Aorta, Illiac arteries & IVC

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1

What is the normal anatomy of the aorta?

smoooth margins

well defined walls

tapers below renals

mas diameter - 2 cm in adults

slightly to the left of midline

adjacent to spine

2

What are the branches of the aorta in order?

celiac

SMA

renals

gonadals

IMA

3

Where is the celiac axis?

card image
4

What makes up the portal vein?

splenic & SMV

portal splenic confluence

5

What is the normal anatomy of the IVC?

right of midline

gradually moves away from spine

6

What is the importance of evaluation of the IVC?

determine patency or cause of obstruction

evaluate filters

7

What happens to the IVC during the valsava manuever?

enlarges

8

Where does the IVC enter the heart?

right atrium

9

What should the blood flow be in the IVC?

continuous

10

What is the sonographic appearance of the Iliac arteries?

smooth marginated

uniform in caliber

max 1 cm at common

bifurcates at umbilicus

EIA slightly small than the common

11

WHat is the measurement of the common iliac arteries

1 cm

12

What is an aneurysm?

weakening of arterial wall

1.5 greater than adjacent

distal exceeds 3 cm

13

What are the different types of aneurysms?

difuse, focal

saccular, fusiform

true, false

mycotic & dissecting

14

What is a saccular aneurysms?

one sided

15

What is a fusiform aneurysms?

both sides

16

What is a diffuse aneurysms?

multiple

17

What are the majority of aneurysms?

true or false?

true

18

What is the problem with suprarenal aneurysms?

much harder to repair surgically

19

What is a true aneurysms?

walls are intact but stretched

involves all walls

20

Explain a Pseudoaneurysm?

a hole in the wall allowing escape of blood to surrounding tissue

may have circulation within the hematoma

common in groin, brachial & radial

21

What are the causes of a Pseudoaneurysm?

trauma

aortic puncture without stasis

infectious agents

leaky graft anastamoses

22

What is an aortic dissection?

misnomer

23

What is the cause of arterial dissection?

torn tunica intima allows blood in the layers of the wall

24

What may occur with arterial dissection?

destruction of the tunica intima

25

What are the two requirements for an arterial dissection?

weakening of the tunica media

tearing of the tunica intima

26

What are the predisposing factors of an arterial dissection?

Marfans syndrome

Age

atherosclerosis

27

What is Marfans syndrome?

connective tissue disorder

tall, long extremities

28

What is the most common site for arterial dissection?

thoracic aorta

go to CT & angio

29

Where is the most common site for arterial dissection seen in U/S?

less common abdominal aortic dissection

30

What is the presentation of an aortic aneurysm?

pain - abd, back, leg

31

How many aortic aneurysms are incidental findings?

30 - 60% asymptomatic

32

What happens when an aortic aneurysm ruptures?

death 50% of the time

33

What increases the risk of rupture of an aortic aneurysm?

size increase

34

When is surgical repair recommended for an aortic aneurysm?

5 cm

imperative at 6cm

35

What is the chance of rupture of an aortic aneurysm at 4.5 cm?

2% within 1 year

36

What is the chance of rupture of an aortic aneurysm at 4.5 cm - 6 cm?

10% within 1 year

37

An 4.5 cm aortic aneurysm grows at what rate?

1 cm per year

38

What is the average growth of an aortic aneurysm?

2 - 5 mm per year variable

39

How often should an aortic aneurysm be examined?

by U/S or CT

6 months

if no enlargement every year

40

Once an aneurysm be moved to CT?

4.5 cm

41

Iliac 3 2 1 rule

...

42

An iliac aneurysm usually occurs in conjunction with what?

AAA

isolated are uncommon

43

What does a rupture of an iliac aneurysm cause

non specific symptoms

44

When does concern start for an iliac aneurysm?

3cm

45

found in common iliac arteris

can be palitated

...

46

What is the sonographic appearance of aneurysm?

focal increase in caliber 1.5 - 2 x greater

absence of tapering

frequently contains thrombus

47

What can be confused with an aneurysm?

tortuous aorta

48

Why does arteriography underestimates aneurysm?

by measuring only active lumen

49

How should the aorta be measured?

outer to outer

90o

50

When looking at the aorta in coronal what is the easiest view?

from the left

51

aneurysm never decrease!

always check iliacs

above or below renals

...

52

What are the splanchnic arteries?

celiac

SMA

IMA

53

What happens when the splanchnic arteries get occluded?

bowel ischemia (IBD)

54

What can prevent bowel ischemia with occluded vessels

collateralization

55

What is the pancreaticoduodenal arcade?

collateral pathway links the celiac to the SMA

surrounds duodenum and pancreas

56

What is the Arc of Riolin?

collateral pathway links the SMA & IMA

57

What is the Marginal Artery of Drumond?

collateral pathway links the SMA and IMA

58

What is the two artery rule?

one vessel occlusion/stenosis is normally asymptomatic due to the collateral routes

normally IBD is clinically important when two of more vessels have been occluded

THIS IS NOT ABSOLUTE

59

What what percent must an occlusion be before surgery?

60% or higher

60

What is Medium arcuate ligament syndrome

medium arcuate ligament of the diaphragm extrinsically compresses the celiac axis - posteriorly

61

What are the symptoms of Medium arcuate ligament syndrome?

vague

random

associated with psychosocial

62

Symptoms of Medium arcuate ligament syndrome become worse with ________.

Why?

expiration

pushes down on celiac

63

How do you determine whether a celiac obstruction is intrinsic or extrinsic?

have the patient inhale deeply during Doppler examination

if flow doesn't change - intrinsic

if flow changes between inspiration and expiration the stenosis is extrinsic

64

What does celiac flow occlusion result in 100% of time?

flow reversal through collaterals

65

The SMA and IMA vary with fasting

What is the resistance with preprandial?

high resistance

66

The SMA and IMA vary with fasting

What is the resistance with postprandial?

low resistance

timing causes increased flow 30 - 90 minutes after eating

67

What is the resistance of the celiac?

low resistance

unaffected by fasting!!!

68

What are the SMA preprandial flow values?

PSV 96 -156 cm/sec

EDV 11 -16 cm/sec

69

What are the SMA postprandial flow values?

PSV 136 - 216 cm/sec

EDV massively increased

70

What are the Celiac flow values?

PSV < 122 cm/sec

EDV 32 -35 cm/sec

71

What is Acute Mesenteric Ischemia?

Surgical emergency

arterial occlusion of SMA & celiac

72

What are the symptoms of Acute Mesenteric Ischemia?

bowel evacuation

abdominal distension - from Air

Fever

dehydration

acidosis

73

What are the symptoms of Chronic Mesenteric Ischemia?

Postprandial pain

fear of food syndrome

weight loss

74

What is the method of evaluation of Chronic Mesenteric Ischemia?

angiography

MRA

CTA

U/S

75

What is the diagnostic criteria for SMA stenosis?

preprandial SMA low resistance

splanchnic artery increased flow from (70% or greater stenosis) in 2 or more vessels

76

What is the celiac flow values if 70% occlusion?

PSV 200 cm/sec

EDV 55 cm/sec

77

What is the SMA flow values if 70% occlusion?

PSV 275 cm/sec

EDV 45 cm/sec

78

What is the pre-renal flow resistance in the abdominal aorta?

low resistance

79

What is the post-renal flow resistance in the abdominal aorta?

high resistance

80

The hepatic artery is

A) hepatopetal

B) hepatofugal

A) hepatopetal

81

The portal vein is

A) hepatopetal

B) hepatofugal

A) hepatopetal

82

The hepatic veins is

A) hepatopetal

B) hepatofugal

B) hepatofugal

83

The hepatic artery is biphasic

...

84

What is the resistance of the splenic artery?

low resistance toward spleen

-negative

85

If a patient has uncontrolled hypertension what exam should be ordered?

renal Doppler exam

86

If a patient has ascites and/or cirrhosis what exam should be ordered?

Portal venous Doppler

87

If a patient has food fear what exam should be ordered?

IMA / SMA Doppler

88

If a patient has caudication what exam should be ordered?

aorta

89

What is caudication?

a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries.

90

How many people in the USA have hypertension?

20 million

> 10 million with fixed hypertension

91

How many people in the USA have renal artery disease?

> 400,000

92

How many people in the USA have true renovascular hypertension?

>260,000

stenosis in renal arteries

93

What is the direct method in renal Doppler?

interrogate entire renal artery, bilaterally

Best choice

94

What is the indirect method in renal Doppler?

interrogate segmental renal arteries only, bilaterally

95

What is the purpose of a Renal Doppler exam?

identify vascular etology of hypertension

prevent renal failure due to permanent parenchyma changes

evaluate renal transplant (contour, thickness of cortex)

96

What is the causes of renovascular hypertension?

atherosclerosis - proximal renal arteries

fibromuscular dysplasia - distal renal artery

dissection - extension of aortic dissection

97

renal vascular anatomy consists of?

Main renal artery

segmental renal artery at hilum

interlobar arteries

arcuate arteries

interlobular

98

How does the left renal vein course?

between the SMA and aorta

99

How does the right renal artery course?

posterior to IVC

100

Which renal artery is longer?

right

101

Which renal vein is longer?

left

102

Normal renal veins should demonstrate phasic flow but can have pulsatile flow from right atrium

...

103

Describe the accessory renal arteries

May arise from aorta above or below the main renal arteries

on right side they may pass anterior to IVC

may arise from the SMA or iliacs

104

What is the patient prep for a renal Doppler?

NPO after mid

simethicone (gasX

morning

105

What can be the cause of a high velocity without PST?

technical error

106

Why should you not invert spectral Doppler in the abdomen?

to check flow direction

107

What is the main renal arteries flow velocity?

High flow velocity

PSV 100 +- 20 cm/sec

108

What is the main renal arteries resistance?

low resistance

RI < 0.75

109

What is the main renal arteries diastolic flow velocity?

High flow velocity

EDV 30 +- 5 cm/sec

110

What is the criteria for diagnosis of a 60% stenosis in the Renal arteries?

Renal - aortic ratio (RAR) >= 3.5

Peak systolic velocity (PSV) . 180 cm/sec

post stenotic turbulence

Low flow in distal renal artery

111

What is the criteria for diagnosis of an occlusion in the Renal arteries?

NO flow

well visulized

low amplitude signal from parenchyma

small kidney size (<9 cm)

112

Renal prenchymal disease

high resistance flow in kidney and main renal artery

velocity is reduced

113

What are the physical limitations of Renal Doppler?

Depth of renal arteries

motion of respiration

intraabdominal gas

obesity

previous abdominal surgery

114

What are the technical limitations of Renal Doppler?

high technical failure rate (12 - 25%)

accessory renal arteries (polar artery)

Poor Doppler angle

Long exam time

requires very skilled tech

115

Renal transplants evaluation

R/O kinks / twists in renal artery

RI rejection

normal 0.73 +- 0.04

abnormal 0.8 +- 0.07

RI not universally accepted

116

What is the Purpose of a Mesenteric Doppler scan?

diagnose mesenteric ischemia

chronic or acute

117

What are the symptoms of mesenteric ischemia?

abdominal pain

pain after eating (food fear)

118

What is the resistance of the renal arteries?

Low resistance

119

What is the resistance of the pre renal?

low resistance

120

What is the resistance of the post renal?

high resistance

121

Eating does not affect the celiac

...

122

What provides blood to the liver?

portal vein (80%)

hepatic arteries

123

What is the purpose of the Portal system?

drains nutrient rich blood from bowel and spleen and takes it to the liver

124

What is portal hypertension?

elevated pressure in the portal venous system due to increased impedance of flow through the liver

125

What are the prehepatic causes of portal hypertension?

thrombosis of portal vein & splenic vein

extrinsic compression of Portal V

126

What are the intrahepatic causes of portal hypertension?

cirrhosis

hepatic fibrosis

lymphoma

127

What are the post hepatic causes of portal hypertension?

IVC obstruction

hepatic vein obstruction

128

What forms the Portal vein?

splenic vein and SMV

129

The right portal vein has what branches?

anterior and posterior

130

The left portal vein has what branches?

medial and lateral

131

What are techniques used for the Portal hypertension exam?

measure portal vein > 13 cm BAD

Doppler use low PRF and wll filters

Portal vein velocity & direction

evaluate portal vein and branches for thrombus

spleen enlarged? > 13 cm BAD

132

13 is magic number for what?

portal vein > 13 cm BAD

spleen > 13 cm BAD

133

How does the portal vein course?

ontra-segmentally in liver

134

What is the normal measurement for the main portal vein?

<13 mm

135

Portal vein has echogenic walls

...

136

Explain the flow in the main portal vein.

low velocity

20 - 40 cm/s

continuous flow

hepatopetal

no varices

normal flow direction in collaterals

137

What are technques used in a portal hypertension exam?

R/O extrinsic compression of portal vein by tumor or mass

evaluate IVC for obstruction

Porto-sysstemic collaterals present

use low Doppler PRF and low wall filters

intercostal windopw = good Doppler angle

appropriate Doppler frequency

138

What is the porto-systemic shunts Lt. Gastric vein?

AKA coronary vein

retro flow occurs in 80-90% of PH

may cause esophageal varices

139

What are the gatric varices located?

stomach (epigastum)

under lt lobe of liver

near spleen

140

What is flow when the paraumbilical vein recanalizes?

hepatofugal

141

What is flow of the splenorenal shunt?

splenic to lt renal vein

142

What is a TIPS?

Transjugular intrahepatic portosystemic shunts

stent placement in liver parenchyma between portal vein and hepatic vein

decompression of portal system

does not address cause of portal hyper tension (bandaide)