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Doppler ultrasound of lower limb arteriesSamir Haffar M.D.Assistant Professor of internal medicine
Doppler US of lower limb arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US cr...
Anatomy of abdominal aorta & its branchesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.• ...
Anatomy of iliac arteryCIA (4 – 5 cm long)From L4 to sacroiliac jointDivides into IIA & EIALeft to corresponding CIVEIA (t...
Anatomy of femoral & popliteal arteriesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Comm...
Anatomy of crural arteriesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.There are several...
Normal diameter of lower limb artery• Sub-diaphragmatic aorta 21 – 24 mm• Infra-diaphragmatic aorta 17 – 20 mm• Common ili...
Anatomical variations of lower limb arteriesMay be occasionally encounteredArtery VariationAorta Duplication (very rare – ...
Duplicated aorta or duplication artifactMeuwly JY et al. Ultraschall Med 2011 ; 32 : 233 – 236.Duplication image artifact ...
Doppler US of lower limbs arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US c...
Arteries scanned in Doppler US of lower limbs• Tibio-peroneal trunk• Posterior tibial artery• Anterior tibial artery• Pero...
Normal wall of the artery3 layers
Transducer positions for scanning AAThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Chu...
Normal aortic bifurcation
Normal external iliac vesselsTransverse scan
Region of the groin
Normal SFA & PFATransverse view Longitudinal view
Region of adductor canal & popliteal fossaRegion of adductor canal is difficult to evaluate
Region of adductor canal & popliteal fossaDistal superficial femoral vessels Normal popliteal vessels
Insonation of leg arteriesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Posterior tibial ...
ProximalNormal anterior tibial artery
Normal posterior tibial vesselsProximal Distal
Normal peroneal vesselsLongitudinal view Transverse view
Normal triphasic waveform of peripheral arteriesArterial high resistance flowNarrow frequency bandSteep systolic increaseQ...
Normal PSV of lower limb arteries
Pulsatility indexMost commonly used of all indicesS: SystolicD: Minimum diastolicM: MeanPI: S – D / MNormal PI: 4 – 13 (av...
Factors influencing pulsed Doppler waveformComplicate evaluation• Cardiac pump function Cardiac insufficiency• Aortic valv...
Arterial monophasic flow• Hyperemic (normal PSV& normal RT*)ExerciseFeverDownstream infectionTemporary arterial occlusion ...
Hyperemic monophasic flowFollowing exerciseNormal triphasic waveformNormal DPA at restMonophasic hyperemic flowFollowing e...
Hyperemic flowPhlegmon of footMonophasic waveformNormal PSVNormal rise time
Doppler US of lower limbs arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US c...
Duplex US criteria for arterial evaluationAnatomy (course, variants)Vessel contour (aneurysm, stenosis)Wall structures (ca...
Doppler US of lower limbs arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US c...
Causes of arterial diseasesAtherosclerosisThrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fi...
Peripheral arterial diseaseFontaine & Leriche classificationStage ComplainsI AsymptomaticII aII bMild claudicationModerate...
Ankle Brachial Pressure Index (ABPI)Continuous wave Doppler (takes 10 - 15 min) Posteriortibial artery Dorsalispedis art...
Grading arterial disease using ABPIABPI Comment> 1.3 Falsely high value (suspicion of medial sclerosis)0.9 – 1.3 Normal fi...
ABPI in diabeticsCalcification of vessel wallsBeaded appearance of color flowAnkle pressure 280 mmHgBrachial pressure 120 ...
Direct & indirect signs of stenosisProximal to stenosisAt site of stenosisDistal to stenosis
Grading of lower limb artery stenosisFlow pattern proximal to lesionHigh resistance, low volume waveformCharacteristic sho...
Grading of lower limb artery stenosisPSV at site of stenosis
Grading of lower limb artery stenosisPSV ratioRobbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.Proximal: 2 cm proxima...
Grading of lower limb artery stenosisPSV ratio
Grading of lower limb artery stenosisRanke scaleLeft vertical line: Pre-stenotic PSVRight vertical line: Intra-stenotic PS...
Grading of lower limb artery stenosisEffect of collateralsExcellent collateralsPoor collateralsAbsence of collaterals
Grading of lower limb artery stenosisFlow pattern distal to lesionTardus: Longer rise timeParvus: Low PSVSevere stenosis o...
Lower limb arterial stenosesMost common sitesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 200...
Stenosis of PFA / Aliasing
Grading of arterial stenosisSFA:PSV of A 69 cm/secPSV of B 349 cm/secB / A 349 / 69 = 5> 80% diameter stenosisThrush A, Ha...
Two severe stenosis of SFA2 severe stenoses demonstrated in SFAAreas of color flow disturbance & aliasing (arrows)Thrush A...
Calcified atheroma in SFADrop-out of color flow signal in parts of lumenThrush A, Hartshorne T. Peripheral vascular ultras...
Occlusion of the CIAOcclusion in CIAReversed flow in IIA (blue) to supply flow to EIA (red)Thrush A, Hartshorne T. Periphe...
Arterial occlusion & collateralsShort occlusion of mid-SFA (large arrow)Large collateral at both ends of occlusion (small ...
Diagnostic reliability of peripheral arterial diseaseSystematic review – DSA as gold standardCollins R et al. BMJ 2007 ; 3...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
FA lumen filled with hypoechoic thrombus or embolusGood delineation of vessel wall without signs of plaqueNormal flow in a...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Definition of aneurysm & ectasiaAneurysmDiameter increase > 50% of normal expected diameterEctasiaDiameter increase < 50% ...
Types of aneurysmTrue aneurysmFalse aneurysmDissecting aneurysm
Common sites for lower limbs aneurysmsMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Abdominal Aortic Aneurysm (AAA)• Normal size of abdominal aorta 1.5 – 2.5 cm• Ectatic aorta 2.5 – 3 cm• Aortic aneurysm > ...
Classification of abdominal aortic aneurysmsClassification CategoriesBy location Suprarenal: Above origin of renal areteri...
Measurement of widest partMeasurement technique of aneurysmMyers KA & Clough A. Making sense of vascular ultrasound. Arnol...
Measuring diameter of AAAIncorrect measurement Correct measurementSchäberle W. Ultrasonography in vascular diagnosis.Sprin...
Shapes of aneurysmFusiform SaccularMost frequentDouble aneurysmHourglass aorta
Abdominal aortic aneurysm / FusiformTransverse imageAnteroposterior diameterfrom outer wall to outer wallSagittal imageDia...
Abdominal aortic aneurysm / HourglassBhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.Two discontinuous focal segments ...
Abdominal aortic aneurysm / SaccularSaccular or mycotic aneurysmThrombus seen as low-level echoes within aneurysmSagittal ...
Battaglia S et al. J Ultrasound 2010 : 13 : 107 – 117.Abdominal aortic aneurysm / Swirling flowPseudo „„yin-yang sign‟‟Sim...
Suprarenal aortic aneurysmSchuster H et al. Ultraschall Med 2009 ; 30 : 528 – 543.Cross section viewLongitudinal section v...
Infrarenal aortic aneurysmDistance between RA & upper limit of aneurysmThrush A, Hartshorne T. Peripheral vascular ultraso...
Abdominal aortic aneurysm / RuptureHigh mortality rate (90%)AAA with peripheral thrombusSmall hypoechoic area (wall ruptur...
Abdominal aortic aneurysm / DissectionB-mode image Color flow imagingDissection into thrombus & vessel wall has occurredTh...
Abdominal aortic aneurysm / Thrombus liquefactionArea of thrombus liquefaction may be confused with dissectionLarge thromb...
Diameter of aneurysm (indication for surgery)Shape of aneurysm (Fusiform, hourglass, sacular)Partial thrombosisInfra-renal...
Stent-graft expands to make firmcircumferential contact with ‘neck’ of relatively normal aortabetween RA & upper end of A...
Endoleak after EVARPersistence flow in aneurysm lumen after procedure• Increase in aneurysmal diameter with risk of ruptur...
Type IVPorosity of graft material (resolved in 1 month)Type IIIPerforation & tear in graft material (rare)Type IFailure of...
EVAR / Mirror artifactDemirpolat G et al. J Clin Ultrasound 2011 ; 39 : 263 – 269.Synchronous pulsatility with flow in pat...
EVAR / Poorly organized thrombusAneurysmal sac contains mix of echoesLarge anechoic area (A) which could represent an endo...
Types of endoleakType I: Distal attachment siteType II: Patent lumbar arteryThrush A et al. Peripheral vascular ultrasound...
Selective screening for AAA• Selective screening3 important risk factors MalesAge > 65 yearsHistory of smoking• Effectiven...
Popliteal artery aneurysm / Partial thrombosisTransverse CDUS Sagittal pulsed & CDUSHamper UM et al. Radiol Clin N Am 2007...
Popliteal artery aneurysm / Complete thrombosisUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.Thrombosed popliteal...
Differential diagnosis of pain in popliteal fossa• Arterial aneurysm or pseudoaneurysm• Arterial dissection• Venous aneury...
Popliteal vein aneurysm / Rare1 MacDevitt DT et al. Ann Vasc Surg 1993 ; 7 : 282 – 286.2 Graham RN et al. Am J Surg 2010 ;...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Intimal dissection of abdominal aortaSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Pseudo-aneurysmMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.To-and-fro flowTypical triphasic flow
Pseudo-aneurysm / “to-and-fro” flowMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.During systole“to”Flow ente...
Pseudo-aneurysm / CFA2 – 4% of cases after catheter interventionLarge perivascularfluid collectionColor Doppler: swirling ...
Pseudoaneurysm / Variations in ‘‘to-and-fro’’ flowMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Limited syst...
Pseudo-aneurysm / Multiloculated typeNot uncommonMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Mistake made ...
Pseudo-aneurysm / Differential diagnosisMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Arborizing flow in enl...
Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Inguinal LN from melanomaVessels at base of LN different from ...
Pseudo-aneurysm / US-guided compression3 stepsFranklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.Preparation Compres...
Pseudo-aneurysm / US-guided compressionThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier ...
Pseudo-aneurysm / US-guided thrombin injectionReplaced compression as technique of choiceNeedle advanced into superficial ...
Pseudo-aneurysm / US-guided thrombin injectionSecond injectionComplete thrombosisCFA pseudoaneurysmSurrounded by hematomaT...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Arterio-venous fistulaLeft external iliac arteryRight external iliac arteryLow resistance arterial flowRight external ilia...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Arteritis / “macaroni or halo sign”Higher-level echoLumen intima interfaceSurrounded byConcentric homogeneous hypoechoic s...
Transverse scanLongitudinal scanGiant cell arteritis / Abdominal aorta“Macaroni sign”Schäberle W. Ultrasonography in vascu...
Moussavian B & Horrow MM. Ultrasound Quarterly 2009 ; 25 : 89 – 91.Retroperitoneal fibrosis / Ormond’s diseaseHypoechoic c...
Retroperitoneal fibrosis / Ormond’s diseaseSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heid...
Inflammatory aortic aneurysmTypical appearanceSchäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd ed...
Thrombangiitis obliterans / Buerger diseaseMale – Smoker – Young (34 years)• Location Distal lower leg & foot• Occlusion m...
Thrombangiitis obliterans / Buerger diseaseStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.37-year-old smo...
Buerger’s Disease / Corkscrew CollateralsFujii et Y. J Am Col Cardiol 2011 ; 57 : 2539.Type I: Large snake sign> 5 mmType ...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Vascular complications of entrapment syndrome Post-stenotic aneurysm Mural thrombi Thrombotic occlusionMethod of choice...
Popliteal entrapment syndrome / Provocation testsExamaging PA just below knee joint space Plantar flexion of footagainst ...
Popliteal artery entrapment syndrome (PAES)Plantar flexion testProgressive compression of popliteal artery by GCMSchäberle...
Popliteal aretery entrapment syndrome (PAES)Isolated popliteal artery occlusionTransverse sectionAS Soleus arteryVS Soleus...
Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneur...
Cystic adventitial disease of PACyst involving long popliteal segmentTransverse view Longitudinal viewDifficult to differe...
Cystic adventitial disease of PATransverse view Longitudinal view Pulsed DopplerSchäberle W. Ultrasonography in vascular d...
Doppler US of lower limb arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US cr...
Bypass graftSonography is the recommended non-invasivetechnique for the postoperative monitoringof bypass graft patency
Types of graft• Synthetic graftPTFE* Above knee• Autologous veinReversed vein Removal – reversal – anastomosisIn situ vein...
Aorto-bi-femoral graft Femoral-to-femoral artery bypass graftPeripheral arterial bypass graft – 1
Peripheral arterial bypass graft – 2Femoro-PoplitealAbove KneeFemoro-PoplitealBelow KneeFemoro-TibialBelow Knee
Bypass graft / Normal USComposite PTFE & vein graftSlightly dilated areacorresponding to valve siteIn situ vein graft
Bypass graft / Normal flow patternHyperemic flow often seenin early postoperative periodHyperemic monopahasic flow Pulsati...
Bypass graft / Normal PSVAverage PSVfrom 3 – 4 siteswithout stenosisGraft flow velocityNormal PSV: 45 – 180 cm/sAbuRahma A...
Bypass graft / Causes of graft failureMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004. Ath...
Bypass graft / Sampling velocities in stenosisRatio 2.0 = 50% stenosisRatio 4.0 = 75% stenosisProximal anastomotic stenosi...
Bypass graft / Severe stenosisStenosisPSV of A 16.4 cm/secPSV of B 319 cm/secSpectral broadeningB / A 19 timesAProximal to...
Hemodynamic criteria & management of graft stenosisCategory Risk PSVcm/secPSVratioGraftvelocityManagementI Maximum > 300 >...
Bypass graft / EntrapmentGraft running between twomuscles causing moderate stenosisVein graft in lower tightGraft compress...
Bypass graft / OcclusionExtremely low volume flow recorded from in situvein graft indicates imminent graft occlusion
Bypass graft / Fibro-intimal hyperplasiaLarge area of intimal hyperplasia in a vein graft
Bypass graft / Aneurysmal area in vein graftAneurysmal area in vein graft corresponding to valve siteArea of hyperplasia o...
Bypass graft / False aneurysmGFAFalse aneurysm at distal end of femorofemoral graftdue to failure of anastomosisNote corru...
Bypass graft / SeromaFluid-filled seromaadjacent to vein graftDifferential diagnosis:– Seroma– Hematoma– Lymphocele– Abscess
Bypass graft / InfectionGEcho region tracking from PTFE graft to skin surfacePus discharging from skin surface at this poi...
ReferencesArnold – 2004 Elsevier – 2005 Springer-Verlag – 2011
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Doppler ultrasound of lower limb arteries

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  • The tibioperoneal trunkThe tibioperoneal trunk divides to form the PTA and peroneal artery.The PTA runs posterior to the tibia to supply the back of calf and continues as the plantar arteries in the foot.The peroneal artery runs medial to the fibula to supply the deep compartment.The ATA The ATA passes anterior to the tibia to supply the anterior compartment and continues as the dorsalispedis artery in the foot.
  • Differential diagnosis Collateral function of a vesselExercise-induced hyperemia- Peripheral inflammation
  • Dysesthesia:
  • While the highest ankle pressure is used in most studies, the sensitivity for the detection of a relevant arterial occlusion disease of 68% was able to be increased to 93% with a comparable specificity of almost 100% in a current study for an ABI &lt; 0.9 by using the lowest foot artery pressure value.
  • Care must be taken when interpreting ABPI measurements from diabetic patients as the arterial walls of the calf arteries are often calcified and rigid.This means that the vessels may not collapse under the pressure of the cuff as it is inflated, leading to falsely elevated recordings.
  • approximate frequency for predominant disease at each level is:● aortoiliac 25 per cent● femoropopliteal 65 per cent● infrapopliteal 10 per cent (more frequent in diabetics).
  • Poststenotic Doppler spectrum recorded behind the most proximal obstruction is also influenced by flow alterations caused by lesions distal to the sampling site.In patients with sequential stenoses or occlusions, the usual stenosis criteria may thus lead to misinterpretation. In grading a second stenosis, the examiner has to take into account the hemodynamic changes (change in pulsatility and pressure drop) produced by the preceding stenosis: the postocclusive decrease in velocity after the first stenosis will result in a lower absolute PSV in the second stenosis (and the PSV of 180 cm/s proposed as a criterion for isolated stenosis does not apply insequentialstenoses). Therefore, only the criterion of a 100% increase in PSV can be used to classify a sequential stenosis as hemodynamically significant.
  • Johnston K W, Rutherford R B, Tilson M D, et al 1991Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. Journal of Vascular Surgery 13(3):452 – 458.
  • TR True lumenI IntimaM MediaA AdventiaFL False lumen
  • Green line Incorrect (not perpendicular to the main axis of the vessel)Red line CorrectBlack line Correct plane but not in the widest part of the aneurysm
  • Dumb-bell appearance: كرتان حديديتان يربط بينهما قضيب تمرن بها العضلات
  • Distance between the renal arteries and upper limit of the aneurysmDistance between the renal arteries and upper limit of the aneurysm can be measured. In practice, this can be an extremely difficult or virtually impossible assessment to make. First, the presence of the aneurysm may obscure views of the upper abdominal aorta. Second, the renal arteries cannot usually be imaged with the probe in the longitudinal direction required to make this measurement.However, the position of the renal arteries can be estimated by identifying the SMA in the longitudinal plane, as the renal arteries should lie approximately 1.5 cm below the SMA origin. Accessory renal arteries may arise well below this pointThe left renal vein can act as another useful landmark, if it is found to be at the level of the renal arteries in a transverse image.Turning the transducer into a longitudinal plane, it is possible to identify the renal vein as it crosses over the top of the aorta. Other imaging techniques, such as CT, MRI or arteriography, are generally used to identify the position of the renal arteries in large aneurysms, especially with the increasing use of endovascular devices to repair aneurysms.
  • In September 1990 an Argentine surgeon, Dr Juan Parodi, performed the first endovascular aneurysm repair.Reference:Parodi JC, Palmaz JC, Barone HD: Transfemoralintraluminal graft implantation for abdominal aortic aneurysms.Ann VascSurg 1991;5:491–499.
  • Computed tomographic angiography (CTA) is the gold standard for postoperative follow-ups. MRA, color Doppler ultrasonography(CDUS), CEUS, and digital subtraction angiography are alternative methods.The sensitivity of CDUS has been reported to be 25% to 100% compared with CTA as the gold standard.In a meta-analysis of 21 studies by Mirza et al, sensitivity of duplex ultrasound for endoleak detection was 77% and specificitywas 94%. Ashoke et al reported similar results in their systematic review.
  • This persistent flow can lead to an increase in diameter of the aneurysm, with subsequent risk of rupture. I Attachment site leak, occurring at the proximal or distal ends of the graft due to an inadequate seal. Corrected by repeated balloon dilatation, or inserting an additional covered stent or collar across the leak to exclude flow.II Collateral endoleaks lead to retrograde perfusion of the sac by a source other than the graft. This is normally a lumbar vessel, inferior mesenteric artery or low polar renal artery. In some cases, when there &gt; 2 vessels patent it is possible for flow channel to occur through sac between branches. Type II leaks are fairly common, but are more likely to spontaneously thrombose than other leaks. Otherwise no treatment may be necessary unless there is continued expansion of the sac.III Occur in the junction area between the modular limb and main body of the graft, or represent fabric tears in the graft. Type III leaks are fairly rare, but are more likely to require treatment than type II leaks. Further balloon dilatation or insertion of a covered stent may be necessary.IV This leak is due to graft porosity or ‘sweating’ of the graft material and normally resolves within a month.V Endotension (controversial classification).Reference:Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.
  • Stent material can cause artifacts.
  • Sonographic examination may require one to one and a half hours to perform.Reverse Trendelenberg position (feet approximately 15 to 20 degrees below the level of the heart).This allows visceral contents to descend into the abdomen, creating larger acoustic windows.
  • abdominal aorta should be examined at least once in men of 65 – 75 years with history of smoking or family history of AA
  • 122 reported cases in the litterature.
  • To-and-fro pattern: Antegrade flow into the aneurysm during systoleRetrograde flow out of the aneurysm during diastole. Note that the diastolic flow reversal persists throughout the entire diastolic portion of the cardiac cycle. Typical triphasic pattern: Antegrade flow in systoleShort retrograde component in early diastolethird phase of limited antegrade flow during mid diastole.
  • Classical “to-and-fro” pattern:Short phase of antegrade systolic flowMore prolonged phase of pandiastolic retrograde flowFlow velocities higher during systole than during diastole
  • False positive examinations are very uncommon because few things can simulate a PSA. Reactive inguinal lymphadenopathy can cause a palpable mass after catheterization and can simulate a PSA clinically.It is also possible to simulate a PSA on sonography.
  • Entrapment of the popliteal artery was first described in 1879 by a medical student in Edinburgh. Few data are available on the incidence of this syndrome, but it seems to be more common than assumed in the past.A study performed in members of the Greek army reported an incidence of 0.17% (Bouhoutsos and Daskalakis 1981), while an autopsy studyfound an incidence of 3.5% (Gibson 1977).The higher incidence of popliteal entrapment in asymptomatic patients appears to be attributable to the fact that malformationof the medial head of gastrocnemius, which causes the entrapment constellation, may occur without causing symptoms. Anentrapment constellation is occasionally seen in patients examined for other reasons (e.g., suspected thrombosis, preoperativevein mapping prior to varicosis surgery).
  • Similar to the compression phenomena of the subclavian artery in the shoulder region that can be provoked, asymptomatic compression of the popliteal artery can be identified by the provocation maneuvers in more than 50% of test subjects. The finding is only significant when claudication symptoms in the calf are present or the feared complication of acute vessel occlusion results in ischemia symptoms during jogging for example.Hypertrophy of the heads of the gastrocnemius muscle plays an important role and there are six different variants.
  • Popliteal entrapment syndrome is also a rare but potential cause of claudication and possible distal embolization due to arterial wall damage. In this situation, the popliteal artery follows an anomalous course below the knee and is trapped by the heads of the gastrocnemius muscle during plantar flexion.The popliteal artery can also be trapped by fibrous bands in this area. To test for popliteal entrapment syndrome, the patient should lie prone with the legs gently flexed and the feet hanging over the end of the examination table. The below-knee popliteal artery should be imaged at the level of the gastrocnemius muscle heads. The patient should point the foot down (plantar flex) against a counterpressure, typically by having a colleague apply moderate pressure against the foot. Narrowing or occlusion of the popliteal artery during this maneuver may indicate popliteal entrapment syndrome. However, there is evidence to suggest that significant compression of the popliteal artery can occur in normal volunteers during this investigation, casting some doubt on the usefulness of this test.
  • Adventitial cystic disease is a rare condition in which cystic structures in the outer wall layer of arteries close to joints and very rarely of veins (20 case reports in the literature until 2002) cause variable stenosis according to their state of filling. In a review of the literature and earlier overviews, we identified a total of 196 reported cases (Schäberle and Eisele 1996). The disorder affects the popliteal artery in over 90% of cases. The cysts resemble articular ganglions in terms of contents and wall composition. There is no agreement in the literature on the etiology and pathoanatomic changes.It should be considered as a potential cause of symptoms in the young patient, especially in the absence of any other pathology. Treatment is by excision and local repair or bypassing.
  • New grafts may demonstrate a hyperemic monophasic flow profile because of sustained peripheral vasodilation, which can be due to a combination of the previous ischemia and healing tissue. Over time, the flow pattern should become pulsatile, and biphasic or triphasic waveforms are usually recorded.
  • Corrugated: المموج ، المتجعد
  • pulsatile mass developing in the groin after bypass grafting may be a:1- Seroma2- Hematoma3- Lymphocele4- Abscess
  • Transcript of "Doppler ultrasound of lower limb arteries"

    1. 1. Doppler ultrasound of lower limb arteriesSamir Haffar M.D.Assistant Professor of internal medicine
    2. 2. Doppler US of lower limb arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US criteria for arterial evaluation Causes of lower limb arterial diseases Doppler US of bypass graft
    3. 3. Anatomy of abdominal aorta & its branchesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.• Lies to left of midline• Inferior vena cava to its right• Extends from L1 to L4• Gives visceral branches• Gives phrenic & lumbar branches
    4. 4. Anatomy of iliac arteryCIA (4 – 5 cm long)From L4 to sacroiliac jointDivides into IIA & EIALeft to corresponding CIVEIA (twice long of CIA)Superficial to corresponding veinGives inferior epigastric arteryBecomes CFA at inguinal ligamentMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
    5. 5. Anatomy of femoral & popliteal arteriesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Common femoral artery (4-6 cm long)Lies superficially in the groinDivides to SFA & PFASuperficial femoral arteryExtends down medial thighPasses deep through adductor hiatusPopliteal arteryCommences below adductor hiatusPasses vertically through popliteal fossaDivides to tibio-peroneal trunk & ATA
    6. 6. Anatomy of crural arteriesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.There are several interconnectionSo that each artery can supply all regions
    7. 7. Normal diameter of lower limb artery• Sub-diaphragmatic aorta 21 – 24 mm• Infra-diaphragmatic aorta 17 – 20 mm• Common iliac artery 10 – 12 mm• External iliac artery 8 – 10 mm• Common femoral artery 7 – 9 mm• Superficial femoral artery 6 – 8 mm• Popliteal artery 4 – 6 mmStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
    8. 8. Anatomical variations of lower limb arteriesMay be occasionally encounteredArtery VariationAorta Duplication (very rare – duplication image artifact)Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.ATA High origin across knee jointMay be small or hypoplastic (2%)Peroneal artery Origin from ATA rather than tibio-peroneal trunkCFA bifurcation Bifurcation can sometimes be very highEIA Aplasia with blood supply to leg via strong IIA
    9. 9. Duplicated aorta or duplication artifactMeuwly JY et al. Ultraschall Med 2011 ; 32 : 233 – 236.Duplication image artifact frequent in lower abdomen:False cases of twin pregnanciesDouble intra-uterine devicesGray-scale USDuplicated aortaColor Doppler US2 aortic lumen filledwith colorTiny sliding probe to rightOnly one lumen filledwith color
    10. 10. Doppler US of lower limbs arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US criteria for arterial evaluation Causes of lower limb arterial diseases Doppler US of bypass graft
    11. 11. Arteries scanned in Doppler US of lower limbs• Tibio-peroneal trunk• Posterior tibial artery• Anterior tibial artery• Peroneal artery• Dorsalis pedis arteryMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Aorta & the following arteries on both sides• Common iliac artery• External iliac artery• Common femoral artery• Profunda femoris artery• Superficial femoral artery• Popliteal artery
    12. 12. Normal wall of the artery3 layers
    13. 13. Transducer positions for scanning AAThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.Sagittal orlongitudinalTransverseCoronal
    14. 14. Normal aortic bifurcation
    15. 15. Normal external iliac vesselsTransverse scan
    16. 16. Region of the groin
    17. 17. Normal SFA & PFATransverse view Longitudinal view
    18. 18. Region of adductor canal & popliteal fossaRegion of adductor canal is difficult to evaluate
    19. 19. Region of adductor canal & popliteal fossaDistal superficial femoral vessels Normal popliteal vessels
    20. 20. Insonation of leg arteriesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Posterior tibial arteryPeroneal arteryMedial approachAnterior tibial arteryAnterolateral approach
    21. 21. ProximalNormal anterior tibial artery
    22. 22. Normal posterior tibial vesselsProximal Distal
    23. 23. Normal peroneal vesselsLongitudinal view Transverse view
    24. 24. Normal triphasic waveform of peripheral arteriesArterial high resistance flowNarrow frequency bandSteep systolic increaseQuick dropEarly diastolic reverse flow(⅕ of systolic flow amplitude)Late diastolic short forward flowABPI: Ankle Brachial Pressure IndexStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
    25. 25. Normal PSV of lower limb arteries
    26. 26. Pulsatility indexMost commonly used of all indicesS: SystolicD: Minimum diastolicM: MeanPI: S – D / MNormal PI: 4 – 13 (average 6.7)Depending on location of peripheral arteries
    27. 27. Factors influencing pulsed Doppler waveformComplicate evaluation• Cardiac pump function Cardiac insufficiency• Aortic valve function Aortic stenosis/insufficiency• Course of vessel Tortuosity• Vessel branching• Peripheral vascular resistance Peripheral inflammationPolyneuropathyWarm or cold extremityVaso-spastic disordersStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
    28. 28. Arterial monophasic flow• Hyperemic (normal PSV& normal RT*)ExerciseFeverDownstream infectionTemporary arterial occlusion by blood pressure cuff• Tardus-Parvus waveform (low PSV & longer RT)Distal to severe stenosis or occlusion* Rise time: Time between beginning of systole & peak systole
    29. 29. Hyperemic monophasic flowFollowing exerciseNormal triphasic waveformNormal DPA at restMonophasic hyperemic flowFollowing exercise
    30. 30. Hyperemic flowPhlegmon of footMonophasic waveformNormal PSVNormal rise time
    31. 31. Doppler US of lower limbs arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US criteria for arterial evaluation Causes of lower limb arterial diseases Doppler US of bypass graft
    32. 32. Duplex US criteria for arterial evaluationAnatomy (course, variants)Vessel contour (aneurysm, stenosis)Wall structures (calcification, plaque, cyst)Pulsation (axial, longitudinal)Perivascular structures (hematoma, abscess, tumor, muscle)B-modeDemonstration of flowFlow directionFlow pattern (laminar, turbulent)Flow profile (monophasic, triphasic)Flow velocityDopplerSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
    33. 33. Doppler US of lower limbs arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US criteria for arterial evaluation Causes of lower limb arterial diseases Doppler US of bypass graft
    34. 34. Causes of arterial diseasesAtherosclerosisThrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial diseaseMost common cause
    35. 35. Peripheral arterial diseaseFontaine & Leriche classificationStage ComplainsI AsymptomaticII aII bMild claudicationModerate to severe claudicationIII Ishemic rest painIV Ulcer or gangreneUnderdiagnosed & therefore undertreated disease
    36. 36. Ankle Brachial Pressure Index (ABPI)Continuous wave Doppler (takes 10 - 15 min) Posteriortibial artery Dorsalispedis arteryThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005. Peroneal arteryHighest ankle pressure / highest brachial pressure
    37. 37. Grading arterial disease using ABPIABPI Comment> 1.3 Falsely high value (suspicion of medial sclerosis)0.9 – 1.3 Normal finding0.75 – 0.9 Mild PAD0.4 – 0.75 Moderate PAD< 0.4 Severe PADABPI: Ankle Brachial Pressure IndexStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
    38. 38. ABPI in diabeticsCalcification of vessel wallsBeaded appearance of color flowAnkle pressure 280 mmHgBrachial pressure 120 mmHgABPI 2.3Falsely elevated recordings in diabetic patientsCalcified & rigid arterial walls
    39. 39. Direct & indirect signs of stenosisProximal to stenosisAt site of stenosisDistal to stenosis
    40. 40. Grading of lower limb artery stenosisFlow pattern proximal to lesionHigh resistance, low volume waveformCharacteristic shoulder on systolic downstrokeDue to pulse wave reflection from distal diseaseShoulder
    41. 41. Grading of lower limb artery stenosisPSV at site of stenosis
    42. 42. Grading of lower limb artery stenosisPSV ratioRobbin ML et al. Ultrasound Clin 2006 ; 1 : 111 – 131.Proximal: 2 cm proximal to stenosisAt stenosis : Same Doppler angle if possible
    43. 43. Grading of lower limb artery stenosisPSV ratio
    44. 44. Grading of lower limb artery stenosisRanke scaleLeft vertical line: Pre-stenotic PSVRight vertical line: Intra-stenotic PSVMiddle vertical line: Degree of stenosis in %Ranke C et al. Ultrasound Med & Biol 1992 ; 18 : 433 – 440.
    45. 45. Grading of lower limb artery stenosisEffect of collateralsExcellent collateralsPoor collateralsAbsence of collaterals
    46. 46. Grading of lower limb artery stenosisFlow pattern distal to lesionTardus: Longer rise timeParvus: Low PSVSevere stenosis or occlusionTardus-Parvus waveformDamping waveformIncreased systolic rise timeLoss of pulsatility
    47. 47. Lower limb arterial stenosesMost common sitesMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004. Aorto-iliac: 25 %Femoro-popliteal: 65%Infra-popliteal: 10%
    48. 48. Stenosis of PFA / Aliasing
    49. 49. Grading of arterial stenosisSFA:PSV of A 69 cm/secPSV of B 349 cm/secB / A 349 / 69 = 5> 80% diameter stenosisThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    50. 50. Two severe stenosis of SFA2 severe stenoses demonstrated in SFAAreas of color flow disturbance & aliasing (arrows)Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    51. 51. Calcified atheroma in SFADrop-out of color flow signal in parts of lumenThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    52. 52. Occlusion of the CIAOcclusion in CIAReversed flow in IIA (blue) to supply flow to EIA (red)Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    53. 53. Arterial occlusion & collateralsShort occlusion of mid-SFA (large arrow)Large collateral at both ends of occlusion (small arrows)Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    54. 54. Diagnostic reliability of peripheral arterial diseaseSystematic review – DSA as gold standardCollins R et al. BMJ 2007 ; 334 : 1257 – 1266.MRA CTA CDUSNo of studies 6 5 7SensibilityMedian (range)94%(85 – 100)97%(89 – 100)90%(74 – 94)SpecificityMedian (range)99.2%(97 – 99.8)99.6%(99 – 100)99%(96 – 100)
    55. 55. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    56. 56. FA lumen filled with hypoechoic thrombus or embolusGood delineation of vessel wall without signs of plaqueNormal flow in adjacent FVHamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.Thrombosis or embolism / Femoral artery
    57. 57. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisCompression syndrome (entrapment syndrome)Cystic adventitial disease
    58. 58. Definition of aneurysm & ectasiaAneurysmDiameter increase > 50% of normal expected diameterEctasiaDiameter increase < 50% of normal expected diameterConsiderable variability in normal diameter of arteriesDepends on physical size, sex, & ageJohnston K W et al. J Vasc Surg 1991; 13:452 – 458.
    59. 59. Types of aneurysmTrue aneurysmFalse aneurysmDissecting aneurysm
    60. 60. Common sites for lower limbs aneurysmsMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
    61. 61. Abdominal Aortic Aneurysm (AAA)• Normal size of abdominal aorta 1.5 – 2.5 cm• Ectatic aorta 2.5 – 3 cm• Aortic aneurysm > 3 cm• Annual growth rate of aneurysms 0.33 cm/yearmeasuring between 4 & 5.5 cm* Bhatt S et al. Ultrasound Clin 2008 ; 3 : 83 – 91.
    62. 62. Classification of abdominal aortic aneurysmsClassification CategoriesBy location Suprarenal: Above origin of renal areteries (very rare)Juxtarenal: Where renal arteries originateInfrarenal: Below origin of RA (most common)Bhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.By morphology Fusiform (most common)HourglassSaccularBy etiology Atherosclerotic (most common)Inflammatory (5% – 10%)Mycotic (1%): saccular, salmonella & SA, high mortality
    63. 63. Measurement of widest partMeasurement technique of aneurysmMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
    64. 64. Measuring diameter of AAAIncorrect measurement Correct measurementSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin, 2nd edition, 2011.Correct diameter measured by rotating transducer clockwiseuntil round image of aorta comes into view
    65. 65. Shapes of aneurysmFusiform SaccularMost frequentDouble aneurysmHourglass aorta
    66. 66. Abdominal aortic aneurysm / FusiformTransverse imageAnteroposterior diameterfrom outer wall to outer wallSagittal imageDiameter measured in transverseimage larger due to obliquityMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
    67. 67. Abdominal aortic aneurysm / HourglassBhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.Two discontinuous focal segments of aneurysmal dilatationAortic diameter in between is normal in caliber
    68. 68. Abdominal aortic aneurysm / SaccularSaccular or mycotic aneurysmThrombus seen as low-level echoes within aneurysmSagittal image of abdominal aortaAbraham D et al. Emergency medicine sonography: Pocket guide.Jones & Bartlett Publishers, Boston, MA, USA, 1st edition, 2010.
    69. 69. Battaglia S et al. J Ultrasound 2010 : 13 : 107 – 117.Abdominal aortic aneurysm / Swirling flowPseudo „„yin-yang sign‟‟Similarity in appearance to pseudo-aneurysm finding
    70. 70. Suprarenal aortic aneurysmSchuster H et al. Ultraschall Med 2009 ; 30 : 528 – 543.Cross section viewLongitudinal section viewInclusion of visceral & renalarteriesPerfused lumen& narrow circular thrombus
    71. 71. Infrarenal aortic aneurysmDistance between RA & upper limit of aneurysmThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.SMALRV
    72. 72. Abdominal aortic aneurysm / RuptureHigh mortality rate (90%)AAA with peripheral thrombusSmall hypoechoic area (wall rupture)Hypoechoic structure at upper endPresence of active bleedingNo further imaging confirmationTaken directly to ORBhatt S et al. Ultrasound Clin 2007 ; 2 : 437 – 453.
    73. 73. Abdominal aortic aneurysm / DissectionB-mode image Color flow imagingDissection into thrombus & vessel wall has occurredThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    74. 74. Abdominal aortic aneurysm / Thrombus liquefactionArea of thrombus liquefaction may be confused with dissectionLarge thrombus separate area of liquefaction from lumenThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    75. 75. Diameter of aneurysm (indication for surgery)Shape of aneurysm (Fusiform, hourglass, sacular)Partial thrombosisInfra-renal or supra-renalInvolvement of iliac arteries: common, internalAdditional criteria if endovascular treatmentDistance of proximal end of aneurysm to renal arteryDegree of angulation in case of elongation of infra-renal aortaConic neck of aneurysmLumen of CFA (large enough for stent insertion)Relevant color duplex findings in AAASchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin, 2nd edition, 2011.
    76. 76. Stent-graft expands to make firmcircumferential contact with ‘neck’ of relatively normal aortabetween RA & upper end of AAA each CIA below aneurysmEndovascular aortic aneurysm repair (EVAR)First performed by Parodi from Argentina in 1990 11 Parodi JC et al. Ann Vasc Surg 1991 ; 5 : 491 – 499.2 Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Stent-graft
    77. 77. Endoleak after EVARPersistence flow in aneurysm lumen after procedure• Increase in aneurysmal diameter with risk of rupture• 20 – 40% at any time after graft placement1• Lifelong surveillance 1st month, 6th month, yearly2• Modalities CTA: gold standardCDUS/CEUS: acceptable alternativeMRA – DSA1 Demirpolat G et al. J Clin Ultrasound 2011; 39 : 263–269.2 Stavropoulos SW et al. Radiology 2007;243:641.Determination of endoleak & aneurysmal size
    78. 78. Type IVPorosity of graft material (resolved in 1 month)Type IIIPerforation & tear in graft material (rare)Type IFailure of proximal or distal attachment sitesType IIFlow through aortic or iliac branches (common)Endoleak following EVARWhite GH et al. J Endovasc Surg 1996 ; 3 : 124 – 5.Carrafiello G et al. Cardiovasc Intervent Radiol 2006 ; 29 : 969 – 974.Type VSource not identified (controversial)
    79. 79. EVAR / Mirror artifactDemirpolat G et al. J Clin Ultrasound 2011 ; 39 : 263 – 269.Synchronous pulsatility with flow in patent graftChanging position while examining from different aspectsSpectral analysis aids in reducing false positiveMirror image behind patent limbs of stent graft
    80. 80. EVAR / Poorly organized thrombusAneurysmal sac contains mix of echoesLarge anechoic area (A) which could represent an endoleakNo flow detected (region of poorly organized thrombus)Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.
    81. 81. Types of endoleakType I: Distal attachment siteType II: Patent lumbar arteryThrush A et al. Peripheral vascular ultrasound. Elsevier, London, 2nd edition, 2005.Hartshorne T. Ultrasound 2006 ; 14 : 34 – 42.Type II: Inferior mesenteric arteryType I: Proximal attachment site
    82. 82. Selective screening for AAA• Selective screening3 important risk factors MalesAge > 65 yearsHistory of smoking• Effectiveness of screening4 RCTs including more than 125,000 menReported results for up to 5 – 10 years of follow-upReduction in mortality from 68% to 21%Lederle FA. Ann Intern Med 2003 ; 139 : 516 – 22.
    83. 83. Popliteal artery aneurysm / Partial thrombosisTransverse CDUS Sagittal pulsed & CDUSHamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.Most common peripheral aneurysm70% of peripheral aneurysms
    84. 84. Popliteal artery aneurysm / Complete thrombosisUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.Thrombosed popliteal aneurysm occluding PAPatency of popliteal vein clearly demonstrated
    85. 85. Differential diagnosis of pain in popliteal fossa• Arterial aneurysm or pseudoaneurysm• Arterial dissection• Venous aneurysm• Adventitial cystic disease• Baker’s cyst• Enlarged lymph nodes• Hematoma, seroma, abscess• Muscle tears• Muscle tumors
    86. 86. Popliteal vein aneurysm / Rare1 MacDevitt DT et al. Ann Vasc Surg 1993 ; 7 : 282 – 286.2 Graham RN et al. Am J Surg 2010 ; 199 : e5 – e6.Dilatation twice or 3 times of normal vein diameter 1PE (70-80% ) – Post-thrombotic syndrome – Swelling in popliteal fossaLongitudinal US Transverse US Color Doppler US
    87. 87. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    88. 88. Intimal dissection of abdominal aortaSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Change in color coding due toposition of re-entry siteColor Doppler USLongitudinal & transverse scanGray-scale USLongitudinal & transverse scanIntimal flap seen if sound beamstrikes at perpendicular angleSearch for involvement of visceral & iliac arteries
    89. 89. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    90. 90. Pseudo-aneurysmMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.To-and-fro flowTypical triphasic flow
    91. 91. Pseudo-aneurysm / “to-and-fro” flowMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.During systole“to”Flow enters PA via the neckPseudo-aneurysm lumen enlargesDuring diastole“fro”Flow exits PA via the neckPseudo-aneurysm lumen contracts
    92. 92. Pseudo-aneurysm / CFA2 – 4% of cases after catheter interventionLarge perivascularfluid collectionColor Doppler: swirling pattern“yin-yang” patternPulsed Doppler: “to-and-fro” flowclassic pattern
    93. 93. Pseudoaneurysm / Variations in ‘‘to-and-fro’’ flowMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Limited systolic flowMore pronounced diastolic flowDiastolic flow decreases progressivelyDiastolic flow increases progressivelyDiastolic flow relatively limitedTwo distinct phases of diastolic flowVariations in duration & velocities ofsystolic & diastolic flow due to arrhythmia
    94. 94. Pseudo-aneurysm / Multiloculated typeNot uncommonMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Mistake made by inexperienced examiners:Recognize most superficial lobe correctlyConfuse deeper lobe with femoral artery
    95. 95. Pseudo-aneurysm / Differential diagnosisMiddleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Arborizing flow in enlarged inguinal LN mistaken for PSLow-resistance arterial flow with continuous diastolic flowVenous flow below baseline
    96. 96. Middleton WD et al. Ultrasound Quarterly 2005 ; 21 : 3 – 17.Inguinal LN from melanomaVessels at base of LN different from pattern seen in PA“to and fro’’ pattern near base of LNPseudo-aneurysm / Differential diagnosis
    97. 97. Pseudo-aneurysm / US-guided compression3 stepsFranklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.Preparation Compression Following repairDuration of compression: 10 – 15 minutesSuccess rate: 75 – 85%Complications: PA rupture, distal embolization, & venous thrombosis
    98. 98. Pseudo-aneurysm / US-guided compressionThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.Marked perivascular tissuevibration associated with arterial jetUS guidedcompressionPseudoaneurysmsuccessfully thrombosedThrombosisPA of CFA
    99. 99. Pseudo-aneurysm / US-guided thrombin injectionReplaced compression as technique of choiceNeedle advanced into superficial aspect of PA to avoid neck100 – 300 units of human thrombinAvoid fast injectionSuccess rate 97% according to several studiesFranklin JA et al. J Am Coll Surg 2003 ; 197 : 293 – 301.
    100. 100. Pseudo-aneurysm / US-guided thrombin injectionSecond injectionComplete thrombosisCFA pseudoaneurysmSurrounded by hematomaThrombin injectionunder US guidanceSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Success rate 97% according to several studies
    101. 101. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    102. 102. Arterio-venous fistulaLeft external iliac arteryRight external iliac arteryLow resistance arterial flowRight external iliac veinArterialized venous flowLeft external iliac vein
    103. 103. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    104. 104. Arteritis / “macaroni or halo sign”Higher-level echoLumen intima interfaceSurrounded byConcentric homogeneous hypoechoic structureIntima media complexSchäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd edition, 2011.
    105. 105. Transverse scanLongitudinal scanGiant cell arteritis / Abdominal aorta“Macaroni sign”Schäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Aortic wall thickening (typical finding)IMA at its origin pierces thickened wall directlywithout first coursing close to aortic wall as in fibrosis
    106. 106. Moussavian B & Horrow MM. Ultrasound Quarterly 2009 ; 25 : 89 – 91.Retroperitoneal fibrosis / Ormond’s diseaseHypoechoic cap-like structure anterior to aorta & IVCInvolvement of IVC important for differential diagnosisInfra-renal abdominal aortaSagittal viewInfra-renal abdominal aorta & IVCTransverse view
    107. 107. Retroperitoneal fibrosis / Ormond’s diseaseSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.IMA arising from left lateral aspect of aortaPushed against aortic wall before piercing hypoechoic layerAorta at origin of IMA
    108. 108. Inflammatory aortic aneurysmTypical appearanceSchäberle W. Ultrasonography in vascular diagnosis. Springer, Berlin, 2nd edition, 2011.Atherosclerotic wall changeCircumferential hypoechoic layer around aneurysm confirmsthe inflammatory origin of aneurysmTransverse scan Longitudinal scan
    109. 109. Thrombangiitis obliterans / Buerger diseaseMale – Smoker – Young (34 years)• Location Distal lower leg & foot• Occlusion material Hypoechoic• Vascular wall Hypoechoic without calcification• Occlusion length alternating normal/abnormal seg• Collaterals “corkscrew vessels”• Vein Phlebitis migransStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
    110. 110. Thrombangiitis obliterans / Buerger diseaseStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.37-year-old smoker – Rest pain in forefoot for 14 daysPTAOcclusion without IMT Inflamed venous wall thickeningSuperficial vein35-year-old smoker – 3-year history of Buerger – Necrosis of toesTypical corkscrew arteries
    111. 111. Buerger’s Disease / Corkscrew CollateralsFujii et Y. J Am Col Cardiol 2011 ; 57 : 2539.Type I: Large snake sign> 5 mmType II: Small snake sign3 – 5 mmType IV: Small dot sign< 1 mmType III: Dot sign1 – 3 mm
    112. 112. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    113. 113. Vascular complications of entrapment syndrome Post-stenotic aneurysm Mural thrombi Thrombotic occlusionMethod of choice for diagnosis & evaluation:Duplex US with provocation testsSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
    114. 114. Popliteal entrapment syndrome / Provocation testsExamaging PA just below knee joint space Plantar flexion of footagainst hand of examiner Standing on tip toe Stretching of kneewhile patient lies proneStiegler H & Brandl R. Ultraschall in Med 2009 ; 30 : 334 – 363.
    115. 115. Popliteal artery entrapment syndrome (PAES)Plantar flexion testProgressive compression of popliteal artery by GCMSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.Asymptomatic compression of PA by provocation tests in > 50%
    116. 116. Popliteal aretery entrapment syndrome (PAES)Isolated popliteal artery occlusionTransverse sectionAS Soleus arteryVS Soleus veinLongitudinal sectionAS Soleus arteryVS Soleus veinSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
    117. 117. Causes of arterial diseasesAtherosclerosis (most common cause)Thrombosis or embolismAneurysmIntimal dissectionPseudo-aneurysmArterio-venous fistulaArteritisEntrapment syndromeCystic adventitial disease
    118. 118. Cystic adventitial disease of PACyst involving long popliteal segmentTransverse view Longitudinal viewDifficult to differentiate from dissection with thrombosis of false lumenSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
    119. 119. Cystic adventitial disease of PATransverse view Longitudinal view Pulsed DopplerSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2nd edition, 2011.
    120. 120. Doppler US of lower limb arteries Anatomy of lower limb arteries Normal Doppler US of lower limbs arteries Duplex US criteria for arterial evaluation Causes of lower limb arterial diseases Doppler US of bypass graft
    121. 121. Bypass graftSonography is the recommended non-invasivetechnique for the postoperative monitoringof bypass graft patency
    122. 122. Types of graft• Synthetic graftPTFE* Above knee• Autologous veinReversed vein Removal – reversal – anastomosisIn situ vein Leaves vein in its bed – anastomosisIn all cases Removal of valves in vein graftPerforating veins tied off* PTFE: Polytetrafluoroethylene
    123. 123. Aorto-bi-femoral graft Femoral-to-femoral artery bypass graftPeripheral arterial bypass graft – 1
    124. 124. Peripheral arterial bypass graft – 2Femoro-PoplitealAbove KneeFemoro-PoplitealBelow KneeFemoro-TibialBelow Knee
    125. 125. Bypass graft / Normal USComposite PTFE & vein graftSlightly dilated areacorresponding to valve siteIn situ vein graft
    126. 126. Bypass graft / Normal flow patternHyperemic flow often seenin early postoperative periodHyperemic monopahasic flow Pulsatile flowOver time, flow normallyassumes a pulsatile flow
    127. 127. Bypass graft / Normal PSVAverage PSVfrom 3 – 4 siteswithout stenosisGraft flow velocityNormal PSV: 45 – 180 cm/sAbuRahma AF et al. Noninvasive peripheral arterial diagnosis.Springer-Verlag, London Limited, 1st edition, 2010.
    128. 128. Bypass graft / Causes of graft failureMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004. Atherosclerosis Graft degeneration Neointimalhyperplasia Technical faults
    129. 129. Bypass graft / Sampling velocities in stenosisRatio 2.0 = 50% stenosisRatio 4.0 = 75% stenosisProximal anastomotic stenosisGraft conduit stenosisDistal anastomotic stenosis
    130. 130. Bypass graft / Severe stenosisStenosisPSV of A 16.4 cm/secPSV of B 319 cm/secSpectral broadeningB / A 19 timesAProximal to stenosisABAt stenosisBCritical stenosis
    131. 131. Hemodynamic criteria & management of graft stenosisCategory Risk PSVcm/secPSVratioGraftvelocityManagementI Maximum > 300 > 3.5 < 45 AnticoagulationImmediate interventionWixon CL et al. J Vasc Surg 2000 ; 32 : 1 – 12.II High > 300 > 3.5 > 45 Elective interventionin 15 daysIII Moderate < 300 > 2 > 45 ObservationCorrection if progressionIV Low < 180 < 2 > 45 Observation
    132. 132. Bypass graft / EntrapmentGraft running between twomuscles causing moderate stenosisVein graft in lower tightGraft compressed between twomuscles causing virtual occlusionLeg flexion
    133. 133. Bypass graft / OcclusionExtremely low volume flow recorded from in situvein graft indicates imminent graft occlusion
    134. 134. Bypass graft / Fibro-intimal hyperplasiaLarge area of intimal hyperplasia in a vein graft
    135. 135. Bypass graft / Aneurysmal area in vein graftAneurysmal area in vein graft corresponding to valve siteArea of hyperplasia or thrombus in area of dilation
    136. 136. Bypass graft / False aneurysmGFAFalse aneurysm at distal end of femorofemoral graftdue to failure of anastomosisNote corrugated appearance of Dacron material
    137. 137. Bypass graft / SeromaFluid-filled seromaadjacent to vein graftDifferential diagnosis:– Seroma– Hematoma– Lymphocele– Abscess
    138. 138. Bypass graft / InfectionGEcho region tracking from PTFE graft to skin surfacePus discharging from skin surface at this pointIGIPTFE (transverse view) PTFE (longitudinal view)
    139. 139. ReferencesArnold – 2004 Elsevier – 2005 Springer-Verlag – 2011
    140. 140. Thank You

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