IVC Physiology and Pathology Flashcards Preview

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Flashcards in IVC Physiology and Pathology Deck (237):
1

CBD is _______ to the Portal Vein

Anterior

2

The CHD is _______ to the Portal Vein

Anterior

3

Portal Vein is _______ to the IVC

Anterior

4

SMV lies __________ to the Portal Vein

Inferior

5

SMV lies _________ to the Uncinate Process

Anterior

6

SMV lies _________ to the Pancreas Neck

Posterior

7

Pancreas Head lies______ to the IVC

Anterior

8

SMV and SMA lies________ to the 3rd portion of the duodenum

Anterior

9

MPV is a combination of

SMV Splenic and IMV

10

IVC displaced _________ by Right Liver Mass

Posterior

11

IVC displaced ________ by Right Renal Artery Aneurysm

Anterior

12

IVC displaced ______ by tortuous Aorta

Right

13

IVC displaced _______ by Right Adrenal Mass

Anterior/Medial

14

IVC displaced _______ by Right Renal Mass

Medial/ Left

15

Splenic Vein displaced _______ by left adrenal mass

Anterior

16

2 vessels in ventral cavity

Aorta and IVC

17

Whats the purpose of the IVC

Brings de-oxygenated blood back to the heart

18

What does the lumen of veins contain to help veins fight gravity

Valves

19

If valves are leaking or damaged what is it called when blood moves backwards

retrograde

20

Does venous system usually demonstrate a pulsatile flow

No

21

What happens when the valsalva maneuver is utilized

distends and dilates

22

Which vessels join to form the common iliac veins

External and Internal Iliac Veins

23

The IVC lies________ to the Liver

Medial and Posterior

24

What reason do we ultrasound the IVC

Look for thrombus and tumor invasion

25

What is rouleaux flow

The aggregation of RBCs

26

What are the 4 sections of the IVC

Hepatic
Pre-renal
Renal
Post-renal

27

If a tumor is in the renal veins what other vessel do you investigate

IVC

28

Where do the hepatic veins originate

Liver

29

What vessels drain all the blood from the liver

Hepatic Veins

30

The RHV empties which lobe

RLL

31

LHV empties which lobe

LLL

32

The MHV empties which lobe

Caudate Lobe

33

Do hepatic veins decrease in diameter as they approach IVC

No

34

What do you call blood flow toward the liver

hepatopedal

35

What do you call blood flow away from the liver

hepatofugal

36

What other vein enters the left renal vein besides the gonadal

left suprarenal

37

What does the right gonadal vein drain into

IVC

38

The major abdominal venous system constist of

IVC- from common iliac to diaphragm
Splenic Vein
IMV
SMV
Hepatic Veins
Renal Veins
Portal Veins

39

The proper hepatic artery shares circulatory supply with what

MPV

40

What does the IVC look like with Ultra Sound

Tube like
Well defined borders (echogenic)
Walls less echogenic and are thinner than arteries

41

How do you differentiate the artery from the vein

You can see pulsations of the arteries more than the veins. Also vein walls are collapsible

42

How do veins act during respiration

Inspiration - decrease size of lumen and blood flow decreases
Expiration - increases size of lumen and blood flow increases

43

How does Valsalva Maneuver affect the veins

Dilation/Distention and stops flow in the vessels

44

How are arteries affected by respiration and Valsalva

They aren't

45

What two vessels combine to make the IVC

Left and Right common iliac

46

Where is the anatomical orientation of the IVC

Courses through retro-peritoneal
Right of Aorta
Anterolateral to vertebra

47

How does IVC relate to surrounding structures

Liver- posterior
Kidney- medial
Diaphragm- Anterior

48

What are the tributaries to IVC that can not be seen by ultrasound

Lumbar
Right suprarenal
Right gonadal vein

49

Is the venous system pulsatile

No

50

What is the Valsalva Maneuver

Patient takes deep breath and holds it and bears down, as if having a bowel movement

51

What shape is the lumen of the IVC

Elliptical

52

How should you measure the IVC

A/P

53

What is rouleaux formation

an aggrigation of the RBC in order to better facilitate the upward movement through the veins. Blood cells are stacked together. May make inner vessel appear complex.

54

Where is the Hepatic section of IVC

where hepatic dumps into IVC

55

Where is pre renal

Inferior to hepatic veins but superior to renals

56

Where is renal

Where renal veins are

57

Where is post renal

Proximal to the Renal veins to the bifurcation

58

Where does tumor invasion most likely occure

renal veins and extend into the IVC

59

Most common renal tumor

Renal Cell Carcinoma

60

What are the normal variants of IVC

Double IVC, IVC on left, absent portion

61

Hepatic Veins originate in

Liver

62

Where do hepatic veins empty

superior to renal veins

63

Do the hepatic veins increase or decrease as they approach IVC

Increase

64

Are hepatic Veins pulsatile

Yes

65

Are hepatic Veins hepatofugal or hepatopedal

hepatofugal

66

What are caudate lobe veins

Small veins that drain directly into the IVC, occasionally seen with ultrasound

67

Which renal veins is longer

Left

68

Left renal vein receives which two veins

Left Suprarenal Vein and Left Gonadal Vein

69

The Renal Veins are ______ to the Renal Arteries

Superior (VAU)

70

What is the nutcracker

LRV is caught between aorta and SMA

71

Where does the Right suprarenal vein and maybe also left gastric vein feed into

IVC

72

What is another name for the gonadal veins

Ovarian veins and gonadal veins

73

What are Azigos and Hemi Azigos

They are veins that run parallel to the IVC and can bypass the IVC if need be.
Left - Hemi azygos
Right - Azygos

74

What structure may be mistaken for the RRA or RRV

Right Crus of the Diaphragm

75

Will left and right veins be symmetrical

No because they collapes

76

Can you always see the vein

No my be collapsed

77

Are Renal veins anterior or posterior to renal arteries

anterior but crossover can frequently occur. Doppler is helpful

78

Do the Portal Veins enter the IVC

NO

79

What is the function of the Portal Veins

It delivers blood from the spleen, gastrointestinal tract to the liver

80

Is the portal vein system similar to the arterial system

No different from the arterial and venous blood supply to the liver

81

What vessels make up the portal system

Portosplenic confluence
Main portal vein
Right portal vein and branches
Left portal vein and its branches

82

Which is more tortuous splenic vein or artery

Artery

83

Where does the splenic vein begin

Helium of the spleen

84

How does splenic vein travel

Travels transversely across posterior abdominal wall inferior inferior to splenic artery and posterior to the pancreas tail

85

What are the landmarks that are anterior and posterior to pancreas

Anterior- splenic artery
Posterior- Splenic vein

86

What vein joins the Splenic vein as it drains distal colon and rectum

IMV

87

Is IMV normally seen by ultrasound

No

88

When is IMV seen by ultrasound

When it dilates with Portal HTN may be confused for Splenic Vein

89

Where does SMV originate

Ileocecal valve where the ilium and small intestines join the cecum of the large intestines

90

How does SMV travel

Superiorly near midline

91

When does it become the portosplenic confluence

When SMV joins the Splenic vein and IMV

92

Portosplenic confluence then travels laterally and becomes

MPV

93

MPV passes____________ to the 1st portion of the duodenum CBD, PHA and GDA

posteriorly

94

How much blood does main portal vein supply to the IVC

80% or 4/5

95

Where does MPV begin

Posterior to the neck of the pancreas

96

Where does MPV enter the liver

Porta hepatis

97

What are the division of the MPV

Left and right portal veins inside the liver

98

What is the portal veins connected to GB by the main lobar fissure

Right portal vein

99

What 3 vessels make up the Porta Hepatis

Main Portal Vein
Common Hepatic Duct
Proper Hepatic Artery

100

What sign is the porta hepatis made of

Mickey Mouse Sign-Mashed (main portal vein) Potatoes (Proper Hepatic Artery), and Corn (Common Bile Duct)

101

What scanning plane can you find mickey mouse

Oblique

102

Which is longer R portal vein or L portal vein

Left and has smaller diameter

103

What does Left portal vein branches feed

Caudate lobe and Left lobe of liver

104

How does Left portal vein travel

Origin- MPV and courses medially

105

What are two segments of Left portal vein

MEDIAL AND Lateral

106

What sign does Left portal vein make when it branches

Steer sign

107

What veins originates from the Right Portal Vein

Cystic vein

108

Cystic vein gives branch to

Caudate lobe before entering into the right lobe of the liver

109

What does Right portal veins branch into

Anterior and posterior

110

What makes Portal Veins stick out

Highly echogenic walls- due to high collagen in the walls

111

Why do we evaluate the portal veins

Tumor or thrombus which causes portal HTN

112

What flow should portal veins show

Hepatopedal

113

What are all the hepatic arteries

Common hepatic which branches into the Proper hepatic and GDA

114

The Common Hepatic Arteries pass _________ to the MPV just proir to bifurcation

Anteriorly

115

How does the proper hepatic flow

Bifurcates from CHA and enters through portahepatis within the folds of the hepatoduodenal ligament

116

Proper Hepatic artery divides into

Left Hepatic Artery and Right Hepatic Artery, the Right Hepatic Artery gives rise to the cystic artery

117

What does cystic artery feed

GB, hepatic ducts and part of CBD

118

Will CBD have color on doppler

NO

119

Does portal venous system enter the IVC

No

120

Function of the portal system

Brings oxygenated blood from spleen and gastrointestinal tract to liver for oxygenation and detoxification

121

Name 4 segments of the portal vein system

Portasplenic confluence
Main Portal Vein
Right Portal Vein
Left Portal Vein

122

What is vessel that landmarks the Pancreas

Splenic Vein

123

Name the ligament that crosses the celiac axis

Medain Arcuate Ligament

124

3 vessels of the portasplenic confluence

SMV IMV and splenic vein

125

What supplies 80% of the Liver blood supply

MPV

126

What is the steer head sign

The branches of the Left Portal Vein (median and lateral

127

What makes up porta hepatis

MPV, PHA, CHD - MICKEY MOUSE SIGN if in oblique

128

Cystic originates in

R portal and branches to Caudate lobe

129

What are Azygo and Hemi Azygo

Back up for IVC

130

How does inspiration affect IVC

Smaller diameter
Less venous return

131

How does expiration affect IVC

Larger diameter
Greater venous return

132

How does valsalva maneuver affect IVC

Venous return is blocked because flow is temporarily reversed causing it to bulge

133

How should exams be done in order to be consistent

Examine as patient examines on suspended inspiration

134

How does an obstruction affect the IVC

Increases in diameter BELOW (proximal) the point of obstruction

135

What is the most common cause of IVC occlusion

Right sided heart failure

136

What is right sided heart failure

When the right side of the heart can't pump out blood in an efficient manner
The blood isn't pumped out and it gets backed up into the IVC

137

What is it indicative of when the IVC does not collapse at least 50% with deep breath

A right sided filling pressure issue- Right sided Heart Failure

138

Other causes of IVC obstruction

Enlarged liver (crushed from the front)
Para-aortic lymph node enlargement (crushed from the left)
Retroperitoneal mass or tumors (crushed from all sides)
Pancreatic tumors (crushed from the front)
Congenital IVC valve issues

139

What are the signs of IVC obstruction

Abdominal pain
Ascites
Tender hepatomegaly
Lower extremity edema

140

How does IVC obstruction appear on ultra sound

With all causes- Dilation below obstruction
With CHF- Decreased collapse with breath,
congestion of hepatic veins, Ascites, Hepatomegaly

141

How do tumors appear in ultrasound

Irregular borders
internal echoes

142

What can be the result of any impinging tumor or structure on the IVC

Thrombus

143

What is the most encountered intraluminal anomaly of the IVC

Thrombus

144

Where will the thrombus usually spread from

Vein in pelvis
Lower Limb
Liver
Kidney

145

How is thrombosis sonographically diagnosed as

an intraluminal filling defect that usually expands the diameter of the vessel

146

Why is important to look at the IVC from thrombus or obstruction

To avoid a fatal PE

147

How do you determine the age of a thrombi

Echogenicity- more echogenic the older it is

148

How does doppler appear on an occluded IVC

No signal

149

What is the most like place from a thrombus to occure

Kidneys

150

What is an IVC filter

metal device placed in the IVC which will filter out any blood clots over 5mm. May be permanent or temporary

151

What complication can occur with an IVC filter

Filter fracture

152

What are the symptoms and intervention of IVC filter fracture

Asymptomatic- do nothing
symptomatic- CT and consider surgery

153

What are the three types of IVC tumors

Primary
Metastatic
Extension from primary

154

What is a primary tumor

Leiomyomas or leiomyosarcomas (2%)
Usually in women around 61
With leiomyosarcoma 40-50% spread to liver or lung

155

Where can metastasis of tumors occur from

Renal Carcinoma
Adrenal Tumors
Retroperitoneal sarcoma
Hepatocellular Carcinoma
Teratoma
Lymphomas

156

Signs and symptoms of tumor (primary/metastatic)

Symptoms are unremarkable but depends on tumor size
Leg edema
Ascites
Abdominal Pain

157

Sonographer apprearence of tumor

Echogenic foci but maybe isodense and hard to see.
If primary- may be heterogeneous, with areas of necrosis
Increase in IVC diameter before Block and decrease change with respiration

158

What different diagnosis can the Radiologist contribute to invading tumor

Primary Vascular Neoplasm
Malignant IVC Mass
Chronic Thrombus
Large primary tumors outside the vessel

159

What is in alternative to a tumor in the vessel

A tumor out of the vessel but distorting into the vessel and may be hard to tell the difference

160

What do you need to ID when you locate an IVC mass

Presence of a primary tumor and its site
The cranial extent of the tumor mass (hepatic veins or right atrium)
Possible tumor involvement or invasion of the wall of the vessel

161

What happens to the blood flow pattern when there is an obstruction

They are changed
Speeds where it is narrowed

162

What is the symptom seen most often which an IVC tumor invasion

Leg Edema

163

When an IVC mass is identified what 2 things must be identified

Involvement of hepatic mass or right atrium
Involvement of tumor or invasion of the wall of the vessel

164

What are the most common causes of renal vein enlargement

1) Increased blood flow do to a splenorenal or gastrorenal shunt
2) Thrombus or portal htn
3) Tumor involvement from renal cell carcinoma
4) Increased flow from an AV malformation in the kidney

165

What are sign and symptoms of a renal vein enlargement

1) Associated with another disease process
2) No specific systems that would make suspicious of tumor extension
3) Renal veins are enlarged past 1.5cm
4) IVC enlargement around the renal veins

166

Sonographer appearance of enlarged renal veins

1) Evaluation symmetry between renal veins (ID causing disease
If bilateral- IVC
If only one veins- portal htn, tumor involvement, AV fistula

167

What will happen in the kidney veins if patient has portal htn

Formation of collateral pathways cause Left Kidney vein fistula

168

What other problems may cause isolated kidney vein enlargement

AV fistula
Tumor

169

How prevalent is renal cell carcinoma in renal vein enlargement

21-55%

170

What happens in AV fistula

Connection of artery in vein causes artery to force blood into the vein

171

Why might an AV fistula occur

1) Blunt trauma
2) Biopsy complication
3) Tumor
4) Nephrectomy
5) Idiopathic (unknown)

172

How does doppler appear in portal htn which causes AV fistula associated with a gastrorenal or splenorenal shunt

Turbulent blood flow in veins
Increased velocity

173

If a sonographer finds an echogenic area in the lumen what should he/she then do

Closely inspect IVC from extension of the tumor

174

What pitfall might one experience when examining the renal veins

1) In tumor free- reverberation artifact which mimics tumor or thrombus
2) Isogenic tumors
3) Left renal vein may appear enlarged when crossing the aorta which is normal
4) Duplicate IVC could appear as left renal enlargement

175

What disorder may cause renal vein thrombus

1) Nephrotic syndrome
2) Renal tumors
3) Renal transplants
4) Trauma
5) Infant dehydration (common)
6) Compression of the renal vein secondary to tumor

176

Signs and symptoms of renal vein thrombus

1) Loin or flank pain
2) Hematuria
3) Leg swelling
4) Protenuria

177

What is the sonographic appearance of a renal vein thrombus

1) Dilation proximal to thrombus
2) Visible thrombus in renal vein or IVC
3) Increased renal size and loss of structure
4) Doppler flow increases

178

How does thrombus appear (staging of a blood clot)

Echogenic foci- especially old thrombus
Acute phase- isochoic to surrounding blood

179

How common are venous aneurysms

Very RARE

180

What causes venous aneurysms

1) Weakened vessel wall by pancreatitis
2) Portal HTN
3) Embryonic malformations

181

What are signs and symptoms of venous aneurysm

None associated with small ones in portal venous system

182

Sonographic appearance of portal vein aneurysm PVA

1) PVA anechoic in portal hepatis- may or may not be thrombus
2) Doppler can be used to see if there is an echo free structure
-Portal htn resembles all other venous aneurysms

183

Where does Portal vein drain blood from

Spleen, pancreas, stomach, gallbladder, small and large intestines

184

What does the left portal vein receive

umbillical and paraumbillical vein

185

What does the coronary vein receive

Distal esophageal veins- enlarge with portal htn

186

How does coronary vein run

Along lesser curvature of stomach

187

Where do thrombus usually occur in portal vein during cirrhosis and hepatic maglignancies

Intrahepacally and will spread to extrahepatically

188

Where do all other etiologies cause portal vein thrombus

starts at the point of origin

189

What vessel can clot and leaded to thrombus in portal vein

Splenic vein- results from an adjacent inflammatory process such as the pancreas

190

What is the normal size of the portal vein

13mm

191

What causes portal venous thrombus

1) Portal htn
2) Inflammatory - appendicitis, peritonitis, pancreatitis
3) Trauma
4) Postsurgical complications
5) Hypercoagulability states
6) Abdominal neoplasm
7) Renal transplant
8) Benign ulcer disease
9) Idiopathic

192

What is a complication of portal vein thrombus

Bowell ischemia and perforation

193

Signs and symptoms of portal vein thrombus

Abdominal pain
Low grade pain
Leukocytosis
Hypovolemia
Shock
Abdominal Rigidity
Elevated LFTs
N & V
Hematemesis
Melena

194

Sonography appearance of portal htn

Stage 1- Echogenic thrombus in vessel lumen
Stage 2- Thrombus and small collaterals
Stage 3- Large collaterals and no identifiable portal veins

195

Direct signs of portal venous thrombus

-Visualization of a clot in the lumen
-Clot appears echogenic
-If acute, clot may be hard to identify
-Local bulge of the vein at clot level
-Total occlusion: no venous doppler
-Partial occlusion: normal doppler but decreased flow

196

Indirect evidence of portal vein clot

-No portal vein landmarks
-Collateral vessel formation
-Increased SMV and splenic vein caliber

197

What is cavernomatous Transformation

Multiple worm like serpiginous vessels in the portal region- will replace clotted portal veins

198

What causes cavernomatous transformation

long standing portal thrombus and collateral vein formation

199

What is portal htn

Increase in pressure in the portal veins

200

What features accompany portal htn

-Superficial collateral vessels- Cruveilhier- Baumgarten syndrome
-Left gonadal vein varix
-Spontaneous splenorenal shunt

201

What are steystemic vein connection to collateral veins to relieve pressure

Varicose veins

202

What are varicose veins most frequent

Esophagus
Stomach
Rectum
Rupture may cause death

203

What is the most common cause of portal htn

Cirrhosis

204

Sign and symptoms of cirrhosis

Ascites
Gastrointestinal bleeding
Poor renal function
Impaired coagulation
Recannalization

205

What is recannalization

Under extreme pressure the round ligament (tere) will reopen to move blood
-Common in cirrhosis or portal htn
-Results in rapid growth of scar tissue in liver

206

How does recannalization occur

So much pressure on vessels surrounding the liver that it forces the round ligament open

207

Sonographer's appearance

-Portal vein enlarged/or normal or small due to collaterals
-Secondary effect of increased pressure results in collateral channel development and recannalization and abnormal respiratory responses

208

Collateral network may involve

-Coronary vein
-Gastroesophageal vein
-Umbilical vein
-Pancreatic duodenal vein
-Gastrorenal and splenorenal vein

209

How often does identifying coronary dilation and esophageal varices indicate portal htn

80-90% of the time

210

How often will umbilical vein recannalization be present

10-20% of the time

211

How can you locate the coronary vein

Locate the splenic vein in midline sagital veiw and move the probe right. It courses cephalad from the splenic vein near the porto-splenic confluence

212

Portal htn from is

Hepatofugal- away from the liver, supposed to be hepatopedal

213

What is the most significant clinical consequence of portal htn

Variceal Hemorrhage

214

What are pericholecystic varices

They are vascular areas of increased flow within the gallbladder wall- associated with portal htn

215

What does Caput Medusae describe

Distended and engorged umbilical veins which are seen radiating from the umbilicus across the abdominal wall to join the splenic vein

216

What does the presence of caput medusae indicate

Posthepatic and intrahepatic portal htn due to recannalization of the umbilical vein which connects with left portal vein. Wont occur if obstruction if below the umbilical vein

217

What is Caput Medusae and indication of

Portal htn which shunting through umbilical veins

218

Where did Caput Medusae derive its name

Medusa's hair of snakes

219

How do normal Portal veins appear

-No intralumenal echoes
-low velocity and respiratory variation
-Smooth fill with color

220

How do Portal vein with thrombus appear

-Enlarged or normal with low lever echoes in the lumen, may be isoechoic in the liver
-Decreased low velocity to absent Doppler
-Hepatofugal flow
-No color

221

How does Portal HTN appear

-Enlarged Portal Veins with recannalization of the umbilical vein
-Look for Hepatofugal flow
-Hepatofugal flow with good color flow

222

How does Cavernous Transformation look

-Multiple vascular channels near the poral hepatis or splenic hilum
-Thrombus of the extrahepatic portal vein
-Recannalized umbilicus
-Continuous velocity flow
-Color fills dilated collateral vessels
-Portal vein hard to fill with color

223

How does a normal Hepatic artery appear

-Hepatic artery should be anterior to portal vein
-Should be level with the celiac axis
-Distal HA should seen in intercostal coronal view level with MPV and CBD

224

How does a thrombosis in the hepatic artery appear

-Increased low level echoes
-Obstruction causes increased waveforms
-Turbulence or absence of flow if completely obstructed

225

How does normal IVC appear

-Low level echoes that changes with respiration
-Returns to right atrium
-Coninuous triphasic waveform with respiratory variation
-Color filled lumen

226

How does a thrombosis in the IVC appear

-Increase echogenicity within the lumen returning to the Right Atrium
-Evaluate Renal Veins for extension of thrombus
-Decreased Doppler waveform for secondary to degree of thrombus
-Decreased color in the lumen
-Color will outline the walls of the thrombus

227

How does the IVC appear in right sided heart failure

-Dilation of lumen that does not change in respiration
-Multiphasic, pullsatile flow
-Color fills lumen of hepatic veins and IVC

228

How does a thrombosis associated with Budd Chiari appear

-Low level echoes within the lumen of the hepatic veins
-May restrict blood flow into the IVC
-Caudate enlargement may mean hepatic vein thrombosis
-Decreased flow signal
-Decreased color fill in hepatic veins
-IVC collapsed with decrease bloodflow

229

What is normal size of portal vein

13mm

230

What is the cavernomatous transformation

Multiple worm-like vessels in the regions of the portal veins that result from long standing thrombus and collateral vessel formation

231

What is portal hypertension

Acute or chronic blocks flow through the liver- causing portal back up. Causes portal blood pressure to increase

232

What helps relieve the high pressure in the portal system

Collateral vein formation and varicose formation

233

Where do these collateral vessels usually form

Esophagus, stomach, rectum

234

Advances portal HTN can cause what signs and symptoms

-Ascites
-Gastrointestinal bleeding
-Poor renal function
- Impaired Coagulation

235

What is the most significant clinical sign or portal htn

Varicose Hemorrhage

236

What kind of blood flow is observed with portal htn

Hepatofugal or retrograde

237

Average measurement of IVC

2-3.7 cm above 3.7 is considered abnormal