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Son5025 Vasc > Topic 8-9 - the aorta and mesenteric system > Flashcards

Topic 8-9 - the aorta and mesenteric system Flashcards

1
Q

Describe the anatomy of the aorta and mesenteric system

A

The coeliac axis (trunk)
• the first abdominal branch of the aorta
The superior mesenteric artery
• begins about 1cm below the coeliac axis
The inferior mesenteric artery
• arises 3-4cm above the aortic bifurcation from the left anterior surface of the aorta
The right renal artery
• arises just inferior to the superior mesenteric artery
The left renal artery
• arises just inferior to the right renal artery

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2
Q

What does the coeliac axis supply?

A
  • gives rise to the splenic artery, hepatic artery and left gastric artery.
  • Supplies the spleen, pancreas, stomach, upper duodenum and liver
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3
Q

What does the SMA supply?

A

• supplies the small intestine (except proximal duodenum), most of the transverse colon, caecum and ascending colon.

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4
Q

What does the IMA supply?

A

• supplies the left third of the transverse colon, sigmoid colon and the rectum.

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5
Q

What are the different aneurysm shapes?

A
  • fusiform
  • saccular
  • berry
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6
Q

What are some ways of describing aneurysms according to their pathology?

A
  • post-stenotic
  • inflammatory
  • infected.
  • mycotic is also used and refers to the mushroom shape formed by some types of infected aneurysms which mostly occur in the aorta from septic emboli from endocarditis
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7
Q

What is ectasia?

A

• Diffuse enlargement of an artery

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8
Q

What is a true aneurysm?

A

A true aneurysm generally forms as a result of weakening of the arterial wall and involves all the layers of the arterial wall

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9
Q

How is an aortic aneurysm defined?

A
  • the aorta normally decreases in diameter as it approaches its bifurcation
  • an increase in diameter compared to the proximal artery can be considered as either ectatic or aneurysmal
  • an aortic diameter of 3cm or greater is also used as a good guide to classifying an aorta as aneurysmal
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10
Q

What are the second most common aneurysms after abdominal aorta?

A

Aneurysms of the popliteal artery are the next most common, with common femoral artery aneurysms coexisting with about 40% of popliteal aneurysms.

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11
Q

How are abdominal and popliteal aneurysms related?

A

The presence of an aortic aneurysm is a strong marker that there will be other aneurysm formation.
Recent studies have suggested that about 50 percent of people with popliteal aneurysm formation will also have an aortic aneurysm.

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12
Q

What is dissection?

A

• the splitting of the intra-luminal layers, causing a tear between the intima and the inner media layers

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13
Q

What defines a chronic dissection?

A

if it has been present for more than two weeks.

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14
Q

What are the different types of dissection?

A

• There are 3 types of dissections of the aorta:
o Type I, II or IIIa and IIIb (DeBakey)
o or as Type A or B(Stanford).
• Type A aneurysms are equivalent to Type I and II
o the aneurysm begins in the ascending thoracic aorta and may extend into the descending aorta (Type II remains in the ascending aorta).
• Type B is equivalent to Type III, where the aneurysm begins at or distal to the left subclavian artery and extends distally.
• Type I and Type IIIb are the only dissections which extent into the abdominal aorta.

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15
Q

What indicates an ultrasound of the aorta is required?

A

• Many aortic and iliac aneurysms are asymptomatic and are only identified by palpation during a routine clinical examination
• or by imaging for an unrelated condition where abdominal imaging is required.
• A clinician identifying a pulsatile abdominal mass (most common)
• sudden abdominal or back pain
hypotension

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16
Q

What are some risk factors for AAA?

A 
•	Family history of aneurysm
•	male gender
•	smoking
•	Increasing age
Less association is seen with:
•	Hypertension
•	Peripheral artery disease
•	Coronary disease
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17
Q

List the measurements required for a AAA exam

A
  • Maximum diameter in the A-P and coronal planes.
  • Diameter of the aorta at the renal arteries
  • Length of the aneurysm
  • Distance from the aortic bifurcation to the end of the aneurysm
  • residual patent lumen if mural thrombus is present
  • Identify and measure the true and false lumen of a dissection if present
  • diameter of the iliac arteries
  • diameter of the proximal aorta above the aneurysm
  • Location in terms of infra-renal or supra-renal.
  • Assess the periaortic region for masses, haemorrhage or adenopathy
  • identify the patency of the renal arteries, presence of hydronephrosis or horseshoe kidney
  • Imaging as much of the aorta as possible is important and documenting what cannot be visualised should become part of your routine.
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18
Q

How can you overcome tortuosity when imaging the abdominal aorta?

A
  • Overestimation of size can occur if the artery is tortuous as oblique views will produce a falsely large diameter.
  • To identify if you are perpendicular to the artery, obtain a transverse view of the vessel and then slowly tilt the beam superiorly and inferiorly along the artery axis.
  • As the beam becomes oblique to the artery, the wall of the artery will appear slightly thickened and slightly less clear (fuzzy).
  • Moving the beam from this oblique view through a perpendicular position will make the artery wall clear and the boundaries of the wall clearer.
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19
Q

What are some technical strategies to overcome bowel gas?

A
  • alternative patient positions – L or R side raised by 15°
  • subtle movement and angulation of the transducer
  • gentle compression with the transducer for a short time
  • fasting (especially for superior aspect)
  • lower frequency transducer
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20
Q

What are some technical strategies to overcome calcification?

A

• try different patient positions

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21
Q

What are some technical strategies to see mural thrombus?

A
  • colour flow imaging
  • colour power imaging
  • higher dynamic range
  • alter patient positioning or transducer position
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22
Q

What are some technical strategies to visualise an aortic dissection-(intimal flap)?

A
  • high gain setting and increased dynamic range for at least part of the examination
  • colour to look for a patent false lumen
  • mirror and other artefacts can generally be determined by pressing on the transducer to move the position of the image. A dissection will move as the image of the aorta moves, but an artefact will change its relative position in the image of the aorta.
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23
Q

Describe the method of surgical repair of an AAA?

A
  • opening the aneurysmal artery and placing a synthetic tube inside.
  • The synthetic tube is stitched to the non-aneurysmal artery at each end to make a liquid tight seal and the aorta is then sewn over the tube.
  • This is an inlay graft and it may be either a straight tube or a bifurcated tube if the iliac arteries also require repairing.
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24
Q

Describe the method of Endovascular aortic repair (EVAR)

A
  • insert a mesh stent which is lined with a non porous material to exclude the aneurysmal sac and provide a new conduit for blood to flow.
  • The aneurysm remains in the body and in time it diminishes in size.
  • These stents are placed via catheters
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25
Q

What is the role of ultrasound in pre operative AAA?

A
  • preoperative monitoring of the changes in dimensions of aneurysmal disease.
  • provide appropriate information regarding the size and extent of aneurysmal disease so that a surgeon can decide if the patient is going to need more extensive imaging investigations
  • Ultrasound is not generally considered sufficient to provide the information needed to plan open surgical or endoluminal repair
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26
Q

What is the role of ultrasound in follow up AAA repair imaging?

A

• primary tool for post graft surveillance.

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27
Q

What are some surgical repair complications for AAA?

A
  • haematoma
  • ischemia from emboli (colon, spinal or lower limb)
  • cardiac and pulmonary complications
  • renal failure
  • pseudoaneurysm at anastomosis
  • infection
  • thrombosis
  • refilling of excluded sac via branch arteries (often lumbar arteries)
  • adjacent aneurysm development
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28
Q

What are some Endovascular aortic repair (EVAR) complications?

A
  • endograft leak
  • thrombosis
  • stent migration
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29
Q

Comment on the use of ultrasound to detect endoleaks/perigraft leaks

A

color Doppler sonography may detect substantial perigraft leaks
helical CT is superior for detecting the origin of the perigraft leak, the outflow vessels, and the detection of complications related to the procedure.

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30
Q

What are the different types of endoleaks?

A
  • A type I endoleak is defined as direct flow into the aneurysmal sac related to the incomplete sealing of the stent-graft to the aortic wall.
  • A type II endoleak is the retrograde filling of the aneurysm mainly from the lumbar arteries and the inferior mesenteric artery.
  • Other types of endoleaks have also been described, such as the transgraft endoleak, graft-fabric degradation, and graft-junction separation
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31
Q

What is the main risk of an endoleak?

A

Endoleaks can lead to aneurysmal growth and rupture

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32
Q

Why is colour Doppler a good method of investigating endoleaks?

A
  • it is less expensive
  • widely available
  • does not require iodine contrast medium injection or radiation
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33
Q

What confirms a perigraft leak on ultrasound?

A

• A leak is considered present when a signal associated with a spectral Doppler signal was observed outside the aorta.

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34
Q

What are important investigations that colour Doppler cannot perform in the case of follow up EVAR?

A

Stent-graft deformation and migration are important parameters that cannot be evaluated by color Doppler sonography.

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35
Q

What are the different types of acute mesenteric ischaemia?

A
  • acute embolic occlusion
  • thrombosis of the mesenteric arteries
  • mesenteric vein thrombosis
  • non occlusive ischemia.
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36
Q

What causes acute embolic occlusion of the mesenteric arteries?

A

• Emboli usually arises from cardiac origins but may also come from proximal aortic atheroma or paradoxic emboli from the venous circulation.

37
Q

What causes thrombosis of the mesenteric arteries?

A
  • Thrombotic occlusion usually arises at the origins of the mesenteric arteries where atheroma is present and an acute thrombosis is associated with the progression of the atheroma.
  • Rheumatic and arteritic pathologies may also promote mesenteric thrombosis.
38
Q

What causes non occlusive ischemia of the mesenteric arteries?

A

• Non occlusive ischemia is mostly due to vasoconstriction of the mesenteric vessels

39
Q

What causes mesenteric vein thrombosis?

A

mesenteric vein thrombosis may be due to sepsis or be due to undetermined causes (idiopathic).

40
Q

What is the best way to assess acute mesenteric ischaemia?

A

primarily an urgent medical condition and angiography is considered the main method of imaging diagnosis.

41
Q

What causes chronic mesenteric ischaemia?

A

• caused by the development of atherosclerosis and the consequent effect on pressure and flow to the mesenteric circulation.

42
Q

How do patients with chronic mesenteric ischaemia usually present?

A
  • pain within about 30min after eating
  • This promotes a ‘fear of food’ with the anticipation of post-prandial pain.
  • These patients also have significant weight loss and frequently have co-existing vascular and/or coronary disease.
43
Q

ow is a patient prepped for a mesenteric artery ultrasound?

A
  • The patient must be fasted prior to the procedure
  • There is considerable debate about the value of a post-prandial procedure and post-prandial tests are not performed in many departments
  • A small amount of water is allowed
44
Q

What anatomy should be assessed in a mesenteric artery ultrasound?

A
  • superior mesenteric artery (SMA): origin, proximal, mid
  • coeliac axis (CA): origin, mid
  • hepatic artery: origin, proximal
  • splenic artery: origin, proximal
  • inferior mesenteric artery (IMA), origin and proximal vessel
  • aorta
45
Q

What is median arcuate ligament syndrome?

A

Coeliac artery compression syndrome

extrinsic compression of the CA may be caused by the median arcuate ligament.

46
Q

When should median arcuate ligament syndrome be suspected?

A

When a focal increase in velocity is isolated to the origin of the coeliac axis, especially in younger people, it should be remembered that extrinsic compression of the CA may be caused by the median arcuate ligament.

Between 30 and 50 percent of adults will have measurable coeliac axis compression syndrome and this is often the source of an abdominal bruit.

47
Q

Why should the CA be scanned on inspiration and expiration?

A

symptoms of abdominal pain in some individuals which results from the superior movement of the aorta during expiration.

Thus, if velocity increase is noted at the CA origin, it should be rescanned on inspiration and expiration.

48
Q

What can a hypertrophied IMA indicate?

A

indicator of disease in the other vessels.

49
Q

What are the stenosis criteria for mesenteric arteries?

A 
SMA >70% stenosis
•	PSV > 275 cm/s
•	EDV > 55cm/s
•	high resistance waveform
•	PSV > coeliac axis in the normal patient
Coeliac axis >70% stenosis
•	PSV > 200cm/s
•	EDV> 45 cm/s
•	Lower resistance waveform
•	PSV < SMA in the normal patient
Hepatic A
•	as per coeliac axis
Splenic A
•	as per coeliac axis. Note: Spectral waveform is often very turbulent.
IMA >50% stenosis
•	PSV > 200cm/s
50
Q

Why is Transjugular intrahepatic portosystemic shunt (TIPS) inserted?

A
  • To relieve the symptoms of portal hypertension.
  • They can be inserted using an endovascular approach or by surgery.
  • to relieve the hypertension, thus protecting the patient from episodes of oesophageal variceal bleeding.
51
Q

What is the objective of the ultrasound examination transjugular intrahepatic portosystemic shunt (TIPS) insertion?

A

• Despite adequate initial shunting, some patients present with recurrence of gastrointestinal bleeding, new onset or reappearance of ascites, or hepatic failure
• each of these problems can result from progressive liver disease, they may also result from hemodynamic failure (stenosis) or occlusion of the portosystemic shunt.
- the aim of ultrasound is to identify which is happening

52
Q

What is the benefit of early problem detection by ultrasound?

A

• If flow-reducing lesions are detected early, nonsurgical shunts may be revised by balloon angioplasty. This extends shunt life and has a favorable impact on patient morbidity and mortality.

53
Q

What is the purpose of ultrasound pre procedure transjugular intrahepatic portosystemic shunt (TIPS) insertion

A
  • to assure that the portal vein is patent with normally directed flow.
  • Assessment of the patency of the jugular vein and central venous system may also be requested
54
Q

What is the role of ultrasound immediately post procedure transjugular intrahepatic portosystemic shunt (TIPS)?

A

o assess the patient for complications related to the procedure.
o usually related to portal vein puncture and stent placement.
o If the patient is stable, the baseline postprocedure CFDU can be deferred to the day following creation of the TIPS.
o to determine shunt patency and to establish baseline morphologic and hemodynamic variables that may become secondary indicators of shunt function in long-term follow-up
o With the wide range of peak velocities that have been reported in patients with normal TIPS, it is imperative that baseline hemodynamics be recorded in each patient for long-term follow-up.

55
Q

What are indications for additional follow up studies?(outside of interval follow up)

A

• recurrence of gastrointestinal bleeding, new onset or reappearance of ascites, or general deterioration of the patient

56
Q

What does a follow up scan of TIPS need to image?

A
  • Image flow in the PV, SMV and SV
  • Show patency of the hepatic veins
  • Image the shunt
  • Perform spectral analysis throughout the length of the shunt
57
Q

What should a normal TIPS follow up scan demonstrate?

A
  • the ends of the shunt in the native vessel at either end
  • good colour fill
  • low impedence waveform with some pulsatility acceptable
  • PSV 50-60cm/s
  • similar velocities at either end of the shunt
  • hepatopedal flow in the PV
  • PV > 30 cm/s
58
Q

What are some indicators of TIPS abnormality?

A

Focal or diffuse narrowing, increased PSV or very low PSVs are all indicative of TIPS abnormality.

59
Q

What should the gray scale evaluation of TIPS look for?

A
  • the presence of ascites
  • intrahepatic hematomas
  • bile collections
  • Measurement of the size of the spleen
  • a search for any known varices or new portosystemic collaterals
  • A careful assessment should also be made of the size, configuration, and position of the stent with respect to the portal branch and draining hepatic vein.
  • The diameter of the stent should be measured along its entire length to assure that the device has properly expanded.
60
Q

What should a haemodynamic evaluation of TIPS include?

A

• a determination of the direction of flow and maximum angle-corrected flow velocity from the following sites:
o extrahepatic portal vein
o right and left portal vein,
o SMV
o splenic vein at the confluence of the SMV
o multiple sites from within the stent
o all three main hepatic veins
o the intrahepatic IVC.
o To assess the arterial response to the TIPS and to avoid missing an arterial injury, a quick survey of the hepatic artery with a calculation of the systolic and diastolic velocity and resistance index is encouraged.

61
Q

How can portal vein flow appear after TIPS?

A

flow may be undetectable or bidirectional in the right or left portal vein.
In others, hepatofugal flow in the portal vein branches is seen.
Hepatofugal flow in the portal branches reflects complete diversion of portal venous flow from the hepatic parenchyma into the shunt

62
Q

What are some signs of TIPS wellbeing

A

a progressive reduction in the size of the spleen, ascites, and the number and size of previously noted portosystemic collaterals may be observed.

63
Q

What is the most common way to transplant a pancreas?

A

It is very common to transplant kidney and pancreas together as the rejection rates are lower using this method.
Commonly the entire pancreas is transplanted together with a loop of duodenum which is in turn, anastomosed to the bladder.

64
Q

What are some common pancreatic transplant complications?

A

rejection, anastomotic leaks, arterial and venous anastomotic complications.

65
Q

Describe Pancreas Transplant: Systemic Venous-Bladder Drainage (Traditional Surgery)

A

Donor portal vein is anastomosed to the external iliac vein
donor artery Y graft to the external iliac artery.
Duodenal stump is anastomosed to the bladder.

66
Q

Why is traditional surgery (systemic venous bladder drainage) not used anymore?

A

Complication risks have resulted in a move toward the intestinal or enteric-based drainage procedure whereby a duodenojejunostomy is created for exocrine drainage of pancreatic secretions.

67
Q

Describe a Pancreas Transplant: Portal Venous-Enteric Drainage (New Technique).

A

Donor portal vein is anastomosed to the superior mesenteric vein
donor artery is anastomosed to the common iliac artery
Duodenal stump is anastomosed to a Roux-en-Y

68
Q

What are the most common reasons for liver transplant?

A

• Hepatitis C is the most common disease requiring transplantation, followed by alcoholic liver disease and cryptogenic cirrhosis

69
Q

What is the traditional means of liver transplant and what does it involve?

A
  • Traditionally, most adult liver transplants involve explantation of the recipient liver and replacement with a cadaveric allograft.
  • The surgery requires four vascular anastomoses (suprahepatic vena cava, infrahepatic vena cava, hepatic artery, portal vein) as well as a biliary anastomosis
70
Q

What does a living donor transplant require?

A

• For living related transplants, donor surgery consists of cholecystectomy followed by right hepatectomy, removing segments V, VI, VII, and VIII as well as the right hepatic vein.

71
Q

How is ultrasound used to assess pancreas transplant?

A
  • Ultrasound is used to detect peripancreatic collections and pancreatic enlargement.
  • Despite early reports that measurement of the RI might be useful (abnormal > 0.7), this has proved to have a very low sensitivity.
  • Colour duplex is primarily used to evaluate the associated vasculature.
72
Q

What does a normal pancreas allograft look like?

A
  • retains the normal gray-scale morphology of a native pancreas with well-defined margins;
  • a homogeneous echotexture, isoechoic or minimally echogenic to liver; and a thin, nondilated pancreatic duct
  • The peripancreatic fat shows a normal echogenicity.
  • Occasionally a trace amount of peripancreatic fluid may be observed and usually resolves without complication.
73
Q

How does colour and spectral ultrasound appear in a normal pancreas allograft?

A
  • Color Doppler ultrasound is useful for locating the mesenteric vessels, particularly when the graft is poorly visualized because of overlying bowel gas.
  • Spectral Doppler sonography of the normal graft shows continuous monophasic venous flow and low-resistance arterial waveforms.
74
Q

What are the most common complications of allograft vessels?

A

venous thrombosis and arterial pseudoaneurysm.

75
Q

What are potential symptoms of pancreatic graft venous thrombosis?

A

unexplained hyperglycemia, graft tenderness, and, in the context of systemic-bladder drainage technique, hematuria and diminished urinary amylase levels.

76
Q

What are some complications of pancreatic allograft venous thrombosis?

A

graft dysfunction and necrosis, pancreatitis, leakage of pancreatic secretions, and sepsis

77
Q

What is the normal appearance of a psot op liver transplant?

A
  • homogeneous or slightly heterogeneous echotexture
  • appearing identical to a normal, nontransplanted liver
  • early postoperative period, there is usually a small amount of free intraperitoneal fluid or small, perihepatic seromas or hematomas, which tend to resolve within 7 to 10 days.
  • Pneumobilia is often observed in patients with choledochojejunostomy and appears as bright, echogenic foci with or without posterior acoustic shadowing in the bile duct lumen
78
Q

What is a differential for pneumobilia?

A

• the sonographer should be aware that intraductal biliary air may be confused with tiny biliary stones or adjacent hepatic arterial calcifications because these structures can appear identical on gray-scale imaging

79
Q

When should the disappearance of pneumobilia be concerning?

A

• The disappearance of previously documented pneumobilia should alert the sonographer to possible interval development of a biliary stricture at the biliary-enteric anastomosis

80
Q

• Vascular patency of the transplanted vessels (hepatic artery, portal vein, hepatic veins, IVC) is assessed by

A

o 1) direct inspection for narrowing of the diameter
o (2) presence of thrombus within the vessel lumen
o (3) documentation of normal spectral waveforms with appropriate directional flow.

81
Q

How does the normal hepatic artery appear?

A

• shows a rapid systolic upstroke and continuous flow throughout diastole, with a resistive index (RI) of 0.5 to 0.7.

82
Q

How does the normal portal vein appear?

A
  • typically smooth in contour, has an anechoic lumen, and may show a subtle change in caliber at the surgical anastomosis.
  • The portal veins show continuous, monophasic, hepatopetal flow with mild velocity variations caused by respiration.
83
Q

What is the normal appearance of hepatic veins?

A

• The Doppler appearance of the hepatic veins shows a phasic waveform, reflecting physiologic changes in blood flow during the cardiac cycle.

84
Q

What are three important measurements on a bmode transverse image of an AAA?

A

The maximum AP diameter (outer to outer)
This is the maximum transverse diameter (outer to outer). This is a more difficult measurement because of edge refraction from the wall. It is often greater than the maximum AP diameter
the size of the abdominal aorta lumen (within mural thrombus) and calculate a % narrowing.

85
Q

What size AAA is considered for surgery?

A

dependent on the vascular surgeon
At 5.0cm aneurysm is considered appropriate for surgical or graft intervention.
Greater than 7.0cm would have been an indication for immediate surgery

86
Q

If a CA measurement of 400cm/s is observed what should you do next?

A

important that we perform our examination in inspiration and expiration to ensure that the stenosis is present in both stages of respiration, thus inferring atherosclerotic stenosis
It is possible that this stenosis has resulted from chronic compression of the median arcuate ligament rather than atherosclerosis.
Identifying arcuate ligament compression from atherosclerosis is an important distinction for the sonographer to make.

87
Q

list ultrasound data that needs to be acquired in the pre liver transplant

A

The pre-liver assessment is focussed toward establishing the suitablity to having the transplant perfomed.
Pre-operative:
• Establish patency of the hepatic veins
• Establish patency of the portal veins
• Establish liver size
• Establish the morphologic state of the liver
• Document changes related to portal hypertension
• Presence and patency of TIPS

88
Q

list ultrasound data that needs to be acquired in the post liver transplant

A 
aimed at confirming the success of the surgery, the presence of complications and data to ensure comparisons can be made in the short and long term.
Post-operative:
•	Exclude major complications
o	Integrity of the anastomoses,
o	texture of the liver
o	no dilation of the biliary tree,
o	free fluid, (small amount is normal)
o	interrogate fluid with colour
o	ensure patency of the hepatic artery and the portal vein
o	RI in the HA
o	PSV in the HA
o	IVC- to exclude thrombosis

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