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Arterial Dopplers ultrasound by tttttttt
- 1. PERIPHERAL ARTERIAL DOPPLER Dr.S.Suresh Mediscan SystemsDiagnostic Ultrasound Research & training Centre, Chennai, India
- 3. Arterial hemodynamics Distends large art. Pr.wave Resistance Elasticity Depends on Systole
- 4. Arterial hemodynamics Propagationspeed increases Propagation speed increases with stiffness of wall with stiffness of wall Arteries stiffer from aorta to Arteries stiffer from aorta to periphery periphery Pulse pressure incr. by Pulse pressure incr. by vasoconstriction & decr. by vasoconstriction & decr. by vasodilatation vasodilatation Pressure waves
- 5. Vascular resistance Segmental Major art. &collaterals Fixed Peripheral Arterioles Cutaneous circulation Variable
- 6. Hemodynamic resistance Resting state Restingstate Segmental resistance Segmental resistance Low Low Peripheral resistance Peripheral resistance High High Pressure drop across Pressure drop across major segmental artery major segmental artery Low Low
- 7. Hemodynamic resistance Post exercise– normal Post exercise – normal Segmental resistance – Low Segmental resistance – Low Peripheral resistance – Low Peripheral resistance – Low No significant pressure drop No significant pressure drop
- 8. Segmental resistancefixed Segmental resistance fixed Peripheral resistance – markedly Peripheral resistance – markedly decreased decreased Inadequate compensation by Inadequate compensation by peripheral circulation peripheral circulation Hemodynamic resistance Post exercise Post exercise Segmental arterial disease Segmental arterial disease Pressure drop occurs Pressure drop occurs
- 9. Arterial Doppler –Protocol Clinical examination Clinical examination Segmental pressures Segmental pressures Exercise testing Exercise testing Decides: Decides: + + arterial insufficiency arterial insufficiency Level of lesion Level of lesion Severity (?) Severity (?)
- 10. Screening for arterial disease Systolic pressure measured Systolic pressure measured High thigh High thigh Low thigh Low thigh Below knee Below knee Above ankle Above ankle Brachial systolic pressure
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- 12. EXERCISE TESTING Treadmillexercise test Treadmill exercise test 12% grade at 2 km/ hr. 12% grade at 2 km/ hr. Exercise time 5 minutes Exercise time 5 minutes Stop exercise if pain develops Stop exercise if pain develops Contraindications Contraindications Cardiac impairment Cardiac impairment Physical disability Physical disability
- 13. Reactive hyperemia Patients withcardiac problems and Patients with cardiac problems and physical disability physical disability Increase systolic pressure Increase systolic pressure Maintain for 3-5 min. – Vasodilatation Maintain for 3-5 min. – Vasodilatation Release and take pressure Release and take pressure Occlusion – Single level 50% drop Occlusion – Single level 50% drop - Multi level > 50% - Multi level > 50% 17-34% overlap of normal and abnormal values
- 14. Ankle – Brachialindex Ankle /Brachial systolic pressure Normal – 1.1 Normal – 1.1 + + 0.10 0.10 Abnormal - < 0.85 Abnormal - < 0.85 Impending gangrene Impending gangrene 0.05 – 0.08 0.05 – 0.08
- 15. Problems in evaluation Incompressibility of vessel Incompressibility of vessel (atherosclerotic calcific vessel) (atherosclerotic calcific vessel) Development of collaterals Development of collaterals (Ankle/Brachial index, doppler (Ankle/Brachial index, doppler waveform may be normal) waveform may be normal)
- 16. Segmental pressures Absolute pressure Absolutepressure (mmHg) (mmHg) >100 >100 80 – 100 80 – 100 50 – 80 50 – 80 < 50 < 50 Circulatory reserve Circulatory reserve Good Good Satisfactory Satisfactory Moderate Moderate Insufficient Insufficient
- 17. Pitfalls Resting period Restingperiod Cuff width Cuff width Quick deflation Quick deflation Distance between the measurement Distance between the measurement area & probe position area & probe position Subclavian obstruction Subclavian obstruction Atherosclerosis Atherosclerosis
- 18. Normal segmental pressures Right Brachial- 126 Left Brachial - 122 140 138 128 124 130 124 124 128 142 148 AA Index 0.98 1.0
- 19. High segmental pressures Right Brachial- 150 Left Brachial - 160 222 208 184 170 164 162 160 172 182 200 AA Index 1.1 1.01 0 20 40 60 80 100 120 140 160 180 200 2 4 6 8 10 TIME (Minutes) PRESSU RE (m m H g ) Right Left Atherosclerotic disease
- 20. Bilateral iliac obstruction Right Brachial- 174 Left Brachial - 200 116 124 116 116 116 108 126 120 AA Index 0.70 0.6 0 20 40 60 80 100 120 2 4 6 8 10 12 TIME (Minutes) PRESSURE ( mmHg) Right Left
- 21. Left iliac obstruction Right Brachial- 120 Left Brachial - 120 150 124 130 120 116 66 72 70 83 96 AA Index 1.0 0.60 0 20 40 60 80 100 120 140 160 2 4 6 8 10 12 TIME (Minutes) PRESSURE (m m Hg) Right Left
- 22. Multisegmental obstruction -Right Right Brachial - 115 Left Brachial - 116 90 62 50 48 122 130 134 146 AA Index 0.42 1.06 0 20 40 60 80 100 120 140 160 2 4 6 8 10 12 TIME (Minutes) PRESSURE (m m H g) Left Right
- 23. Multisegmental obstruction Right Brachial -165 Left Brachial - 159 130 110 94 72 76 100 102 110 152 164 Index 0.44 0.64 30 40 50 60 70 80 90 100 4 6 8 10 12 TIME (Minutes) PRESSU RE (m m H g) Right Left
- 24. Rt. Popliteal art.embolism Right Brachial - 124 Left Brachial - 120 160 140 130 70 70 119 124 130 134 140 AA Index 0.58 1.03
- 25. DUPLEX USG vsCW DOPPLER Exact number, size & extent of the Exact number, size & extent of the lesion lesion Determine the severity of lesion Determine the severity of lesion Focal stenosis vs long segment Focal stenosis vs long segment occlusion occlusion
- 26. PERIPHERAL ARTERIAL DOPPLER -INDICATIONS Occlusive arterial disease Occlusive arterial disease Follow up after bypass graft, Follow up after bypass graft, angioplasty angioplasty Diagnosis & follow up of aneurysms Diagnosis & follow up of aneurysms Diagnosis & treatment of Diagnosis & treatment of pseudoaneurysm pseudoaneurysm Evaluation of pulsatile swelling Evaluation of pulsatile swelling Assessment of dialysis shunts Assessment of dialysis shunts
- 27. Occlusive Arterial Disease Arteriosclerosis Obliterans Arteriosclerosis Obliterans Thromboangitis Obliterans Thromboangitis Obliterans Atherosclerosis
- 28. OCCLUSIVE ARTERIAL DISEASE H/oclaudication H/o claudication Pain on exercise Pain on exercise Rest pain Rest pain Intermittent claudication Intermittent claudication Instep claudication Instep claudication Diminished pulse volume Diminished pulse volume Chronic non-healing ulcer Chronic non-healing ulcer Muscle group distal to the obstruction develops pain
- 29. Classify peripheralarterial disease Classify peripheral arterial disease Locate stenotic sites Locate stenotic sites Grading of severity of stenosis Grading of severity of stenosis Negative study excludes Negative study excludes hemodynamically significant disease hemodynamically significant disease APPLICATIONS OF ARTERIAL DUPLEX
- 30. ARTERIAL DOPPLER Protocol Imagefrom abdominal aorta to distal vessels Image from abdominal aorta to distal vessels Aortic bifurcation Aortic bifurcation Common iliacs Common iliacs External iliacs External iliacs (internal il.) (internal il.) Common femoral Common femoral Profunda Profunda Superficial femoral A Superficial femoral A Popliteal A Popliteal A Ant tib. / post tib / peroneal A Ant tib. / post tib / peroneal A
- 31. Arterial doppler Spectraldoppler Spectral doppler Flow dynamics Flow dynamics Peak systolic velocity Peak systolic velocity Spectral waveform shape Spectral waveform shape
- 32. Small dia.of art.- Sp. broadening
- 33. ARTERIAL DOPPLER Surveyof the arteries Survey of the arteries Diameter, wall pathology Diameter, wall pathology Study plaque morphology Study plaque morphology Selection of patients for Selection of patients for angiography angiography ARTERIOGRAM IS GOLD STANDARD
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- 36. Mean arterial diametersand peak systolic velocities Artery Artery Diameter Diameter (mm) (mm) Velocity Velocity cms/sec cms/sec Ext.iliac Ext.iliac 7.9 7.9 + + 1.3 1.3 120 120 + + 20 20 Common Common Femoral Femoral 8.2 8.2 + + 1.4 1.4 115 115 + + 25 25 Sup. Fem A Sup. Fem A 6.0 + 1.2 6.0 + 1.2 90 90 + + 13 13 Sup Fem A Sup Fem A distal distal 5.4 + 1.1 5.4 + 1.1 93.6 + 14.1 93.6 + 14.1 Popliteal Popliteal 5.2 + 1.1 5.2 + 1.1 68.8 + 13.5 68.8 + 13.5
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- 40. DOPPLER CRITERIA FORFLOW OBSTRUCTIVE LESIONS Tri – or biphasic Tri – or biphasic Systolic window + Systolic window + no spectral broadening no spectral broadening NORMAL NORMAL
- 41. 1 – 19%diameter reduction Peak systolic velocity- <30% inc. Peak systolic velocity- <30% inc. Adj. to the proximal segment Adj. to the proximal segment Triphasic waveform Triphasic waveform – – minimal spectral broadening minimal spectral broadening
- 42. 20 – 49%diameter reduction 30 – 50% increase in peak syst. vel. 30 – 50% increase in peak syst. vel. Reverse flow present Reverse flow present Marked spectral broadening Marked spectral broadening
- 43. 50 – 99%diameter reduction 50 – 100% increase in peak syst.velocity 50 – 100% increase in peak syst.velocity Reverse flow absent Reverse flow absent Monophasic waveform marked spectral Monophasic waveform marked spectral broadening broadening CLINICAL CLASSIFICATION OF STENOSIS > 50% or < 50%
- 44. Occluded No flow detected Noflow detected Prox.& distal waveforms disturbed Prox.& distal waveforms disturbed
- 45. Forward flow Distal toocclusion Distal to occlusion Proximal to occlusion Proximal to occlusion
- 46. Sites of occlusion Superficial femoral artery- Adductor Superficial femoral artery- Adductor canal canal Aorto iliac segment Aorto iliac segment Popliteal artery Popliteal artery Presence of symptoms depends on Presence of symptoms depends on the collateral supply the collateral supply
- 47. Iliac & SFAocclusion
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- 49. Stenosis calculation Ratio= Ratio = PSV at stenosis PSV at stenosis Normal PSV prox. to stenosis Normal PSV prox. to stenosis 3.7 – 75% stenosis 3.7 – 75% stenosis 7.0 – 90% stenosis 7.0 – 90% stenosis
- 50. Multiple tandem lesions Cumulative effect seen distally Cumulative effect seen distally “ “resistances in series” resistances in series”
- 51. COLOUR DOPPLER Identifiescourse of vessels Identifies course of vessels calcified vessels – better seen calcified vessels – better seen Detects : Detects : Isoechoic lesions Isoechoic lesions Areas of stenosis and occlusion Areas of stenosis and occlusion Identifying collaterals Identifying collaterals Reduces examination time
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- 56. Flow direction incollaterals
- 58. Marked forward flowin diastole
- 59. COLOUR PITFALLS Impropergain settings – Aliasing Improper gain settings – Aliasing Varying velocities – Turbulence Varying velocities – Turbulence Mimicking obstruction Mimicking obstruction
- 60. Colour pitfall –Inc. velocity due to turbulence mimicking jet
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- 62. ARTERIAL EVALUATION OTHER INDICATIONS Graftpatency Graft patency AV malformation AV malformation Detection & management Detection & management of pseudoaneurysm of pseudoaneurysm
- 63. ASSESSMENT OF GRAFT PATENCY Non- patent graft Non- patent graft PSV < 45 cms/sec PSV < 45 cms/sec Ratio of PSV at stenosis vs Ratio of PSV at stenosis vs proximal normal velocity proximal normal velocity 50% stenosis > 2 50% stenosis > 2 75% stenosis > 3-4 75% stenosis > 3-4
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- 70. Colour doppler of Aneurysms Superior to arteriography Superior to arteriography Identifying intramural thrombus Identifying intramural thrombus Serial USG in aneurysm < 2 cms Serial USG in aneurysm < 2 cms in diameter in diameter Increase in the size (to decide Increase in the size (to decide intervention) intervention) Embolism in distal arteries Embolism in distal arteries
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- 75. TRUE vs PSEUDOANEURYSM Distension of parent Distension of parent artery artery Arterial wall + Arterial wall + No feeder vessel No feeder vessel Inc. velocity at Inc. velocity at the origin of the origin of aneurysm aneurysm Collection of blood in Collection of blood in the soft tissue plane the soft tissue plane adjacent & in adjacent & in communication with communication with the parent artery the parent artery No arterial wall No arterial wall Feeder vessel + Feeder vessel + Biphasic flow at neck Biphasic flow at neck of feeding vessel of feeding vessel COLOUR SUPERIOR IN DIAGNOSING TRUE Vs PSEUDOANEURYSM
- 76. Pseudo aneurysm Therapy Therapy Feedingchannel can be occluded Feeding channel can be occluded with transducer pressure with transducer pressure Thrombosis Thrombosis
- 77. Pseudo aneurysm Criteria Criteria Pseudoaneurysm < 1 month Pseudo aneurysm < 1 month Length of the neck (> 5mm) Length of the neck (> 5mm) Duration of compression Duration of compression varies varies
- 79. 50 days afterdetection Occluded 45 days after occlusion -Refilling
- 80. A-V FISTULA Congenital Congenital Traumatic Traumatic Iatrogenic Iatrogenic High velocity arterialised flow in vein High velocity arterialised flow in vein Marked increase in systolic flow in Marked increase in systolic flow in artery artery
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- 86. Congenital Clinical –skin discolouration Clinical – skin discolouration USG – Limited role USG – Limited role Helpful in patients who had Helpful in patients who had undergone sclerotherapy undergone sclerotherapy
- 87. Acute thrombus -? Embolus - Normal lumen size
- 88.
- 89. Thoracic outlet Recordingthe pressures on the Left Recording the pressures on the Left 90 90 0 0 abduction & external rotation abduction & external rotation Adson maneuver Adson maneuver
- 90. Pathology of upperextremity Raynaud’s syndrome Raynaud’s syndrome Arterial occlusions Arterial occlusions Thoracic outlet Thoracic outlet syndrome syndrome
- 91. Raynaud’s syndrome Vasospasticdisorder Vasospastic disorder Episodic digital ischaemia Episodic digital ischaemia Discolouration of digits – Associated with Discolouration of digits – Associated with embolisation / occlusion embolisation / occlusion DUPLEX USG DUPLEX USG Differentiate between occlusion & Differentiate between occlusion & vasospasm vasospasm Cold intolerance testing Cold intolerance testing Digital blood pressure Digital blood pressure
- 92. Occlusions Atherosclerosis Atherosclerosis Takayasu’sdisease Takayasu’s disease Buerger’s disease – associated Buerger’s disease – associated proximal obstruction in small vessel proximal obstruction in small vessel disease disease
- 93. Thoracic outlet syndrome Neurogenic Neurogenic Vascular Vascular
- 94. Trauma Detect obstruction Detectobstruction False aneurysms False aneurysms Large intimal flap Large intimal flap
- 96. CASE I Mr.M, 35 yrs Mr. M, 35 yrs Intermittent claudication – LLB, Intermittent claudication – LLB, 1yr 1yr Smoker – 5 yrs Smoker – 5 yrs Diabetes – 6 mths Diabetes – 6 mths
- 97. Segmental pressures 138 140 120 140 110 98 96 90 92 82 Brachial - 120 Brachial -120 AAI – 1.0 AAI – 0.75
- 98. Post exercise Duration in Durationin (min.) (min.) Right Right Left Left 2 2 128 128 56 56 4 4 124 124 78 78 6 6 122 122 84 84 8 8 122 122 90 90 10 10 122 122 90 90 12 12 124 124 90 90 Patient had unbearable pain in left leg after 3mnts.
- 102. USG FINDINGS Totalocclusion of left common iliac artery. Total occlusion of left common iliac artery. Left external iliac artery was fed by the left Left external iliac artery was fed by the left internal iliac artery. internal iliac artery. OCCLUSIVE ARTERIAL DISEASE. OCCLUSIVE ARTERIAL DISEASE. TOTAL OCCLUSION OF LEFT COMMON TOTAL OCCLUSION OF LEFT COMMON ILIAC ARTERY. ILIAC ARTERY. REFORMATION OF LEFT EXTERNAL ILIAC REFORMATION OF LEFT EXTERNAL ILIAC ARTERY SEEN THROUGH LEFT INTERNAL ARTERY SEEN THROUGH LEFT INTERNAL ILIAC ARTERY. ILIAC ARTERY.
- 103. Case II Mr.PM – 48 Yrs Mr. PM – 48 Yrs Smoker– 10 Yrs Smoker– 10 Yrs Pain in left foot since 3 weeks Pain in left foot since 3 weeks
- 104. Segmental pressures 170 100 100 70 100 30 30 Brachial - 140 Brachial -150 AAI – 0.67 AAI – 0.21
- 108. USG findings Rightside : - Right side : - Total occlusion of right superficial femoral Total occlusion of right superficial femoral artery. artery. Collateral seen joining the popliteal artery with Collateral seen joining the popliteal artery with reduced forward flow distally. reduced forward flow distally. Left side : - Left side : - Total occlusion of external iliac artery and lower Total occlusion of external iliac artery and lower limb arteries. limb arteries. Normal flow seen in aorta, both common iliac Normal flow seen in aorta, both common iliac artery and external iliac artery on right side. artery and external iliac artery on right side. Normal flow seen in right common femoral artery Normal flow seen in right common femoral artery and profunda femoris. and profunda femoris.