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Doppler ultrasound of lower limb arteries

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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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