • – True aneurysm: diameter > 3.0 cm or 1.5 x proximal aorta – Dissecting aneurysm: two lumina with asymmetrical blood flow – False aneurysm: rare and usually traumatic • : maximum systolic velocity > 200 cm/s • Prostheses Double abdominal aorta Refraction artifact

Meuwly, J. Y., A. S. Knopfli, et al. (2011). "Duplication of abdominal aorta: a very rare congenital anomaly but a common ultrasound artifact." Ultraschall Med 32(3): 233-236. Arteriosclerosis

Aneurysm Aneurysm Aneurysm Aneurysm • Measurement in the anterioposterior diameter, in transverse scan plane • Location of the upper and lower margins • Additional aneurysm in other vascular segment of the peripheral arteries • Risk of leakage: – > 5 cm – Annual growth > 1 cm Dissecting aneurysm Dissecting aneurysm Dissecting aneurysm Dissecting aneurysm Dissecting aneurysm Celiac trunk: normal findings Stenosis of the celiac trunk • Maximum systolic velocity > 250 - 300 cm/s • Aliasing with color Doppler • Thrill • Tardus parvus waveform in hepatic artery • Low resistance in the periphery • Sensibility 100% • Specificity 88%

Harward T, J Vasc Surg 1993 Stenosis of the celiac trunk Stenosis of the celiac trunk Stenosis of the celiac trunk Anomaly of the celiac trunk Anomaly of the celiac trunk Anomaly of the celiac trunk Anomaly of the celiac trunk Stenosis of the hepatic artery Normal celiac trunc Stenosis of the hepatic artery Superior mesenteric artery Stenosis of the SMA • Systolic velocity > 300 ± 30 cm/s • Diastolic velocity > 45 cm/s • Aliasing with color Doppler • Thrill Stenosis of the IMA • Elevated maximum systolic velocity • Increased end-diastolic flow velocity

• Quantitative measurements not available Stenosis of the IMA Investigation of intestinal ischemia • Demonstration of stenosis of two of the three splanchnic arteries is strongly suggestive of diagnosis • Possible multiple collaterals

• 18% of patients over 60 years without symptoms of mesenteric ischemia have been shown to have significant disease on Doppler Roobottom CA, AJR 1993 Indications for renal Doppler • To confirm renal perfusion • Diagnosis of renal vein • Renal obstruction • Renal tumor • – Screening – Follow-up • Arterioveinous anomalies • and aortic Renal artery stenosis • Morphological renal artery stenosis – Angiography – Doppler – Spiral CT – MR Angiography • Functional renal artery stenosis – Scintigraphy – Doppler sensibilised with Captopril – MRI sensibilised with Captopril Morphological stenosis • Arterial narrowing >50% leads to a significant reduction in renal blood flow – (75%) – Dysplasia (25%)

No information on the relationship between stenosis and HTA Angiography • Gold standard • Invasive • Nephrotoxicity • Irradiation • Expensive Doppler ultrasound • Morphologic and hemodynamic criteria • Assessment of renal arteries – Origins and course of both renal arteries – Increase in flow velocity with spectral broadening – PSV  200 cm/s, RAR  2.5 • Assessment of intrarenal vessels – Tardus parvus pattern – Reduced resistance index < 0.5 • Sensitivity 92 - 98% • Specificity 81 - 98% de Haan, M. W., A. A. Kroon, et al. (2002). "Renovascular disease in patients with : detection with duplex ultrasound." J Hum Hypertens 16(7): 501-7. Staub, D, Canevascini, R, Huegli R. W., et al. Best Duplex-Sonographic criteria for the assessment of renal artera stenosis – Correlation with intra-arterial pressure gradient. (2007) Ultraschall in Med 28: 45-51 Normal Doppler spectrum

Origin of the arteries Normal Doppler spectrum

Intrarenal vessels Increase in flow velocity

Origin of the right renal artery « Tardus parvus » pattern

Intrarenal vessels Comparison of techniques

Vasbinder JBC, Nelemans PJ, Kessels AGH, et al. Diagnostic tests for renal stenosis in patients suspected of having renovascular hypertension: A meta-analysis. Ann Intern Med 2001; 135:401-411 Arterioveinous Arterioveinous fistula Portal vein • 70% of incoming blood volume to the liver • Oval lumen, 7-15 mm maximum diameter • Hepatopetal flow • Average flow velocity 15 ± 3 cm/s • Flow of «PLUG» type • Postprandially: – Increased velocity of 25-50 % – Increased flow of 180-200 %

• Prehepatic – Portal thrombosis – Portal vein compression – Arterio-venous fistula – Schistosomiasis (most frequent origin throughout the world) • Intrahepatic – Toxic, drugs or viral induced hepatopathy – Veno-occlusive disease of bone morrow transplantation – – Hepatocarcinoma, metastases, lymphoproliferative disease • Posthepatic – Budd-Chiari syndrome (HVOO) – Cardiac disease Portal hypertension • Elevation in portal vein pressure by 5 mmHg • Development of collateral pathways – Short gastric, left gastric and coronary veins varices – Paraumbilical veins – Splenorenal-mesenteric collaterals – Pericholecystic varices – Haemorrhoideal collaterals • Haemorrhagic risk when pressure rises to 12 mmHg Portal hypertension • Extrahepatic dilatation of the portal vein • Rounded cross-section • Decreased respiratory modulation • Decreased flow in the portal vein • Dilated splenic vein (>10 mm) • • Collateral circulation • Ascites • Pathological findings in the liver parenchyma Portal hypertension: collaterals

3 1. Paraombilical vein: 2 Caput medusae 2. Left gastric and 4 coronary veins 3. Right gastric veins 1 4. Splenorenal veins 5. Mesenteric et rectal 5 veins Reversed flow in left gastric vein Reversed flow in left gastric vein Left gastric vein varices Left gastric vein varices Recanalized paraumbilical vein Recanalized paraumbilical vein Caput medusae Reversed portal flow Reversed flow in SMV Mesenteric collaterals • Idiopathic (most frequently) • Tumoral: – HCC – Pancreatic tumor – Metastasis • Post-operative • Blood dyscrasia • Sepsis, pyelophlebitis • Pancreatitis • Cirrhosis, portal hypertension Portal vein thrombosis Portal vein thrombosis Portal vein thrombosis? Portal vein thrombosis: CEUS Cavernous transformation Cavernous transformation Budd-Chiari syndrome (HVOO)

• Occlusion (BCS) or stenosis of hepatic vein(s) • May be associated with IVC thrombosis or stenosis • Primary: – Membranous obstruction – fibrous web (major cause in South Africa and Asia) • Secondary: – Hypercoagulation disorders – Trauma – Cancer – Toxic – Pregnancy – Oral contraceptives • Idiopathic (70%) Spiegel veins Hepatic venous outflow obstruction Hepatic venous outflow obstruction Control after repermeabilization Surgical portosystemic shunts

• Portocaval • Mesenterico-caval • Splenorenal (Warren) • Mesoatrial • TIPS TIPSS TIPS Shunt patency

Cardiac modulation in the portal vein Shunt compromise

• Intimal hyperplasia • Focal stenosis

• Portal flow < 50 cm/s – Chong WK et al, Radiology 1993 • Flow < 50 cm/s in the shunt – Feldstein VA et al, Radiology 1996 • Increase or decrease in shunt velocity of > 50 cm/s compared with initial value – Dodd GD III, 1992 • Hepatopetal flow in portal vein branches • Hepatofugal flow in main portal vein Shunt compromise Shunt compromise Shunt compromise

HVPG 19 mmHg Dilatation of stenosis

HVPG 13 mmHg Double middle hepatic vein ? Pancreatic cyst? False aneurysm! Renal vein thrombosis Renal vein thrombosis Renal vein thrombosis Renal vein thrombosis Renal vein thrombosis