Doppler Hepático

US Doppler hepático
Técnica de exploración, anatomía y patología vascular

DR. ERIC KIMURA HAYAMA
Instituto Nacional de Cardiología Ignacio Chávez
CT Scanner
de México Grupo CT Scanner

Thursday, May 31, 2012

STROINTESTINAL IMAGING
GASTROINTESTINAL IMAGING 161

Doppler US of the Liver
Made Simple
Made Simple11

Abbreviations: CHF = congestive hear
CME FEATURE portosystemic shunt
E FEATURE
RadioGraphics 2011; P
1
From the Department of Radiology, U
LEARNING Laude award for an education exhibit a
OBJECTIVES August 26; accepted August 27. For th
ARNINGTEST 4
FOR correspondence to D.A.M. (e-mail:
JECTIVES
R TEST 4 taking
article and ©
RSNA, 2011

le andDiscuss the basic
I taking
concepts and termi-
nology for vascular
Doppler US.
uss the basic the
I Recognize
©
RSNA, 2011
pts and termi- ap-
characteristic
y forpearances of normal
vascular
er US. abnormal liver
and
Doppler waveforms.RSNA, 2011
©
ognize the May 31, 2012
Thursday,

STROINTESTINAL IMAGING
GASTROINTESTINAL IMAGING 161

Made Simple
Made Simple11

Abbreviations: CHF = congestive hear
CME FEATURE portosystemic shunt
E FEATURE
RadioGraphics 2011; P
1
From the Department of Radiology, U
LEARNING Laude award for an education exhibit a
OBJECTIVES August 26; accepted August 27. For th
ARNINGTEST 4
FOR correspondence to D.A.M. (e-mail:
JECTIVES
R TEST 4 taking
article and

le andDiscuss the basic
I taking
concepts and termi-
???? ©
RSNA, 2011

nology for vascular
Doppler US.
uss the basic the
I Recognize
©
RSNA, 2011
pts and termi- ap-
characteristic
y forpearances of normal
vascular
er US. abnormal liver
and
Doppler waveforms.RSNA, 2011
©
ognize the May 31, 2012
Thursday,

Objetivos


Objetivos
1. Describir aquellos parámetros técnicos útiles en la obtención
de un estudio diagnóstico y que pueden condicionar artificios


Objetivos

2. Describir las características normales de los vasos hepáticos


Objetivos

2. Describir las características normales de los vasos hepáticos

3. Describir algunas patologías donde el US Doppler es de
utilidad en su estudio


1. TÉCNICA

2. Anatomía y fisiología

3. Patología

incich/grupo ct scanner Departamento de Radiología/Unidad PET-CT


Técnica de revisión: ventanas

• Depende del vaso, tamaño del hígado y del paciente

Transabdominal

Lóbulo izquierdo
• Porta izquierda
• VSH izq





Transabdominal Intercostal (DLI)

Porta hepatis
Lóbulo izquierdo • Porta principal
• Porta izquierda • Art. Hepática principal
• VSH izq y ramas der e izq
• VSH der y media





Transabdominal Intercostal (DLI) Subcostal

Lóbulo derecho (segm
Porta hepatis posteriores)
Lóbulo izquierdo • Porta principal
• VSH y su llegada a la
• Porta izquierda • Art. Hepática principal VCI
VSH izq y ramas der e izq
• • Bifurcación portal
• VSH der y media (“H”)



Doppler: parámetros técnicos
Doppler color y espectral

Doppler espectral

Doppler color



Doppler color y espectral • Línea basal
 • Escala de velocidad (PRF)
• Filtros
• Inversión de flujo

Doppler espectral

Doppler color



• Filtros

Doppler espectral • Ganancia espectral
 • Ángulo
• Tamaño y posición de la
muestra

Doppler color



• Filtros

 • Ángulo
muestra

Doppler color • Ganancia de color
 • Barra y caja de color
• Escala de velocidad de color
• Prioridad



• Filtros

 • Ángulo
muestra

Doppler color • Ganancia de color
 • Barra y caja de color
• Escala de velocidad de color
• Prioridad

TODOS los parámetros DEBEN individualizarse


Sobrerrango (aliasing)

• Causa: PRF “muy bajo” (los
cambios de frecuencia
superan el límite Nyquist -2

veces el PRF-)


Sobrerrango (aliasing)

• Causa: PRF “muy bajo” (los
cambios de frecuencia
superan el límite Nyquist -2

veces el PRF-)

SOLUCIÓN
1.  PRF
2. Mover la línea basal
3.  ángulo Doppler
4. Transductor <frecuencia


Doppler espectral: PRF y línea basal



¿Espectro pequeño?

Solución: mover línea
basal o  PRF



Doppler espectral: PRF y línea basal

Mover línea basal


¿Espectro pequeño?

Solución: mover línea Mover PRF
basal o  PRF



Ganancias color

¿Hemorragia de color?









Ganancias color

¿Hemorragia de color? Solución:  ganancia color









Ganancias espectrales

id
ru o



Tamaño y posición de la muestra

Mejor definición del espectro y de la ventana espectral



Ventana espectral

Caus
Artiﬁ
Lar
Hig
Physi
No
No
Patho
Co
Tur

vessel e
aorta. T
Figure 10. Diagrams illustrate “spectral window” andRadiología/Unidad PET-CT
incich/grupo ct scanner Departamento de
tral wa
spectral broadening. In the proximal aorta (top left),

color Doppler examination includes gray-scale US (B-
Generalidades
mode imaging).

Figure 2. Spectral Doppler examination components.
Diagram at left shows the general layout of a spectral
Doppler image. The spectral waveform is displayed

on the lower half of the image, a color Doppler image

Generalidades

Magniﬁed view of a spectral waveform illustrates its features.
Cardiac phasicity creates a phasic cycle, which is composed of phases as de-
termined by the number of times blood ﬂows in each direction. The baseline
(x = 0) separates one direction from another. Moving from left to right along
the x-axis corresponds to moving forward in time. Moving away from the
baseline vertically along the y-axis in either direction correspondsRadiología/Unidad PET-CT
incich/grupo ct scanner Departamento de
to increas-

Generalidades

trate th
used to
undula
velocity
wavefo
and no
phasic
phasic
teries b
veins. N
a phas
no velo
though
The te
out ph
is no ﬂ


radiographics.rsna.org

Figure 6. Phase interpretation ambiguity. Schematics illustrate how different
interpretations of what constitutes a phase can affect waveform characteriza-
tion and nomenclature. D.A.M. interprets a phase as a component of the
waveform on either side of the baseline; M.M.A.Y. interprets a phase as an
inflection.

Figure 6. Phase interpretation ambiguity. Schematics illustrate how different
interpretations of what constitutes a phase can affect waveform characteriza-
tion and nomenclature. D.A.M. interprets a phase as a component of the
waveform on either side of the baseline; M.M.A.Y. interprets a phase as an
inflection.

Figure 7. Directionality and phase quantification. When phase is defined as
a component of phasic flow direction, waveforms may be described in terms
of the number of phases. All monophasic waveforms are unidirectional; bidi-
rectional waveforms may be either biphasic, triphasic, or tetraphasic.


the PI in the portal vein (V2/V1). The most fre- theless u
quently used index in the hepatic arteries is the the RI o
RI, which is calculated as
1. A h
(PSV − EDV) (V1 − V2) therefor
RI = = ,
(PSV) V1 ing than

Table 1 where PSV = peak systolic velocitycorrelates with, the number of sounds
and EDV = 2. An
audio Doppler US. With this interpretthe post
end diastolic velocity. Calculating the RI is phases (phase quantificatio
number of prob-
ably the easiest part of measuring and reporting inflection diffuse d
Internal carotid arteries
to the number of points con
Hepatic arteries
arterial impedance; most US vendors provide one cycle.wide var
Renal arteries
waveform during
Perhaps in the future, a consensusease due
software that automatically performs this calcula-
Testicular arteries addressing what constitutes a phase an
tion. What to radiographics.rsna.org is much less clear. will be3. An
do with the result ate phase quantification forthc
Note.—RI = resistive index.
This is because the normal range varies from oneto overall waveform
cially as it pertains proxima
n- institution, and publishedarteries. Schematics illustrate thatarticle, D.A.
High- versus low-resistance
article to the in this a(arteriov
ture. Nonetheless,
Table 2 artery, high-resistance artery (left) allows less blood flow during end diastole (the
nce; pretation of phase will be used for pha
e next. Furthermore,such that the
trough is lower) than does significance of (right). These visual findings severe
ization of any wave can be achieved the a low-resistance artery an abnor-
cation and subsequent waveform nom in
are confirmed by calculating an RI. High-resistance arteries normally have RIs
words usedmal result 0.7,not could be entered Therefore, it is wise to 0.7.
External carotid arteries is wave always clear.
to describe the whereas low-resistance arteries have RIs ranging from 0.55
over injury);
Extremity arteries (eg, external iliac is a low-resistance artery.
arteries,
into a computer to relyhepatic artery these measurements; rather,
- not andThe waveform recreated.
the solely on
axillary arteries)good to know that phase
Unidirectional versus Bidirectional.—
they should such as and supporting unidirectionaldirection of flow can also
Regardless, it is
Fasting mesenteric arteries be used asinferior
quantification descriptors (superior
,
data. the and
describe Flow 7)
(Fig P
mesenteric arteries)
ter- , and In general, ambiguous given arteries normally direction (whetherar
can be low-resistance flow in only one There a
Note.—RI = in the RI of 0.55–0.7. The hepatic retrograde) can be said to have un
have an index.
this differenceresistivedefinition of phase. Another or artery is Causes of Spectral Bro flow (no
e- point to keeplow-resistance vessel; however, wider normalonly be monophasic
a in mind is that nonphasic waves do flow, which can Artificial
not actually lack phasicity; rather, they have one
lent flow
High- versus low-resistance arteries
earlier). Vessels thatLarge samplein twofl
have flow PET-CT
m- volume
incich/grupo ct scanner
ranges of 0.55–0.81 have been reported to have bidirectional flow, of
phase (ie, are monophasic) without any inflec- for
high-resistance artery (left) allows less blood
effect wh
Departamento de Radiología/Unidad
ion
Thursday, May 31, 2012 trough issaid than does a low-resistance arter
are lower) High gain

Parvus tardus

incich/grupo ct scanner Diagram illustrates upstream stenosis
Departamento de Radiología/Unidad PET-CT


1. Técnica

2. ANATOMÍA Y FISIOLOGÍA

3. Patología


Anatomía



Anatomía (Couinaud)

SEGMENTO NOMBRE

I Caudado

II Lateral sup

III Lateral inf

IV Medial

V Anterior inf

VI Posterior inf

VII Posterior sup

VIII Anterior sup



Couinaud

ESTRUCTURA LOCALIZACIÓN UTILIDAD

Separa segmentos
VSHD Cisura intersegmentaria derecha
anterior/posterior
Separa lóbulos
VSHM Cisura lobular principal
derecho/izquierdo
Separa segmentos
VSHI Cisura intersegmentaria izquierda
medial/lateral



Couinaud

ESTRUCTURA LOCALIZACIÓN UTILIDAD

Separa segmentos
VSHD Cisura intersegmentaria derecha
anterior/posterior
Separa lóbulos
VSHM Cisura lobular principal
derecho/izquierdo
Separa segmentos
VSHI Cisura intersegmentaria izquierda
medial/lateral

ESTRUCTURA LOCALIZACIÓN

VPD (rama anterior) Intrasegmentaria

VPD (rama posterior) Intrasegmentaria

VPI (segmento horizontal) Anterior al caudado

VPI (segmento ascendente) Cisura intersegmentaria izquierda



VSH normales

• Abordaje: variable

• Morfología trifásica:
• Suprabasal (1): sístole
atrial

• Infrabasal (2): fases de
llenado auricular



Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
Espectro normal vena suprahepática

Figure 18. Diagram illustrates normal hepatic venous ﬂow direction
and waveform. The direction of normal ﬂow is predominantly antegrade, PET-CT
incich/grupo ct scanner Departamento de Radiología/Unidad



a contracción auricular
and waveform. The direction of normal flow is predominantly antegrade,
which llenado auricular
S corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The tricúspide , which refers to the a, S, and D inflection
v apertura term
points,diástole
D is commonly used to describe the shape of this waveform; according
to D.A.M., however, this term is a misnomer, and the term tetrainflectional is
more accurate, since it includes the v wave and avoids inaccurate phase quan-
tification. Normal hepatic venous waveforms may be biphasic (bottom left) or
tetraphasic (bottom right).

Normal time-correlated electrocardio-
graphic (ECG) findings, central venous pressure (CVP)
tracing, and hepatic venous (HV) waveform (4). The
incich/grupo ct scanner peak of the retrograde a wave corresponds with atrial

Thursday, May 31, 2012 contraction, which occurs at end diastole. The trough


v apertura term
points,diástole

Contracción auricular
(fin de diástole)




v apertura term
points,diástole

(fin de diástole)

Efecto “succión” post
contracción auricular
y tricúspide cerrada



v apertura term
points,diástole

(fin de diástole)

Aumento presión intraauricular
con válvula tricúspide cerrada (telesístole) (HV) waveform (4). The
tracing, and hepatic venous



v apertura term
points,diástole

(fin de diástole)

Aumento presión intraauricular Fase de llenado
con válvula tricúspide cerrada (telesístole) (HV) waveform (4). The
tracing, and hepatic venous rápido ventricular


Espectro NORMAL vena suprahepática

D
v
and waveform. The direction of normal ﬂow a predominantly antegrade,
1) Relaciones normales: is
S
which corresponds to a waveform that is mostly below the baseline at spectral
Doppler US. The term , which refers to the a, S, and D inﬂection
points, is commonly used to describe the shape of this waveform; according




D
v
a>v a >D S
which corresponds to S waveform that is mostly below the baseline at spectral
points, is commonly used to describe the shape of this waveform; according




D
v
a>v a >D S
points,2) commonly Valsalva:
is Efecto de used to describe the shape of this waveform; according
Pérdida de pulsatilidad




D
v
a>v a >D S
points,2) commonly Valsalva:
is Efecto de used to describe the shape of this waveform; according
Pérdida de pulsatilidad
3) ¿Cómo revisarla?:
Inspiración ligera



Venas hepáticas: anomalías espectro

176 January-February 2011 radiographics.rsna.org

• Alta pulsatilidad:
corresponds to maximal retrograde hepatic ve-
nous flow. In physiologic states, the peak of the
Table 6
Causes of Pulsatile Hepatic Venous Waveform
a wave is above the baseline, and the a wave is
• Origen: cardiaco
wider and taller than the v wave (the other po- Tricuspid regurgitation
Decreased or reversed S wave
tentially retrograde wave). Even in pathologic
states, the a wave remains wider than the v wave, Tall a and v waves
which represents the best way to initially orient Right-sided CHF
oneself on the waveform. The only time this rule Maintained S wave/D wave relationship
breaks down is in cases of severe tricuspid regur- Tall a and v waves
gitation, when the S wave becomes retrograde
and merges with the a and v waves to form one
large retrograde a-S-v complex.
The S wave is the next wave encountered grade diastolic velocity is maximal. The subse-
on the waveform. Its initial downward-sloping quent rising portion results from increasing right
portion is generated by decreasing right atrial atrial pressure generated by the increasing right
pressure, as a result of the “sucking” effect cre- ventricular blood volume.
ated by the downward motion of the atrioven- It is almost unheard of to describe flow in the
tricular septum as it descends toward the cardiac hepatic veins as hepatofugal, since the term is
apex during early to midsystole. Note that the reserved for describing the state of pathologic
tricuspid valve remains closed. If it were open flow in the portal veins. However, it is important
(tricuspid regurgitation), the result would be to remember that physiologic flow in the hepatic
pathologic retrograde flow. The S wave corre- veins is hepatofugal (ie, away from the liver and
sponds to antegrade hepatic venous flow and is toward the heart). In summary, the hepatic ve-
the largest downward-pointing wave in the cycle. nous waveform is normally phasic and predomi-
The lowest point occurs in midsystole and is the nantly antegrade.
point at which negative pressure is minimally op- Abnormal (pathologic) hepatic venous flow
Thursday, May 31, 2012velocity is maximal. After
posed and antegrade may manifest in one of several basic ways.

OJO: NO aplica en
casos de cirrosis

Table 6
on the waveform. Its initial downward-sloping quent rising portion results from increasing right
ated by the downward motion of the atrioven- It is almost unheard of to describe ﬂow in the
tricular septum as it descends toward the cardiac hepatic veins as hepatofugal, since the term is
the largest downward-pointing wave in the cycle. nous waveform is normally phasic and predomi-

OJO: NO aplica en
casos de cirrosis

Table 6
• Baja pulsatilidad:
The S wave is the next wave encountered
on the waveform. Its initial downward-sloping
grade diastolic velocity is maximal. The subse-
quent rising portion results from increasing right
• Origen: pérdida de
distensibilidad venosa (por
ated by the downward motion of the atrioven-
tricular septum as it descends toward the cardiac
It is almost unheard of to describe flow in the
hepatic veins as hepatofugal, since the term is
aumento en la presión
apex during early to midsystole. Note that the
tricuspid valve remains closed. If it were open
reserved for describing the state of pathologic
flow in the portal veins. However, it is important
intraparenquimatosa
(tricuspid regurgitation), the result would be
pathologic retrograde flow. The S wave corre-
to remember that physiologic flow in the hepatic
veins is hepatofugal (ie, away from the liver and
hepática)
sponds to antegrade hepatic venous flow and is
the largest downward-pointing wave in the cycle.
toward the heart). In summary, the hepatic ve-
nous waveform is normally phasic and predomi-

OJO: NO aplica en
casos de cirrosis

Table 6
S wave becomes retrograde
gitation, when the 178 January-February 2011 radiographics.rsna.org
This is because the waveform is affected not only
• Baja pulsatilidad:
by the cardiac cycle, but also by respiratory varia-
on the waveform. Its initial downward-sloping
Table 7
quent rising portion Causes of Decreased Hepatic Venous Phasicity
tion. It has been shown that inspiration and expi-
results from increasing right
• Origen: pérdida de
ration both affect the systolic/diastolic ratio, and
pressure, as a result of the “sucking” effect cre-
Cirrhosis
ventricular blood volume. vein thrombosis (Budd-Chiari syndrome)
that the Valsalva maneuver can markedly reduce Hepatic
distensibilidad venosa (por
ated by the downward motion of the atrioven- It is almost unheard of toveno-occlusive disease
pulsatility, even to the point of nonphasicity (1).
tricular septum as it descends toward the cardiac
Hepatic describe flow in the
hepatic veins as hepatofugal, since outflow obstruction from any cause
Hepatic venous the term is
The ideal time to acquire the spectral waveform
aumento en la presión
is during a small (incomplete) inspiratory breath
hold. Once proper technique has been confirmed,
intraparenquimatosa
pathologic causes of nonphasicity may be consid-
ered, including cirrhosis, hepatic vein thrombosis literature indicates that approximately 25% of
hepática)
(Budd-Chiari syndrome), hepatic veno-occlusive
the largest downward-pointing wave in the cycle.
patients with Budd-Chiari syndrome also have
nous waveform is normally phasic and predomi-
disease, and hepatic venous outflow obstruction portal vein thrombosis (23).
incich/grupo ct scanner from any cause (Table 7). As disease severity Budd-Chiari Departamento de Radiología/Unidad PET-CT
syndrome is typically classified
progresses and the veins become more com- into one of three types on the basis of the loca-

Diagnóstico????



Diagnóstico????

Insuficiencia tricuspídea
moderada (S < D, >>> a/v)



Diagnóstico????

Insuficiencia tricuspídea grave
Insuficiencia tricuspídea
moderada (S <onda S) a/v)
(inversión D, >>>



“a” o “v”, como identificarlas????

a v



Insuficiencia cardiaca derecha sin IT grave

Figure 21.

Right-sided CHF without tricuspid re-

Insuficiencia cardiaca derecha sin IT grave

Insuficiencia cardiaca derecha
(relación S/D conservada, y >>>> a/v)

Figure 21.

Right-sided CHF without tricuspid re-

Baja pulsatilidad: aplanamiento a inversión “a”

Figure 22. Decreased hepatic venous
phasicity. Diagrams illustrate varying
degrees of severity of decreased phasicity
in the hepatic vein. Farrant and Meire (5)
ﬁrst described a subjective scale for quan-
tifying abnormally decreased phasicity in
the hepatic veins, a ﬁnding that is most
commonly seen in cirrhosis. The key to
understanding this scale lies in observing
the position of the a wave relative to the
baseline and peak negative S wave excur-
sion. As the distance between the a wave
and peak negative excursion decreases, pha
sicity is more severely decreased.


Baja pulsatilidad: aplanamiento a inversión “a”

This is because the waveform is affected not only
Table 7
by the cardiac cycle, but also by respiratory varia- Causes of Decreased Hepatic Venous Phasicity
tion. It has been shown that inspiration and expi-
ration both affect the systolic/diastolic ratio, and Cirrhosis
that the Valsalva maneuver can markedly reduce Hepatic vein thrombosis (Budd-Chiari syndrome)
pulsatility, even to the point of nonphasicity (1). Hepatic veno-occlusive disease
The ideal time to acquire the spectral waveform Hepatic venous outflow obstruction from any cause
is during a small (incomplete) inspiratory breath
hold. Once proper technique has been confirmed,
pathologic causes of nonphasicity may be consid-
ered, including cirrhosis, hepatic vein thrombosis literature indicates that approximately 25% of
(Budd-Chiari syndrome), hepatic veno-occlusive patients with Budd-Chiari syndrome also have
disease, and hepatic venous outflow obstruction portal vein thrombosis (23).
from any cause (Table 7). As disease severity Budd-Chiari syndrome is typically classified
progresses and the veins become more com- into one of three types on the basis of the loca-
pressed by fibrotic constriction or parenchymal tion of the obstruction. Type 3, also called hepatic
Figure 22. Decreased hepatic venous
edema, they lose their ability to accommodate veno-occlusive disease, is rare and involves dif-
retrograde flow. This is the one case in which phasicity. Diagrams illustrate varying
fuse narrowing at the venule level. Types 1 and 2
our model for understanding the hepatic venous are the mostof severity of decreased phasicity
degrees common and involve obstruction at
waveform in terms of right atrial pressure breaks the level of the hepatic vein or vena and Meire (5)
in the hepatic vein. Farrant cava. The ob-
down. Decreased venous compliance is seen as struction is usually secondary to bland thrombus
first described a subjective scale for quan-
a waveform with a proportional loss of phasicity. related to a hypercoagulable state; however, the in
tifying abnormally decreased phasicity
A quick and reliable way to grade the severity list of causes of hepatic vein occlusion is long and
of decreased phasicity is to visually assess the the hepatic veins, a finding that is most
is traditionally divided into primary (eg, congeni-
waveform, focusing on how far the a wave drops talcommonly seen in cirrhosis. The key to
webs) and secondary (eg, benign or malignant
below the baseline (Fig 22). As long as the a wave thrombosis) causes. this scale lies in observing
understanding
remains above the baseline, there is normal pha- Overall, hepatic the a wave relative to the
the position ofvein thrombosis is much less
sicity; once the a wave goes below the baseline, common than portal vein thrombosis. Malignant
baseline and peak negative S wave excur-
there is at least mildly decreased phasicity, which hepatic vein thrombosis (ie, tumor thrombus) is
has been observed in less than 10% of healthy
sion. As the distance between the a wave
usually the result of direct invasion from an adja-
patients (1). Once the peak of the a wave is at and peak negative excursion decreases, pha
cent parenchymal hepatocellular carcinoma; how-
least halfway between the baseline and the peak ever, anyis more severely decreased.
sicity other malignant vena cava thrombosis,
negative excursion of the waveform, there is at such as renal cell carcinoma, adrenal cortical car-
incich/grupo ct scanner least moderately decreased phasicity. This degree cinoma, or Departamento de Radiología/Unidad PET-CT
primary inferior vena cava (IVC) leio-
Thursday, May 31, 2012 of decreased phasicity is never normal. When the myosarcoma, may also cause Budd-Chiari syn-

Arteria hepática (AH) normal

• Abordaje: intercostal

• 20% flujo hepático

• Baja resistencia (flujo
diastólico anterógrado)

• IR: 0.5-0.7

• VPS: 30-60 cm/seg



Cómo se clasifica a la anatomía de la AH



Clasificación de Michels AH

AJR 2004;183:145


Arteria hepática: IR normal



Arteria hepática: IR alto



Arteria hepática: IR alto radiographics.rsna.org

Table 4

Pathologic (microvascular compression or disease)
Chronic hepatocellular disease (including cirrhosis)
Hepatic venous congestion
Acute congestion diffuse peripheral vasoconstriction
Chronic congestion ﬁbrosis with diffuse peripheral compression
(cardiac cirrhosis)
Transplant rejection (any stage)
Any other disease that causes diffuse compression or narrowing of
peripheral arterioles
Physiologic
Postprandial state
Advanced patient age



Diagnóstico????

373 cm/seg 362 cm/seg

168 cm/seg


Diagnóstico: ????

T12-L1



Inspiración Espiración



Arteria hepática



Arteria hepática
Advanced patient age

Proximal arterial narrowing
Transplant stenosis (anastomosis)
Atherosclerotic disease (celiac or hepatic)
Arcuate ligament syndrome (relatively less common than transplant
stenosis or atherosclerotic disease)
Distal (peripheral) vascular shunts (arteriovenous or arterioportal ﬁstulas)
Cirrhosis with portal hypertension
Posttraumatic or iatrogenic causes
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)



Arteria hepática... conclusiones

• IR alto = inespecífico

• IR bajo = más específico (cortocircuitos o
estenosis)



Vena porta

• 70-80% flujo hepático

• Ventanas
• Intercostal oblicua derecha
• Oblicua subxifoidea con angulación craneal

• Intrasegmentarias (excepto porción ascendente de
VPI, que es intersegmentaria)



Porta principal

• Unión de esplénica y
mesentérica sup

• Orden (post a ant)
• Porta-Colédoco-Arteria

• Diámetro 11 +/- 2 mm

• Visibles por colágena



Porta izq

• Más corta, craneal y
anterior

• Su unión con la porta
común indica la porta
hepatis

• “H” reclinada 4 3

• Subdivisión med/lat

2
1


Porta derecha

• Más larga, caudal y
posterior

• División ant/post

• 10% VPD inferior
8 5 accesoria

• “H” reclinada

7 6


Clasificación Nakamura

• Variantes anatómicas 10%
• Generalmente afectan a la VP derecha



Porta normal

• Abordaje: variable, en general
intercostal
LAMINAR: petal y ligeramente ondulante

• Flujo normal (petal)
• Hacia el transductor (rojo)
(excepto rama posterior der –
azul -)

• Variante: flujo helicoidal


Porta normal

• Abordaje: variable, en general
intercostal
LAMINAR: petal y ligeramente ondulante

• Flujo normal (petal)
• Hacia el transductor (rojo)
(excepto rama posterior der –
azul -)

• Variante: flujo helicoidal

15-40 cm/seg


Porta común



Variante normal: flujo HELICOIDAL
HELICOIDAL: petal/fugo (espiral)



Flujo helicoidal: causas

1. Normal: 2.2% población

2. Shunts portosistémicos patológicos (20% pacientes
hepatópatas con HP) o quirúrgicos

3. Invasión o desplazamiento tumoral

4. PO inmediato TOH: 43%
• Desproporción diámetros de
la anastomosis (>50%)

5. Post TIPS: 28%



Flujo helicoidal: causas

1. Normal: 2.2% población

2. Shunts portosistémicos patológicos (20% pacientes
hepatópatas con HP) o quirúrgicos

3. Invasión o desplazamiento tumoral

}
4. PO inmediato TOH: 43%
• Desproporción diámetros de
Transitorio. Si persiste,
la anastomosis (>50%)
descartar estenosis portal
(anastomosis/stent)
5. Post TIPS: 28%



Flujo portal normal: índice pulsatilidad



Flujo portal normal: índice pulsatilidad

La pulsatilidad depende de la transmisión del flujo venoso
de forma trans-sinusoidal, en particular de la contracción
auricular (onda a, contracción auricular, telediástole)



Análisis de la pulsatilidad portal: IP alta
180 January-February 2011

Spectral Doppler US image shows
tile waveform with flow reversal in the right por
The waveform may be systematically characte
predominantly antegrade, pulsatile, biphasic-b
tional, and di-inflectional.


Figure 24. Normal and abnormal portal FigureSpectralSlow portalimage shows a pulsa-
26. Doppler US venous flow. Spectra
incich/grupo ct scanner tile waveform with flow reversal in the right portal vein.
venous phasicity. Images show a spectrum pler US image shows slow flow in the main po
Thursday, May 31, 2012 The waveform may be systematically characterized as


NORMAL Spectral Doppler US image shows
tile waveform with ﬂow reversal in the right por


NORMAL



Anormal: IP Doppler US image shows
elevado
NORMAL Spectral
tile waveform with derreversal in the right por
= Falla ﬂow o IT


NORMAL Anormal: IP elevado
= Falla der o IT


blue on the color Doppler US image and is displayed
the
below the baseline on the porta: waveform. Hepa-
Análisis espectral spectral IP alta
tofugal ﬂow is due to severe portal hypertension from the
any cause. sati
scri
pre
Table 8
por
Causes of Pulsatile Portal Venous Waveform side
tran
Tricuspid regurgitation
arte
Right-sided CHF
ver
Cirrhosis with vascular arterioportal shunting
her
Hereditary hemorrhagic telangiectasia–arteriove- this
nous ﬁstulas I
am
red
usu
Findings That Are Diagnostic for Portal Hy- tion
pertension
by


Análisis de la pulsatilidad portal: IP normal
Spectral Doppler US image shows a pulsa-
tile waveform with flow reversal in the right portal vein.
The waveform may be systematically characterized as
predominantly antegrade, pulsatile, biphasic-bidirec-
tional, and di-inflectional.flow reversal in the right por
tile waveform with

Figure 24. Normal and abnormal portal Figure 26. Slow portal venous flow. Spectral Dop-
venous phasicity. Images show a spectrum pler US image shows slow flow in the main portal vein.
of increasing pulsatility (bottom to top). Slow portal venous flow is a consequence of portal hy-
Note that increasing pulsatility corresponds pertension. In this case, the peak velocity is 9.0 cm/sec,
to a decrease in the calculated PI. Although which is well below the lower limit of normal (16–40
normal phasicity ranges widely in the portal cm/sec). Although portal hypertension may cause a
pulsatile-appearing waveform as venousthis case, the
Figure 26. Slow portal seen in flow. Spectra
Figure 24. PI should and abnormal 0.5
veins, the Normal be greater than portal
incich/grupo ct scanner and bottom). When the PI is less
(middle slow flow helps differentiate this condition from hyper-
venous phasicity.the waveform may spectrum
Images show a be called pler US image shows such as CHF and tricuspidpo
pulsatile high-velocity states
slow flow in the main
Thursday, May 31, (top),
than 0.5 2012

NORMAL predominantly antegrade, pulsatile, biphasic-bidirec-
tile waveform with

NORMAL

than 0.5 2012

NORMAL predominantly antegrade, pulsatile, biphasic-bidirec-
tile waveform with
Anormal:
IP normal PERO baja velocidad
= hipertensión portal

NORMAL

than 0.5 2012

Análisis de la pulsatilidad portal: no flujo

182 tile waveform with2011 reversal in the right por
January-February flow

Figure 28. Portal vein thrombosis (acute bland
thrombus). On a spectral Doppler US image, the
interrogation zone shows no color flow in the main
portal vein. The spectral waveform is aphasic, which
indicates absence of flow. An aphasic waveform may
be produced by either obstructive or nonobstructive
Figure 24. Normal and abnormal portal disease.
Figure 26. Slow portal venous flow. Spectra



NORMAL



Anormal:
flujo lento/trombosis

NORMAL


1. Técnica

2. Anatomía

3. PATOLOGÍA


Trombosis e hipertensión portal (HP)

• Presión >30 mm de Hg
(gradiente >10)

• Causas:  del flujo o de
resistencia

US, TC y RM dan información sobre permeabilidad vascular y
colaterales; PERO sólo el US Doppler aporta información sobre la
dinámica del flujo



HP: circulación colateral y derivaciones

1. Derivaciones quirúrgicas
1. Portocava, mesocava, espleno/gastrorrenal y TIPS

2. Colaterales
a. Tributarias
• Coronaria (plano longitudinal, cefálica a VMS)
• Gástricas cortas (borde inferior LHI)
• VMS y VMI
b. Desarrolladas (derivaciones espontáneas)
• Vena paraumbilical
• Esplenorrenal
• Esplenorretroperitoneal



Permeabilidad vena paraumbilical
• Colateral portosistémica (caput medusae)
• Porta izquierda  v.paraumbilical  v.pared abdominal

Importancia de su dx: 1. podría prevenir la aparición
de VE, PERO 2. riesgo EH


Cortesía: Dr. Yukiyosi Kimura


Cortesía: Dr. Yukiyosi Kimura

Signo de HP grave
(gradiente 15-28 mm
Hg)


Flujo hepatofugo

• Definición: Flujo que se ALEJA del hígado

Importante en:
1. Diagnóstico HP
2. Conocer permeabilidad de
shunt portosistémico
3. Px hepatópatas
4. Seleccionar pacientes NO
candidatos a
• Quimioembolización
intraarterial
• Portografía arterial por
TC


Flujo hepatofugo

• Definición: Flujo que se ALEJA del hígado

Importante en:
1. Diagnóstico HP
2. Conocer permeabilidad de
shunt portosistémico
3. Px hepatópatas
4. Seleccionar pacientes NO
candidatos a
• Quimioembolización
intraarterial
SIEMPRE demostrar en la misma
• Portografía arterial por imagen el flujo petal de la arteria
TC con el fugo portal


Flujo hepatofugo: fisiopatología

• Formación de FÍSTULAS ARTERIOPORTALES
(FAP) por:
1. HP (causa y consecuencia
de FAP)
2. Trauma o iatrogenia (bx o
colangiografía PC)
3. Tumores (ej. hepatoCA)
4. Ruptura aneurisma AH
5. Congénitas



Flujo hepatofugo en cirróticos

• Incidencia: 1-23%

• Causa
• “Aparición” de FAP normalmente presentes* por 
presión intrahepática ( presión intraarterial y
portal)

* Arteriosinusoidales, arteriovasales (vasa vasorum de
las paredes portales) y plexos peribiliares



Flujo hepatofugo en HP

• Localización
• Intrahepática, por
1. FAP grandes (ejemplo: postbx, etc)
2. Cirrosis (FAP “microscópicas”, no visibles por US)
3. Obstrucción venosa
4. TIPS o permeabilidad vena paraumbilical

• Extrahepática (porta, VMS o esplénica), por
1. Obstrucción portal (trombo sanguíneo o neoplásico,
compresión extrínseca)
2. = intrahepáticas (pero más avanzadas)

Obstrucción: presión portal  flujo a zona de < presión (shunts)



Flujo fugo extrahepático: shunts qx o espontáneos

Derivación esplenorrenal: flujo fugo esplénico y petal

zq
v. renal i



Flujo fugo intrahepático: shunts en tumores

1. Erosión de arteria y vena por
el tumor, o

2. Compresión extrínseca de
vena hepática (tumor o
hematoma SC)

Obstrucción del flujo venoso
( presión intrahepática)

Comunicación arterioportal



Circunstancias particulares del flujo fugo

• En los TIPS y en la permeabilidad vena paraumbilical
(PVPU), el shunt arterioportal genera flujo
1. Petal en porta principal, y
2. Fugo intrahepático (29% pac con PVPU)

Permeabilidad vena
paraumbilical

RAMA
PORTAL
SEGM 4



Conclusiones del flujo fugo

1. En pacientes SIN shunts o TIPS, es un signo de
HP grave y de mal pronóstico

2. Puede ser intra y/o extrahepático

3. Su presencia
• Habla de permeabilidad de shunts quirúrgicos y TIPS
• Contraindica la quimioembolización intrarterial



2.  diámetro (>15 mm), 3.  +  velocidad VP, ascitis,
vel normal, flujo petal en “barra” no  bazo
oscilante

1. VP normal

5.  + flujo fuga (1%)

4.  +  diámetro y vel AH, colaterales, flujo helicoidal
o To-and-fro


TIPS
• Siglas de Transjugular
Intrahepatic Portocaval
Shunt, dígase…

“Derivación transyugular
portocava intrahepática”

• Indicaciones (HP)
• Prevención secundaria
de HTDA
• Ascitis refractaria

• Permeabilidad a 1 año:
23-66%



TIPS

1. Pre TIPS
• Tamaño del hígado
• Permeabilidad/orientación de
VSH, VP, VMS y VE
• Bifurcación portal intra o
extrahepática

2. Post TIPS ¿Qué es NORMAL (post-TIPS)?
• Objetivo: evaluar eficacia y 1. Flujo intrashunt pulsátil
permeabilidad 2. Velocidad intrashunt
• 24h, y 1, 3 y 6 meses • Al menos: 50-60 cm/s
• Doppler: dirección y • Ideal: 90-120 cm/s
permeabilidad del stent 3. Velocidad similar al principio y al
final del stent
4. Flujo portal/esplénico petal
5. Velocidad pre stent VP
• Ideal: 37-47 cm/s

¿Qué es ANORMAL?
 Ausencia de flujo intra stent
 Estenosis:  ó  vel intra
stent (>190 o < 90 cm/seg)
 Flujo no pulsatil (intra stent)
o turbulento
(postestenosis)
  velocidad de un punto a
otro del stent > 100 cm/s
  vel VP (con previo) ó
<30 cm/s
 Flujo portal/esplénico fugo

Cortesía: Dr. Antonio Sosa/Dr. Yukiyosi Kimura



TIPS malfunction (hepatic vein stenosis).
Spectral Doppler US image shows high-velocity ﬂow


).

-
in
TIPS malfunction (hepatic vein stenosis).
Spectral Doppler US image shows high-velocity ﬂow
TIPS malfunction (cephalic stenosis). In a

Conclusiones

1. El adecuado conocimiento y por ende manejo de
parámetros técnicos es indispensable para la
obtención de imágenes de calidad diagnóstica

2. El US Doppler es un método no invasivo, de bajo
costo y gran disponibilidad, útil en la evaluación de
múltiples patologías vasculares hepáticas

3. Es un método operador-dependiente



Bibliografía

1.-Chen W, et al. Doppler ultrasonographic findings on hepatic arterial vasospasm early after liver
transplantation. J Ultrasound Med 2006;25:631-638
2.-Portal Vein Stenosis and occlusion stenting after liver transplantation. Acta Radiol
2006;47:130-134
3.-Karakayali H, et al. Venous complications after orthotopic liver transplantation. Transplant Proc
2006;38:604-606
4.-Ozochukwu LN, et al. Early postoperative hepatic sonography as a predictor of vascular and
biliary complications in adult orthotopic liver transplant patients. Am J Roentgenol
2005;185:1558-1570
5.-Kaneko T, et al. Intrahepatic venous anastomosis formation of the right liver in living donnor liver
transplantation: evaluations by Doppler ultrasonography. Surgery 2005;138:21-27
6.-Kim HJ, et al. Hepatic artery pseudoaneurysms in adult living-donor liver transplantation: efficacy
of CT and Doppler sonography. Am J Roentgenol 2005;184:1549-1555
7.-Bolognesi M, et al. Acute liver rejection: accuracy and predictive values of Doppler US
measurements. Radiology 2005;235:651-658
8.-Kyoden Y, et al. Hepatofugal portal flow due to acute cellular rejection. Abdom Imag
2005;30:303-305
9.-Kruskal JB, et al. Optimizing Doppler and color flow US: application to hepatic sonography.
RadioGraphics 2004;24:657-675
10.-McNamara MM, Emergency Doppler evaluation of the liver and kidneys. Radiol Clin North Am
2004;42:397-415



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