1. Diagnostic Medical Sonography Program
Abdominal Sonography 2
Abdominal Vascular Parts A and B
Holdorf

2. Contents Part A Abdominal Vasculature physiology Arterial Anatomy
Layers of the arterial wall
Arterial Anatomy
The aorta
Aortic aneurysms
Main visceral branches of the abdominal aorta

3. CONTENTS PART B Venous anatomy Inferior Vena Cava
Main Venous Tributaries
Aorta and IVC Locations
Aorta and IVC size
IVC sonographic appearance
Abdominal Vasculature Examination Technique
Abdominal Arterial Pathology
Abdominal Venous Pathology

4. Abdominal Vasculature Physiology
Functions of the Vascular System:
Arteries and arterioles carry oxygenated blood away from the heart
Veins and venules carry blood toward the heart
Capillaries connect the arterial and venous systems
Extremity veins contain valves
Valves extend inward toward the intima

5. VESSEL WALL LAYERS
Venous walls are thinner and less elastic when compared with arterial walls
 THE ARTERIAL WALL LAYERS…
Tunica adventitia
Outer layer
Lends greater elasticity to the arteries
Tunica media
Middle muscle layer
Helps to regulate blood flow by controlling the vessel wall diameter
Tunica intima
Inner layer
Comprised of a single layer of cells giving it a smooth surface

6. Layers of the Arterial wall

8. Arterial Anatomy ABDOMINAL AORTA
Originates at the diaphragm and courses inferiorly until it bifurcates into the right and left common iliac arteries
Tapers in size as it courses anterior and inferior in the abdomen
Common iliac arteries are the terminal branches of the abdominal aorta.
Common iliac artery bifurcates into the external and internal (hypogastric) iliac arteries.
External iliac artery becomes the common femoral artery after passing beneath the inguinal ligament
Internal iliac artery bifurcates into anterior and posterior divisions

11. Aorta cont. Diameter: Proximally 2-2.5 cm At bifurcation 1.5 cm
Ectatic (3cm) abdominal aorta is seen with age and is usually tortuous.
Aneurysm > 3cm
US Appearance:
Anechoic
Tubular structure
Pulsatile
High resistance flow.

12. Ventral branches of AA:
Celiac Axis( Trunk): 1-3 cm in length.
Splenic A; SA- toward the spleen, tortuous and difficult to visualize, courses superior to Pancreas; Supplies blood to the spleen , pancreas.
LGA (Lt. Gastric A.) - Usually not seen on US. Courses superior and to the left. Supplies left side of the lesser curvature of the stomach and eventually anastomosis with RGA.
Common Hepatic A. ( CHA); enters porta hepatis with PV.
GDA (Gastroduodenal A.) – is the first branch of CHA, has a caudal course. delineates the Anterolateral aspect of the HOP: supplies the duodenum, parts of stomach and HOP.

13. The Common vs. the Proper Hepatic Artery

14. Ventral branches of AA Cont.
Superior Mesenteric Artery(SMA)- Post to body of Panc. On trv. View. In sag. runs parallel and ant. to the aorta.
Supplies small intes. (jejunum, ileum), HOP,cecum ascending colon & part of transv. Colon.
Doppler signature ( fasting /post prandial)
Inferior Mesenteric Artery (IMA)- Originates from Ao. close to the umbilicus. Rarely seen on US.
Supplies blood to the left transverse colon, the descending and sigmoid colon, and upper rectum.
Doppler signature; very high resistant in Fasting

15. Lateral Branches Of Aorta
Right Renal Artery- Is the Only vessel that courses posterior to IVC.
Left Renal Artery- LRA < RRA
Notes:
33%population have accessory RAs.
Normal Doppler signature – High diastolic: low resistance
Branch from Aorta cm distal to the SMA
Gonadal Arteries- Arise off the anterolateral aspect of the aorta, inferior to the renal arteries and are difficult to visualize on US.

16. Scanning techniques for evaluation of Aorta
Long and Transverse views
Begin at the level of diaphragm and follow to Aortic bifurcation.
Because a significant # of AAAs involve Iliac arteries, they should be also evaluated as part of Aortic exam.
Look for thrombus, intimal flaps and any paraortic masses.
Measurement are done in; TRV, AP
Outside to outside wall.

17. Scanning techniques for evaluation of Aorta cont.
Although 95% of AAA are below the level of renal arteries > try to identify the level of RAs.
Note- Prox. Ao. Is seen posterior to IVC
Be aware of Anatomical varieties/abnormalities; Interruption- transposition.
Aorta has a high resistant Doppler signature.

18. Keywords
Abdominal aortic aneurysm – dilatation of the aorta equal to or exceeding 3 cm in diameter; Aka: AAA Aneurysm – a localized widening or dilatation of a blood vessel. Arteriovenous fistula – an abnormal connection between an artery and vein; Aka: arteriovenous shunting Berry aneurysm – small saccular aneurysms primarily affecting the cerebral arteries

19. Dissecting aneurysm – a result of a tear in the intimal lining of the artery creating a false lumen within the media. This false lumen allows blood to dissect the media and adventitia layers.
Ectatic aneurysm – dilatation of an artery when compared with a more proximal segment. In cases of abdominal aorta the ectatic dilatation does not exceed 3.0 cm.
Fusiform aneurysm – characterized by a uniform dilatation of the arterial walls; most common type of abdominal aortic aneurysm
Mycotic aneurysm – a saccular dilatation of a blood vessel caused by a bacterial infection.
Pseudoaneurysm – dilatation of an artery due to damage to one or more layers of the arterial wall caused by trauma or aneurysm rupture; Aka: pulsatile hematoma
Saccular aneurysm – dilatation of an artery characterized by a focal out-pouching of one arterial wall; most often due to trauma or infection.  

20. Dissecting (Pseudo) Aneurysm

21. Ectatic Aneurysm

22. Fusiform aneurysm

23. Mycotic aneurysm

24. Saccular aneurysm

26. Common locations of Berry Aneurysms

27. Aortic Aneurysm
Aneurysm= localized dilatation of a weakened part of an arterial wall.
NL Aortic diameter < 3cm
NL Iliac a. =1.5 cm (1.3 cm in female)
Renal arteries: located 1.5 cm dist. to SMA
AAA= focal enlargement > 3cm AP diameter
Rare< 50 Y
70-90% AAAs occur in men> 65 Y
Major causes:
Idiopathic : The most common, usu. Infrarenal and associated with atherosclerosis
Congenital defects
Infection: Syphilis
Trauma

28. Histological AAA Classification
True Aneurysm: All 3 layers of arterial wall are stretched. A minority of them are due to rare identified underlying diseases such as Marfan’s Syndrome, however the majority of true aneurysms are idiopathic with a multifactorial origin. (atherosclerosis, smoking, hyperlipidemia)
False Aneurysm: A hole in the wall allows leakage of blood, ex. Trauma, Infection (Mycotic Aneurysm), graft anastomoses.
Dissecting aneurysm: A special type of pseudo- aneurysm, separation of the intima and media; creating a false lumen.

29. AAA Types Fusiform; diffuse (gradual)- most common
Bulbous; focal (sharp)
Eccentric, Saccular- usually due to trauma

30. SAG AAA

31. AAA Symptoms Pulsatile abdominal mass, abdominal bruit
Abdominal pain, may radiate to back
If ruptures; hypotensive shock (50% mortality rate)
Growth rate: cm/year
AAAs usually are silent and can be lethal.

32. US Role in AAA Identify unknown aneurysm
Surveillance of the known AAAs
Surgical follow up
Technique:
Prox., mid., dist.- outer wall to outer wall
Trans. And long.
2 cm rule: Are the renal arteries involved?
You can measure the residual lumen and show how much flow pass through
Note: Aortic tortuosity due to aneurysm

33. AAA Treatment
Note; if > 6cm candidate for surgery, and if > 7cm- 75% risk of fatal rupture.
Treatment of AAA:
Open repair; not common any more
Endovascular Aortic graft. An endovascular stent is placed transluminal.

34. Mesenteric arteries SMA and IMA- High resistance
SMA fasting PSV < 156 cm/s EDV =11-16 cm/s postprandial EDV rises
Celiac- Low resistance
Celiac fasting PSV < 122 cm/s EDV=32-35 cm/s No change postprandial

35. Main Visceral Branches of the Abdominal Aorta
Celiac Axis (CA)
First major branch of the abdominal aorta
Arises from the anterior aspect of the aorta
Branches into the splenic, left gastric and common hepatic arteries
1-3 cm in length
Low resistance blood flow with continuous forward flow in diastole
Peak systolic velocity remains unchanged after a meal

36. Celiac Axis

37. Superior Mesenteric Artery (SMA)
Second major branch of the abdominal aorta
Arises from the anterior surface of the aorta, inferior to the celiac axis
Courses inferiorly and parallel to the aorta
Branches supply: jejunum, ileum, cecum, ascending colon, portions of the transverse colon and the head of the pancreas
High resistance multiphasic blood flow when fasting
Low resistance elevated systolic and diastolic velocities with continuous forward flow in diastole following a meal
Distance from the anterior wall of the aorta to the posterior wall of the SMA should not exceed 11 mm.

38. SMA

39. Mesenteric Ischemia Rare due to vast collateral system
It is caused by the low blood supply to the intestine.
Requires significant stenosis of both Celiac and SMA
Can be:
Acute( Life threatening)
Chronic ( Fear of food)
US Criteria for DX: “ 2 artery rule”
SMA > 275 cm/s
Celiac > 200 cm/s

40. Middle Supra-renal Arteries
Arise from the lateral aspect of the abdominal aorta
Courses laterally and slightly superior over the crura of the diaphragm to the adrenal glands

41. Supra-renal arteries

43. Main Renal Arteries
Arise from the posterior lateral aspects of the abdominal aorta
Located 1.0 – 1.5 cm inferior to the superior mesenteric artery
Course posterior to the renal veins
Right side arises superior to the left and courses posterior to the inferior vena cava
Renal artery bifurcate into segmental arteries at the renal hilum
Renal artery gives rise to the inferior suprarenal artery
Low resistance blood flow with continuous forward flow in diastole
Duplicated arteries are found in percent of the population

44. Main Renal Arteries

45. Renal Artery Aneurysm Uncommon Usually Pseudoaneurysm Etiology:
Congenital
Post-traumatic: more common, ex. Post BX

46. Renal artery stenosis Causes; hypertension. Ethology:
Atherosclerosis ( usually Affects prox. RA)
Fibromuscular hyperplasia (usu. Affects mid to distal RA):
Rare
Affecting young women
Patient population:
Young people with acute onset of difficult to control HT, sever HT with diastolic > 115 mmHg

47. Renal artery stenosis cont.
Treatment: Angioplasty/ stent
US Diagnostic Criteria:
RAR or RENAL AORTIC RATIO > 3.5
PSV> 180 cm/s
Acceleration time (AT) > 0.07(0.1) second
Loss of early systolic peak (ESP)

48. NL Renal Artery Spectral Doppler

49. Renal Vein Thrombosis Causes: Renal disease; Acute glomerulonephritis
Renal tumors: Renal cell CA, Wilm’s tumor, Lymphoma
Lupus
Amyloidosis
Hypercoagulable states
Sepsis
Trauma
Kidney transplant (1% of pts with renal transplant)

50. Renal Vein Thrombosis cont.
Clinical signs/symptoms:
Acute; Large kidneys, flank pain, hematuria
Chronic; atrophic kidneys, hematuria, proteinuria
US findings:
Acute; enlarged hypoechoic kidneys
Chronic: small echogenic kidneys
Doppler study shows no renal vein flow/thrombus, and high R. arterial pattern

51. Gonadal Arteries
Arise from the anterior aspect of the abdominal aorta inferior to the renal arteries
Course parallel to the psoas muscle into the pelvis
Low resistance blood flow with continuous flow through diastole
Not visualized with ultrasound

53. Gonadal Arteries

54. Inferior Mesenteric Artery
Last major branch of the abdominal aorta prior to the aortic bifurcation
Arises from the anterior aorta
Courses inferior and to the left of midline
Supplies the left transverse colon, descending colon, upper rectum and sigmoid
Visualized on ultrasound in an oblique plane, slightly to the left of midline and approximately 1 cm superior to the aortic bifurcation

55. IMA

56. MAIN PARIETAL BRANCHES of the ABDOMINAL AORTA
Inferior Phrenic Artery
Arise from the anterior aspect of the abdominal aorta branching into the right and left inferior phrenic arteries artery just below the diaphragm near the level of the 12th thoracic vertebrae.
Supplies the inferior portion of the diaphragm
Gives rise to the superior suprarenal artery

57. Inferior Phrenic Artery

59. Lumbar Arteries Median sacral artery
Four arteries arise on each side of the abdominal aorta
Supplies the abdominal wall and spinal cord
Located inferior to the gonadal arteries and superior to the inferior mesenteric artery
Median sacral artery
Located inferior to the inferior mesenteric artery and superior to the aortic bifurcation.

60. Lumbar Arteries

61. Median/middle sacral artery

62. ADDITIONAL ABDOMINAL ARTERIES
Gastroduodenal artery (GDA)
Branch of the common hepatic artery
Lies between the superior portion of the duodenum and the anterior surface of the pancreatic head

63. GDA

64. Hepatic Artery
Common hepatic artery is a branch of the celiac axis
Gives rise to the gastroduodenal artery and is now termed the proper hepatic artery
Courses adjacent to the portal vein
The proper hepatic artery bifurcates into the right, middle and left hepatic arteries at the hepatic hilum
Low resistance blood flow with continuous flow through diastole
Increased flow velocity is associated with jaundice, cirrhosis, lymphoma and metastases

65. Hepatic Artery

66. Splenic Artery
Tortuous branch of the celiac axis
Gives rise to the left gastroepiploic artery and additional branches to the pancreas and stomach
Courses along the superior margin of the pancreatic body and tail
Low resistance blood flow with continuous flow through diastole
May be mistaken for a dilated pancreatic duct

67. Splenic Artery

68. End Part A Abdominal Vasculature

69. Begin Part B Abdominal Vasculature

70. From Arterial to venous blood…

71. How does Arterial Blood turn into Venous Blood?
Capillary blood is that blood which is from the capillary beds that consist of the smallest veins (venules) and arteries (arterioles) of the circulatory system. The venules and arterioles join together in capillary beds forming a mixture of venous and arterial blood.
It is in the capillary bed that the arterial blood turns into venous blood.

72. The Capillary bed system
Blood moves very slowly through capillaries. As the blood moves through a capillary, nutrients, oxygen, and food leave the blood and enter the body cells. The blood also picks up wastes and carbon dioxide. This nutrient, oxygen and food depleted blood then starts its course toward the left atrium of the heart.

73. VENOUS ANATOMY Inferior Vena Cava (IVC)
Formed at the junction of the right and left common iliac veins
Carries oxygen depleted blood from the body superiorly to the right atrium of the heart
Major abdominal branches include: lumbar veins, right gonadal vein, renal veins, right suprarenal vein, inferior phrenic vein and hepatic veins.

74. IVC

75. IVC

76. IVC pathologies Congenital Anomalies Obstruction Duplication
Transposition
Interruption
Obstruction
Extrinsic: Tumors, Hematoma
Intrinsic
Thrombosis
The most common intraluminal IVC anomaly
IVC tumor invasion origin;
Renal cell CA; most common
Wilm’s tumor
Adrenal CA
Hepatoma
Lymphoma
Renal angiomyolipoma

77. Budd-Chiari Syndrome
Thrombosis of IVC, hepatic veins, and their tributaries.
Symptoms:
Hepatomegaly,
Abd. pain,
ascites,
abnormal liver lab. results.

78. US Protocol for the Budd-Chiari syndrome
Document the patency and flow direction within the HVs, IVC, as well as Portal and splenic veins.
B-mode; shows the intraluminal thrombus
Doppler; shows no flow within the IVC
If it is a tumor the arterial flow may be seen within the thrombus.
Note-As part of the treatment, IVC filters are being inserted within IVC to prevent PE.

79. MAIN VENOUS TRIBUTARIES
Common Iliac Veins
Drain blood from the lower extremities and pelvis
Formed by the junction of the external and internal iliac veins

80. Common Iliac Veins

81. Renal Veins
Course anterior to the renal arteries
Left renal vein courses posterior to the superior mesenteric artery and anterior to the abdominal aorta
Left renal vein receives the left suprarenal and gonadal veins
Left renal vein may appear dilated due to compression from the mesentery
Right renal vein has a short course to the IVC
Demonstrates spontaneous phasic blood flow

82. Renal Veins

83. Hepatic Veins
Lie at the boundaries of the hepatic segments and course toward the IVC
Three major branches: left, middle and right hepatic veins
Right hepatic vein courses coronally between the anterior and posterior segments of the right hepatic lobe
Middle hepatic vein follows an oblique course between the left and right hepatic lobes
Left hepatic vein courses posterior between the medial and lateral segments of the left hepatic lobe
Blood flow toward the IVC (hepatofugal)
Increase in blood flow with inspiration and diminished flow with Valsalva maneuver

84. Hepatic Veins

85. ADDITIONAL ABDOMINAL VEINS
Main Portal Vein
Drains the gastrointestinal tract, pancreas, spleen and gallbladder
Provides approximately 70 % of the liver’s blood supply
Formed by the junction of the splenic and superior mesenteric veins
Bifurcates into the right and left portal veins
Should not exceed 1.3 cm in diameter
Demonstrates phasic low flow velocities towards the liver (hepatopetal)
Blood flow will decrease with inspiration
Diameter will increase after a meal
Additional tributaries include
coronary vein – enters at the superior border of the porto-splenic confluence
inferior mesenteric vein – enters at the inferior border of the porto-splenic confluence

87. Portal Vein
Portal v. bring blood from Spleen, pancreas, stomach, and intestine to the liver.
Is formed at portal-splenic confluence from the junction of SMV and SV posterior to the neck of Pancreas (at level of L2) and then courses cephalad , ant. to the IVC and enters the liver through the porta hepatis. In liver, it divides into :
LT portal vein: Smaller, more anterior, more cranial.
RT portal vein: Larger, more posterior, more caudal.
On US PV is visualized on transverse plane lying anterior to the IVC.
Size: Equal or less than 13mm.
Affected by: Valsalva maneuver, respiratory changes, and PHT.
Hepatopetal: flow towards liver (above baseline)
Hepatofugal: flow away from liver (below baseline)
PV – Provides 75% of the liver’s blood flow and run transversely and cranially.
Note- With deep inspiration: PV, SV ,and SMV’s diameter increases.

88. Portal Vein sonographic features.
Tubular structures
Bright echogenic walls( due to collagen)
Branch horizontally
Oriented toward “porta hepatis”
Larger as they get closer to ports hepatis

89. Portal Vein Occlusion Causes: Thrombosis due to Tumor from:
Hyper coagulation state
Stagnant PV flow due to PV HT
Inflammation; Pancreatitis, Appendicitis
Tumor from:
Liver
Pancreas

90. Splenic Vein
Joins the superior mesenteric vein to form the main portal vein
Courses posterior to the pancreas and crosses anterior to the superior mesenteric artery
Demonstrates spontaneous phasic flow away from the spleen and towards the liver
Increase in caliber with inspiration

91. Splenic Vein:
Courses medially from the splenic hilum and runs post. and inf. to body & tail of the pancreas joins the IMV, before meeting the SMV.
Superior Mesenteric Vein:
Post. to the neck of panc. but ant. to the Uncinate process (A small extension off head of panc.). Seen parallel to the aorta and to the rt. of the SMA. It courses inf. to sup. drains small intestine and portions of large intestine (ascending, part of transverse colon).

92. Splenic Vein

93. Superior Mesenteric Vein
Courses parallel to the superior mesenteric artery
Demonstrates spontaneous phasic flow towards the liver
Caliber will increase with inspiration and following a meal
Gonadal Veins
Right gonadal vein empties directly into the inferior vena cava
Left gonadal vein empties into the left renal vein and occasionally the left suprarenal vein
Lumbar Veins
Branches of the common iliac veins
Course lateral to the spine and posterior to the psoas muscles

94. SMV

95. Gonadal Veins/ovarian

96. Gonadal Veins/Testicular

97. Lumbar Veins

98. LOCATION Abdominal Aorta
Lies to the left of midline adjacent to the inferior vena cava
Courses inferior and anterior in the abdomen to the level of the 4th lumbar vertebra (umbilicus) where it bifurcates into the right and left common iliac arteries.
Lies anterior to the spine and psoas muscle
Separated from the spine by 0.5 – 1.0 cm of soft tissue

99. Re-Cap of the Great Vessels
Abdominal Aorta
Inferior Vena Cava

100. Size
Aorta
The size of the normal abdominal aorta should not exceed 3 cm in diameter
The aorta tapers as it courses inferiorly and measures approximately:
Suprarenal: 2.5 cm
Renal: 2.0 cm
Infrarenal: 1.5 cm
Common iliacs: 1.0 cm

101. Inferior Vena Cava
Lies to the right of midline adjacent to the abdominal aorta
Formed at the level of the 5th lumbar vertebra at the junction of the right and left common iliac veins coursing superiorly in the abdomen to the right atrium of the heart
Lies anterior to the spine, psoas muscle, crus of the diaphragm and right adrenal gland
Lies posterior to the head of the pancreas

102. Inferior Vena Cava
Usually measures less than 2.5 cm
Decrease in caliber is demonstrated in inspiration and an increase in size when respiration is suspended.

103. IVC SONOGRAPHIC APPEARANCE:
Anechoic tubular structure
Thin hyperechoic wall margins
Internal vascular flow
Aorta demonstrates a high resistance multiphasic parabolic flow pattern
Inferior vena cava demonstrates spontaneous phasic flow and multiphasic pulsatile flow as it nears the diaphragm

104. Technique Preparation
Preparation for the abdominal vasculature is typically nothing by mouth 6-8 hours prior to the examination.

105. Examination Technique
Use the highest frequency abdominal transducer possible to obtain optimal resolution for penetration depth
Proper focal zone and depth placement
Decrease in dynamic range
Proper Doppler controls (PRF, gain, wall filters)
Evaluation and documentation of the abdominal aorta, common iliac arteries and inferior vena cava in the sagittal and transverse planes
Evaluation and documentation of the maximum diameter of the abdominal aorta, common iliac arteries and inferior vena cava
Duplex evaluation and documentation of any additional vascular structures requested
Duplex evaluation, documentation and measurement of any abnormality should be included.
If intraluminal thrombus is present, measurement of the vessel lumen should be included

106. Indications for Examination
Pulsatile abdominal mass
Family history of abdominal aortic aneurysm
Hypertension
Abdominal pain
Lower back pain
History of arteriosclerosis
Severe post prandial pain
DVT?
Pulmonary embolism
Liver disease
Evaluate mass from previous medical imaging study (i.e. CT)

107. ABDOMINAL ARTERIAL PATHOLOGY

108. arterial pathology
description
Aneurysm
Weakening of the arterial wall
All layers of the artery are stretched but intact
Rare in patients under 50 years
Male prevalence 5:1
Growth rate of 2mm /year is average and considered normal up to 5 mm/year
Exceeds 3.0 cm in diameter for the abdominal aorta
Exceeds 2.0 cm in diameter for the common iliac artery
Exceeds 1.0 cm in diameter for the popliteal artery
Twenty five percent of popliteal aneurysms are associated with an abdominal aortic aneurysm

109. Arterial stenosis
Narrowing or constriction of an artery
Caused by atherosclerosis,
arteriosclerosis or fibrointimal hyperplasia
Arteriosclerosis
Pathologic thickening, hardening and loss of elasticity of the arterial walls
Atherosclerosis
Disorder characterized by yellowish plaques of lipids and cellular debris in the inner layers of the arterial walls
Pseudoaneurysm
Dilatation of an artery caused by damage to one or more layers of the artery as a result of trauma or aneurysm rupture

110. ANEURYSMS OF THE ABDOMINAL AORTA

111. aneurysm
etiology
clinical findings
sonographic findings
differential considerations
Abdominal Aortic Aneurysm
Arteriosclerosis – most common
Infection
Asymptomatic
Pulsatile abdominal mass
Back and/or leg pain
Abdominal pain
Typically fusiform shaped dilatation of the aorta
Saccular dilatation of the aorta may be demonstrated
Diameter of 3 cm or greater
Vessel becomes tortuous
Wall calcifications
Intramural thrombus
Lymphadenopathy
Retroperitoneal tumor
Dissection

112. Dissecting
Aneurysm
Extension of a dissecting thoracic aneurysm
Hypertension
Marfan’s syndrome
Idiopathic
Pregnancy
Sharp chest or abdominal pain
Audible bruit
Thin hyperechoic membrane within the aorta
Membrane flaps with arterial pulsations
Doppler demonstrates opposite flow direction between the membrane during diastole
Chronic intraluminal thrombus
Post surgical repair

113. Ectatic Aneurysm
Weakening of the arterial wall
Asymptomatic
Dilatation of the aorta when compared with a more proximal segment
Dilatation measures less than 3 cm in diameter
Tortuous artery
Technical error

114. Mycotic Aneurysm
Bacterial infection
Asymptomatic
Abdominal pain
Pulsatile abdominal mass
Typically saccular shaped dilatation of the aorta
Asymmetrical wall thickening
Lymphadenopathy
Retroperitoneal tumor
Intramural thrombus

115. Pseudoaneurysm
Trauma to the arterial wall permits the escape of blood into the surrounding tissues
Most common complication of an aortic graft
Pulsatile mass
Fluid collection communicating with an artery
Doppler will demonstrate turbulent swirling blood flow within the fluid collection
To and fro blood flow pattern is demonstrated in the neck of the aneurysm
Hematoma
Lymphadenopathy
Aneurysm
Arteriovenous fistula

116. Ruptured Aneurysm
Risk of Rupture within 5 years
5 cm = 5%
6 cm = 16%
7 cm = 75%
Severe abdominal pain
Severe groin pain
Hypotension
Normal aortic size
Aneurysm may still be visualized
Asymmetrical or unilateral para-aortic hypoechoic mass
“veil appearance” over the aorta and surrounding structures
Free fluid in the peritoneal cavities
Lymphadenopathy
Chronic intraluminal thrombus

117. Surgical Repair
Previous history of aneurysm
Asymptomatic
Abdominal or lower back pain
Anechoic space between the graft and repaired aorta
Hyperechoic parallel echoes along the arterial walls
Dissection
Rupture aneurysm
Chronic intraluminal clot
Retroperitoneal pathology

118. ABDOMINAL VENOUS PATHOLOGY

119. Venous pathology
Etiology
Clinical findings
sonographic findings
differential considerations
Arteriovenous Shunts
(AV Fistula)
Trauma
Congenital
Surgery
Inflammation
Neoplasm
Presence of a bruit or “thrill”
Lower back or abdominal pain
Edema
Hypertension
Doppler Demonstrates:
Pulsatile flow within the vein
Increase in arterial flow proximal to site of shunting
Decrease in arterial flow distal to site of shunting
Turbulent waveform with high velocities in both the artery and vein
Tortuous vessel
Stenotic vessel

120. Enlargement
Congestive heart failure
Thrombosis
Infiltrating neoplasm
Asymptomatic
Edema
Inferior vena cava exceeding 3.7 cm in diameter
Main portal vein exceeding 1.3 cm in diameter
Splenic or superior mesenteric vein exceeding 1.0 cm
Intraluminal medium to low level echoes seen with neoplasms or thrombus
Extrinsic compression
Arteriovenous shunting
Portal hypertension
Technical error

121. Infiltrating Neoplasm
Renal carcinoma
Asymptomatic
Edema
Intraluminal medium to low level echoes
Venous thrombosis
Primary caval tumor
Technical error
Primary Caval Neoplasm
Leiomyosarcoma is most common
Infiltrating tumor
Thrombosis
Extension of thrombus from femoral, iliac, renal, hepatic or gonadal veins

122. FIN