Chapter 24: The Mesenteric Arteries Flashcards
relating to additional blood vessels that aid or add to circulation
collateral vessels
occurring after a meal
postprandial
relating to or affecting the viscera
splanchnic
relating to internal organs or blood vessels in the abdominal cavity
visceral
four most common celiac and mesenteric variances
replaced right hepatic originating from the SMA
replaced common hepatic originating for SMA
common hepatic originating from the aorta
common origin of the celiac and SMA celiacomesenteric
relative incidence of visceral artery splenic aneurysm
60
relative incidence of visceral artery hepatic aneurysm
20
high-velocity flow with aliasing
color bruit
high-velocity flow with postenotic turbulence
stenosis >50%
no coloring filling at origin of celiac artery
retrograde hepatic artery flow
absent Doppler flow signal at the origin
retrograde Doppler flow in the hepatic artery
celiac artery occlusion
increase in color velocity in celiac artery with exhalation
increase in velocity with exhalation and decrease with inhalation celiac artery
celiac artery compression syndrome
no color filling at the orgin of superior mesenteric artery occlusion, reconstitutes distally, absent Doppler flow signal in proximal artery
superior mesenteric artery occlusion
focal dilation with mixed color filling observed in dilated region; disturbed flow usually present in dilated regions
aneurysm
color separation with separate flow channels of antegrade and retrograde flow; disturbed or stenotic signals may be present, sometimes with separate flow channels of antegrade and retrograde flow
dissection
The mesenteric duplex ultrasound examination includes examination of the:
celiac artery
superior mesenteric artery
inferior mesenteric artery
CMI
chronic mesenteric ischemia
occurs more frequently in women
typical age range 40-70 years
active smokes or history of tobacco use
CMI
most common indication for assessment of CMI
postprandial abdominal pain; weight loss
occurs when there is insufficient visceral blood flow to support increased oxygen demand required by intestinal motility, secretion, and absorption; epigastric or periumbilical pain
intestinal angina
younger; more likely to be female; months or years of diffuse upper abdominal pain; almost all very thin
median arcuate ligament syndrome
MALS
median arcuate ligament syndrome
first abdominal branch artery arising from abdominal aorta
celiac artery
The celiac artery originates from the _____
anterior aspect of the aorta
The celiac artery is only __ - __ cm long
2-4
The celiac artery branches into the _____ and ______
common hepatic
splenic
typically originates from anterior surface of aorta 1-2 cm below celiac artery
superior mesenteric artery
arises from distal aorta just proximal to the bifurcation
inferior mesenteric artery
The ____ and _____ pancreaticoduodenal arteries bridge the celiac artery and SMA
superior
inferior
meandering mesenteric artery; provides communication between IMA and SMA
Arc of Riolan
most common anomaly; originates from SMA; should be suspected when a low-resistance flow pattern is found in otherwise normal appearing proximal SMA
replaced right hepatic artery
Patient prep
fast for at least 6 hours
The fasting patients SMA Doppler waveform
low flow, high resistance
The postprandial patients SMA Doppler waveform
high flow low resistance pattern
What is the seagull sign>
The celiac bifurcation
The wings of the seagul
common hepatic artery coursing toward the liver
splenic artery coursing toward the spleen
Normal celiac artery Doppler waveform
sharp systolic upstroke
low-resistance flow pattern characterized by forward flow throughout cardiac cycle
Normal hepatic and splenic Doppler waveforms
low-resistance signals with flow throughout the cardiac cycle
The SMA fasting Doppler waveform is _____
multiphasic
found 1-3 cm proximal from aortic bifurcation; originates from anterior aorta slightly to left of midline; high-resistance waveform
inferior mesenteric artery
In the postprandial patient the PSV nearly _____ and the EDV nearly _____
doubles
triples
mid graft mean PSV
140-200 cm/s
Stenosis if PSV is greater than ___ cm/s or less than ___ cm/s in mid graft
300
50
______ demonstrates focal velocity increases with poststenotic turbulence, while _______ does not
stenosis
compensatory flow
Preferred screening test for CMI
duplex ultrasound
Preferred definitive imaging test for CMI
CTA
Primary target for revascularization in CMI
SMA
Suggested surveillance techniques post revascularization
scan within 1st month
every 6 months for first two years
annually
transient compression of celiac artery by median arcuate ligament of diaphragm during exhalation; relieved or lessened by descent of diaphragm with inhalation
median arcuate ligament syndrome
PSV of celiac artery is ______ during exhalation and ______ during inhalation
increased
decreased
The proximal celiac artery has a _____ appearance
hooked
most common aneurysm occuring in 60% of cases
splenic artery
causes of dissection
trauma
connective tissue disorders
vasculitis
iatrogenic events
Dissections occur most frequently in the ____
SMA
can result from embolus to mesenteric arteries or thrombosis or an artery with existing chronic disease; 2/3 of patients women with median age being 70
acute mesenteric ischemia
What is the first major branch arising from the abdominal aorta?
celiac artery
What is the most common indication for mesenteric artery duplex evaluation?
chronic mesenteric ischemiao
How many mesenteric arteries are typically involved in atherosclerotic occlusive disease before a patient becomes symptomatic?
two
When does the abdominal pain that many patients feel, which is associated with chronic mesenteric ischemia, typically occur?
after eating
Because of the abdominal pain, which of the following do patients oftern experience?
a. overeating and weight gain
b. fear of exercise
c. nausea and vomiting
d. fear of food and weight loss
d
Which of the following is a collateral system that is present in the mesenteric vascular system?
a. pancreaticoduodenal arcade
b. arc of Riolan
c. internal iliac to inferior mesenteric artery
d. all of the above
d
From which vessel does a replaced right hepatic artery originate most often?
superior mesenteric artery
With a patient in a fasting state, what should the superior mesenteric artery exhibit?
high resistance flow pattern
Standard criteria for determining velocity thesholds in order to identify stenosis in the celiac and superior mesenteric arteries were performed with the patient in which state?
fasting
Which of the following vessels does the term “seagull sign” describe?
a. SMA and its major branches
b. IMA and its major branches
c. celiac, hepatic, and splenic arteries
d. left and right renal arteries
c
What should Doppler waveforms obtained from the celiac, splenic, and hepatic arteries demonstrate?
low resistance flow
During a mesenteric artery evaluation, retrograde flow is noted in the common hepatic artery. What does this finding suggest?
celiac artery occlusion
Which technique can NOT be used to positively identify and differentiate the celiac and superior mesenteric vessels?
a. Having the patient suspend breathing to reduce vessel movement
b. visualizing both the celiac and superior mesenteric arteries in the same image
c. visualizing aliasing with color flow in the superior mesenteric artery
d. documenting characteristic low resistance flow in the celiac artery
d
What can turning off color flow imaging help identify?
a. arterial dissection
b. characterization of atherosclerotic plaque
c. stent placement within the vessel
d. all of the above
d
During duplex evaluation of the mesenteric vessels, the SMA is noted to have velocities of 350 cm/s proximally with velocities close to 300 cm/s in the midsegment. No spectral broadening or turbulence is noted. What are these findings consistent with?
compensatory flow through the SMA likely caused by occlusion of the celiac artery
Which of the following describes the velocity criteria for diagnosis of more than 70% in the celiac and superior mesenteric arteries?
a. greater than 275 cm/s PSV in the celiac artery and greater than 200 cm/s PSV in the superior mesenteric artery
b. greater than 325 cm/s PSV in both the celiac and superior mesenteric arteries
c. greater than 200 cm/s PSV in the celiac artery and greater than 275 cm/s PSV in the superior mesenteric artery
d. greater than 50 cm/s EDV in the celiac artery and greater than 55 cm/s EDV in the superior mesenteric artery
c
Why may standard duplex ultrasound velocity criteria for mesenteric vessels NOT be accurate after treament by stent placement?
velocities in treated vessels are typically higher than standard criteria
What is transient compression of the celiac artery origin during exhalation, which is relieved by inhalation?
median arcuate ligament compression syndrome
Visceral artery aneurysms are rare; however, the greatest incidence of aneurysms occurs in which of the following vessels?
a. splenic artery
b. common hepatic artery
c. celiac artery
d. superior mesenteric artery
a
What is the general role of the vascular laboratory in the diagnosis of acute mesenteric ischemia?
no role due to the emergent nature of the illness
The celiac artery is best visualized with the transducer oriented in a ______ plane, whereas the superior mesenteric artery is best visualized with the transducer oriented in a _____ plane.
transverse
sagittal
The diagnosis of chronic mesenteric ischemia is often _____ because the disorder is rare and the symptoms may be due to a vast number of abdominal disorders
delayed
Postprandial abdominal pain that occurs when there is insufficient visceral blood flow to support the increased oxygen demand required by intestinal motility, secretion, and absorption is often termed _____.
chronic mesenteric ischemia
The inferior mesenteric artery arises from the aorta just proximal to the _____.
bifurcation
A replaced right hepatic artery originating from the superior mesenteric artery should be suspected when the SMA demonstrates a ______ flow pattern.
low resistance
It is critically important for the patient to fast for at least 6 hours before mesenteric artery evaluation because the superior mesenteric artery changes dramatically from _____ resistance to _____ resistance after eating.
high
low
When performing spectral Doppler and high velocities are noted in a mesenteric artery, it is important to document _______ to confirm a flow-limiting stenosis
post stenotic turbulence
A technique that can be used to decrease movement of mesenteric vessels and help capture Doppler waveforms with a correct angle is to have the patient ______.
suspend breathing
In the presence of celiac artery occlusion, the common hepatic artery almost always demonstrates _____ flow.
retrograde
An important technique to use when evaluating the mesenteric vessels that can help detect vessel wall abnormalities or vessel tortuousity is to inspect the image with _____ imaging only.
grayscale
In preparation for a duplex scan after mesenteric revascularization, the _____ note will detail the location of the proximal and distal anastamoses and type of graft or other intervention.
surgical/operative
When following up on a mesenteric bypass graft, if the PSV is greater than 300 or less than 50 cm/s. It is recommended to _____ the time between surveillance scans.
decrease
If abdominal gas is obscuring visualization, moving the patient to a _______ position may provide an adequate window through the liver.
lateral decubitus
Increased velocities in the absence of stenosis could be the result of _______ flow.
compensatory
According to one study, when end-diastolic velocities are used as thresholds for more than 50% stenosis, the corresponding velocities are ____ cm/s in the celiac artery and ___ cm/s in the superior mesenteric artery.
55
45
Recent studies suggest velocity guidelines for IMA stenosis, with a PSV of _______ corresponding to a more than 50% stenosis.
> 200 or >250 cm/s
Percutaneous visceral artery intervention has lower morbidity/mortality rates than traditional surgical repair; however, it is associated with higher _____ rates and the requirement for reintervention.
restenosis
Velocity thresholds for in-stent restenosis in the celiac and superior mesenteric arteries, in general, are _____ than those reported for native arteries.
higher
An advantage of using duplex ultrasound to evaluate median arcuate ligament compression syndrome is that Doppler waveforms can be obtained during changes in _____.
respiration
splenic artery aneurysm, when discovered during pregnancy, is associated with a 95% ____ rate, leading to high maternal and fetal mortality.
rupture
Visceral artery dissections are most common in the _____ and are often the extensions of aortic dissection.
SMA
In patients with suspected MALS, if velocities fail to normalize with inspiration, the patient can be put in a ______ position.
standing
In a patient with MALS, the image of the proximal celiac artery typically demonstrates a characteristic _____ appearance.
hooked
Embolus to or thrombosis of the mesenteric arteries can lead to _______.
acute mesenteric ischemia
Symptoms associated with the abovementioned pathology are typically described as pain ______ to physical findings.
out of proportion
