Flashcards in IVC Abnormalties Deck (118):
With deep INSPIRATION, venous return _____ (increases/decreases) and the IVC _____ (increases/decreases).
With deep EXPIRATION, venous return _____ (improves/decreases) and the IVC _____ (increases/decreases).
When performing the Valsalva maneuver, venous return is _____ and flow temporarily _____ in the IVC causing it to bulge.
Because IVC examinations need to be done in a consistant manner, it is usually best accomplished when the patient _____ inspiration.
When the normal blood flow in the IVC is obstructed, the normal response of the vessel is to _____ (increase/decrease) in caliber _____ (above/below) the point of obstruction. Respiratory changes are _____ (increased/decreased) below the obstructed segment.
decreased or absent
The most common cause of IVC obstruction is
right-sided heart failure
Other causes for IVC obstruction are (5)
1) enlarged liver
2) para-aortic lymph node enlargement
3) retroperitoneal masses or tumors
4) pancreatic tumors
5) a congenital IVC valve may obstruct the lumen of the IVC
Symptoms of IVC obstruction may include (4)
1) abdominal pain
3) tender hepatomegaly
4) lower extremity edema (often in most severe forms of IVC obstruction)
In right-sided heart failure, the distal IVC and hepatic veins (HVs) become congested, resulting in a(n) _____ (increase/decrease) in diameter. Respiratory changes are markedly _____(increased/decreased).
decreased or absent
"Respiratory changes" refers to the IVC _____ or _____ with breathing patterns.
Sonographic signs and physical signs of CHF are (3)
1) Dilation of the IVC and HVs
An indication that there is possible CHF and an US is needed is often
If large enough, a solid, complex, or echo-poor tumor in the retroperitoneum or pancreas may obstruct the IVC, causing lower trunk and leg _____.
Overall enlargement of the liver would cause the IVC to _____ (constrict/dilate) as it presses on the vessel.
The most encountered intraluminal anomaly of the IVC is _____, which usually spreads from another vein in the pelvis, lower limb, liver, or kidney.
Typically, the more echogenic a thrombus is, the _____ (younger - acute/older - chronic) it is.
older - chronic
T or F? A doppler of a thrombus produces no signal.
Where is the most likely site of origin for a thrombus in the IVC?
The normal response of a vein below the point of obstruction will be _____ (dilation/constriction), but above the obstruction the vein should remain normal diameter.
What is the metal device called that is made of either stainless steel or nitinol and placed in the IVC to trap clots that are 5mm or larger?
T or F? Most IVC filters in the US are placed temporarily rather than permanantly.
False - they are usually permanant
When an IVC filter fracture occurs, it means a fragment migrates to
If an IVC fracture occurs without symptoms (asymptomatic), is treatment necessary?
Tumors of the IVC may be _____, _____, or _____.
an extension from primary
A primary tumor of the IVC is one that
started in the IVC
A metastatic tumor of the IVC is one that
started in another organ and invaded the IVC
An extension from a primary tumor of the IVC is one that
a large tumor that grows from another adjacent organ
A leiomyoma is a _____ (benign/malignant) tumor of the smooth muscle.
A leiomyasarcoma is a _____ (benign/malignant) tumor of the smooth muscle.
Primary tumors of the IVC are not very common, and have a vascular incidence of only ____%.
Primary tumors, if any, tend to develop in _____ (men/women) and have a median age of detection at _____ years old.
With leiomyosarcomas, metastasis to the liver and lung has been reported in _____-_____% of cases. A _____% recurrence rate is also reported, and prognosis is _____ (good/poor).
A mass _____ (has/doesn't have) color flow, a clot _____ (has/doesn't have) color flow.
The most common incidence of metastasis/extension of tumors in the IVC is
If there is a primary tumor in the IVC (which is rare), it is most likely a _____ or a _____.
Tumors within the IVC tend to appear as _____ (echogenic/hypoechoic) foci.
Large primary tumors of the IVC may be _____ (homogeneous/heterogeneous), with areas of necrosis.
When an IVC mass is identified, it is important to attempt to identify (3)
1) the presence of a primary tumor
2) does it involve the HVs or right atrium (extent of cranial involvement)?
3) possible tumor involvement or invasion of the wall of the vessel
Doppler and color flow in the IVC is usually steady. When the IVC is partially obstructed, the blood velocity at the narrowed segment _____ (increases/decreases).
When blood flow in the IVC is obstructed, the normal response of the vessel is to _____ (increase/decrease) in caliber _____ (above/below) the point of obstruction.
In right-sided heart failure, the distal IVC and HVs become _____, resulting in a(n) _____ (increase/decrease) in diameter.
Malignant invasion or tumor extension of the IVC may occur from (6)
1) renal carcinoma
2) secreting/non-secreting adrenal tumors
3) retroperitoneal sarcomas
4) hepatocellular carcinoma
What is the most common physical sign of an IVC tumor invasion?
The most common reasons that renal veins enlarge are (3)
1) increased flow due to splenorenal/gastrorenal shunt or AV malformation in kidney
2) portal HTN or thrombosis
3) tumor involvement from renal cell carcinoma
T or F? Tumor involvement of the renal veins (RVs) usually produces no specific symptoms that would lead to suspicion of tumor extenstion.
T or F? Symptoms of the presence of an enlarged renal vein (RV) are generally associated with the initial disease process, not because of the actual venous enlargement.
An enlarged renal vein is one that exceeds
Another sonographic finding that suggests increased flow into the renal vein is abrupt IVC dilation at the level of the _____ _____ _____.
renal insertion point
If enlargment of the RVs IS NOT bilateral or symmetric, this would indicate that the disease process _____ (does/does not) involve(s) the IVC at the level above the insertion of the RVs.
If enlargement of the RVs IS bilateral or symmetric, this would indicate that the disease process _____ (does/does not) involve(s) the IVC at the level above the insertion of the RVs.
T or F? In portal HTN, several collateral pathways are apt to develop as the pressure in the portal system increases. These collateral pathways connect to _____ veins, and these are known as _____ veins.
In portal HTN, blood flow is diverted to the collaterals, which may in turn affect the LRV how and why?
The collaterals may fistulize to the LRV in order to alleviate pressure.
In portal venous HTN, is the LRV, RRV, or both typically involved? Why?
Because collaterals that form loop around and reconnect to the LRV
If portal venous HTN occurs, the doppler flow will show blood _____ (entering/leaving) the liver because
because the blood is being blocked from the liver and is forced to flow backwards
In tumor invasion or an AV fistula, is the LRV, RRV, or both typically involved (as compared to PV HTN vessel involvement).
LRV or RRV
It has been determined that the prevalence of RV involved in renal cell carcinoma is approximately _____ to _____%.
21% - 55%
When renal cell carcinoma invasion occurs, obstruction to the RV result in _____ (constriction/dilation).
What is the normal PV caliber?
Multiple worm-like serpiginous vessels in the region of the PV that result from longstanding thrombus and subsequent collateral vessel formation of a network of vessels that replace the obliterated PV is called
What is the acute or chronic hepatocellular disease that blocks the flow of blood through the liver, causing it to back up into the hepatic portal circulation and causes the blood pressure in the hepatic circulation to increase?
What helps to relieve high pressure in the portal system?
the formation of callateral vessels or varicose veins
Where do collateral vessels usually form (3)?
What is the most clinical consequence of portal HTN?
What kind of blood flow is observed in patients with portal HTN?
hepatofugal or retrograde
Because of the variations in caliber of the IVC during respiration, it is imperative that examinations are done in a consistent manner. This is usually best accomplished by examining while the patient ______ inspiration.
The average measurment of an IVC is ______. Above ______ is considered abnormal.
2 cm - 3.7 cm
Abnormal connection between the arterial and venous vessels is called
What causes blood to be routed directly from the artery into the vein in order to increase blood flow through the veins (AV malformation/fistula)?
high pressure in the arterial system
The natural response for a vein under increased blood flow is to ______ (constrict/dilate).
AV fistulas may occur for a number of reasons, including (5)
1) blunt or penetrating trauma
2) biopsy complications
3) tumor involvement
4) nephrectomy (kidney removal)
5) idiopathic causes
If a tumor is found in the RVs, the _____ should be checked to identify if there is an extension beyond the RVs.
In a tumor-free vessel, _____ may mimic a tumor or possibly a thrombus.
Some metastatic tumors may appear _____ (type of echogenicity) with the surrounding blood, making them difficult to identify.
The LRV may appear enlarged at the point that it crosses over the AO, before entering the IVC; this is normal unless
the entire length of the RV is enlarged
T or F? Although extremely rare, IVC duplication may be misintrepreted as LRV enlargement. To avoid this confusion, it is wise to
follow the vessel in question to its origin
RV thrombosis may occur in these disorders (6)
1) nephrotic syndrome
2) renal tumors
3) renal transplants
5) infant dehydration
6) compression of RV secondary to tumor
Signs and symptoms of acute RV thrombosis (Renal Vein Clot) may include (4)
loin or flank pain
With RV thrombosis, the RV is dilated at the point _____ (proximal/distal) to the occulsion.
With RV thrombosis, renal size generally _____ (increases/decreases) in the acute phase and a loss of normal renal structure may be identified. Doppler flow _____ (increases/decreases).
Thrombus generally appears as a(n) _____ (echogenicity) focus, especially in longstanding cases.
In acute phases of thrombus, it may not appear _____ (echogenicity) but may appear _____ (echogenicity) to the surrounding blood.
T or F? Venous aneurysms are very rare.
Some possible causes of venous aneurysms are (3)
1) weakening of vessel wall by pancreatitis
2) portal HTN
3) embryonic malformations (congenital anomalies)
T or F? There are often symptoms associated with small aneurysms of the PVS.
Portal venous aneurysms can be recognized as _____ (echogenicity) areas in the porta hepatis. There may or may not be thrombus and also a communication with the PV can be seen.
The PV drains blood from the (6)
The SMV and SV unite behind the neck of the pancreas to form the
The portal trunk divides into 2 lobar veins. The right branch drains the _____ and the left branch receives the _____ and _____ veins that enlarge to form umbilical varices in portal HTN.
The coronary vein, which runs along the _____ curvature of the stomach, receives _____, which also enlarge in portal HTN.
distal esophageal veins
A potential complication of portal vein thrombus is
bowel ischemia and perforation
Portal venous thrombosis goes through several stages and appearance varies with each stage. In stage 1, the thrombus is _____ (echogenicity) in the vessel lumen.
In stage 2 of portal venous thrombosis, the _____ and _____ are seen.
In stage 3 of portal venous thrombosis, the ______ is/are seen and the ______ is not seen/identifiable (which is called ______).
cavernomatous transformation of the PV
Direct signs of PV thrombosis are (6)
(as in, what is seen visually to suggest PV thrombosis)
1) visualization of clot in lumen
2) clot appears echogenic
3) if acute, clot may be difficult to see
4) local buldge of the vein at clot level
5) total occlusion: no venous or doppler signals
6) partial occlusion: normal doppler but decreased flow in vein
The most common cause of portal HTN in the western world is
Clinical signs and symptoms of portal HTN are (5)
2) gastrointestinal bleeding
3) poor renal function
4) impaired coagulation
Under extreme pressure, the round ligament (AKA ligamentum teres) may reopen to allow the passage of blood. This is called
Recannalization is most common in patients with ______ and ______.
T or F? A dilated coronary vein detected along with identification of esophageal varices is a good indicator of portal HTN. (80%-90%).
A very useful landmark for the location of recannalized veins (especially the paraumbilical vein) is the _____ vein along with esophageal varices, because it increases in size in 80-90% of cases. 20% of patients also have a patent _____ vein.
The most significant clinical consequence of portal HTN is
The term to describe the appearance of distended and engorgeed umbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins is
_____ is a sign of severe portal HTN with portal systemic shunting through the umbilical veins.
Portal HTN flow is _____. Which is odd because flow should be _____.
T or F? In portal HTN there is isolated LPV involvement. But with tumor invasion or AV fistulas, the LRV and/or RRV may be involved.
IVC thrombus is sonographically diagnosed/described as
An intraluminal filling defect that usually expands the diameter of the vessel.
The differential diagnosis of vascular tumor masses tends to be large because
because the similarity in echographic appearance.
What are the main indicators of portal HTN? (2)
dilated coronary vein
A collateral network may involve (5)
pancreatic duodenal vein
gastrorenal and splenorenal veins
This vein is identified by locating the splenic vein in a midline sagittal view and moving the probe to the right. It is recognized as a small vessel coursing cephalad from the splenic vein near the portal splenic confluence.
What does the presence of caput medusae indicate?
posthepatic or intrahepatic portal HTN
How is caput medusae formed?
by the recannalization of the umbilical vein which connects with the left hepatic branch of the PV
When shouldn't caput medusae be observed and why?
with isolated extrahepatic PV obstruction because the obstruction would be below the origin of the umbilical vein
Under extreme pressure, the round ligament (ligamentum teres) reopens to allow the passage of blood. This is common in patients with cirrhosis and portal HTN. Patients with cirrhosis experience rapid growth of scar tissue in and around the liver, often functionally obstructing nearby vessels.
What is the sonographic appearance of PV thrombosis?
goes through about 3 stages
1) echogenic thrombus in lumen
2) thrombus and small collaterals visible
3) large collaterals and no identifiable PV (cavernomatous transformation)
Leiomyosarcomas are known to mestastitize to the ______ and ______.
What is a rare tumor of the IVC and where does it originate?
outside the adrenal gland