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Sonocan Vasc Review > Liver Vasculature > Flashcards

Liver Vasculature Flashcards

1
Q

What is the learning outcome for assessing liver vasculature?

A

Sonographically assess the vasculature of native and transplant livers.

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2
Q

What are the objectives for assessing liver vasculature?

A
  1. Identify normal and variant vascular anatomy of the liver and IVC.
  2. Describe potential collateral pathways of the pathologic liver.
  3. Identify pathologies affecting blood flow in the portal system.
  4. Describe a protocol to assess liver and IVC vasculature using duplex Doppler.
  5. Produce duplex Doppler images of liver vasculature.
  6. Analyze flow characteristics of liver vasculature.
  7. Correlate sonographic findings with other diagnostic tests.
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3
Q

What vessels are evaluated for blood flow to and from the liver?

A

Hepatic veins, portal veins, hepatic artery, IVC, and collaterals.

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4
Q

What is the typical number of major hepatic veins?

A

Typically, there are three major hepatic veins: right, middle, and left.

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5
Q

What is the flow pattern of hepatic veins as seen in Doppler? 2

A

Hepatic veins demonstrate
1. Multiphasic flow
2. Primarily retrograde to the transducer, termed hepatofugal.

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6
Q

What is the role of portal veins? How much of the blood to the liver does it account for?

A

Portal veins drain nutrient-rich blood from the bowel and spleen to the liver, accounting for 75% of blood to the liver.

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7
Q

What is the normal flow direction in portal veins?

A

Normal flow is towards the liver, or hepatopedal.

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8
Q

What is the velocity range for the main portal vein (MPV)?

A

The MPV velocity can range from 16-40 cm/s.

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9
Q

What supplies the liver with the remaining blood flow?

A

The hepatic artery supplies the liver with the remaining 25% of blood flow.

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10
Q

What is the typical resistive index range for the hepatic artery?

A

The resistive index of the hepatic artery is typically in the range of 0.5-0.7.

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11
Q

What is considered a dilated IVC?

A

The IVC is considered dilated if the diameter exceeds 2.5 cm.

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12
Q

What is portal hypertension?

A

Portal hypertension is an elevation of pressure in the portal venous system, impeding blood flow through the liver.

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13
Q

What are common causes of portal hypertension? 3

A
  1. Cirrhosis of the liver
  2. Hepatitis C
  3. Alcoholism.
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14
Q

What are the categories of portal hypertension? 3

A
  1. Pre-hepatic
  2. Intrahepatic (Most Common)
  3. Post-hepatic
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15
Q

What is portal vein thrombosis?

A

A condition where the main portal vein is obstructed, often requiring Doppler evaluation.

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16
Q

What are the most common causes of intrahepatic obstruction? 5

A
  1. Cirrhosis
  2. Hepatitis
  3. Fatty infiltration
  4. Inflammation.
  5. Fibrosis
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17
Q

What can cause post-hepatic obstruction? 4

A
  1. Congestive heart failure (CHF)
  2. Tricuspid regurgitation
  3. Budd Chiari
  4. Thrombosis of the hepatic veins or IVC.
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18
Q

What is the role of ultrasound in the liver duplex exam?

A

To determine flow direction in vessels and assess waveforms for normalcy.

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19
Q

What are common collateral routes in portal hypertension? 3

A
  1. Portocaval
  2. Mesocaval
  3. Splenorenal.
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20
Q

What is the most common collateral route?

A

The coronary vein (left gastric vein) takes blood from the portal vein to the gastroesophageal.

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21
Q

What are the common collateral routes for blood flow in portal hypertension? 3

A

The most common collateral routes are:
- Portocaval
- Mesocaval
- Splenorenal

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22
Q

What is the coronary vein’s role in portal hypertension? What is the route? Reversed flow is seen how often?

A
  1. The coronary vein is the most common collateral route
  2. Taking blood from the portal vein to the gastroesophageal collaterals.
  3. Reversed flow is seen in 80-90% of PHT cases.
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23
Q

Where is the coronary vein located? What path does it take does it take?

A
  1. It is located posterior to the common hepatic artery or splenic artery
  2. Follows an oblique path, travelling superior to the left of the Porto-splenic confluence.
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24
Q

What can the presence of the coronary vein lead to? What does this imply?

A

It can progress to esophageal varices, which implies an increased risk for variceal hemorrhage.

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25
Q

What is the umbilical vein’s significance in portal hypertension?

A

The umbilical vein can recanalize, demonstrating hepatofugal flow from the tip of the LPV to the umbilicus, with varices potentially seen at the umbilicus.

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26
Q

What does the splenorenal collateral route do?

A

The splenorenal collateral can shunt blood from the splenic hilum to the left renal vein, potentially leading to varices near the splenic hilum.

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27
Q

What are surgical shunts used for in portal hypertension?

A

Surgical shunts are required to decompress the portal system in severe cases, effective for reducing ascites, preventing hemorrhage from gastroesophageal varices, and improving quality of life.

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28
Q

What is TIPS?

A

TIPS stands for Trans-jugular Intrahepatic Portosystemic Shunt, a metallic expandable stent installed percutaneously to connect the IJV to a PV branch.

29
Q

What are the common complications of the TIPS procedure? (Early +late) 2

A
  1. Early complications include stenosis or thrombosis
  2. Late complications may involve neointimal hyperplasia invading the stent.
30
Q

What is the normal velocity range for TIPS? 2 (normal and preshunt)

A
  1. In a normal TIPS, the velocity range is 90-190 cm/s
  2. with pre-shunt PV PSV at least 30 cm/s.
31
Q

What is a potential complication of TIPS? What is it characterized by?

A
  1. Hepatic Encephalopathy can develop post-procedure
  2. Characterized by
    - confusion
    - disorientation
    - alterations in quality of life due to bypassing the liver.
32
Q

What is the role of duplex ultrasound in liver transplant assessment?

A

Duplex ultrasound is used for pre and post-operative assessment, detecting vessel patency, tumors, and biliary tree status.

33
Q

What complications are assessed post-liver transplant? 4

A

Post-operative complications include:
1. Rejection
2. Pseudo aneurysm
3. Hepatic infarction
4. Thrombosis of major liver vessels.

34
Q

What ishould the hepatic artery demonstrate spectrally in post-transplant ultrasound?

A

The hepatic artery should demonstrate a sharp upstroke and a resistive index of 0.5 - 0.8, with an acceleration time of less than 0.08 seconds.

35
Q

What is the learning outcome for assessing liver vasculature?

A

Sonographically assess the vasculature of native and transplant livers.

36
Q

What are the objectives for assessing liver vasculature?

A
  1. Identify normal and variant vascular anatomy of the liver and IVC.
  2. Describe potential collateral pathways of the pathologic liver.
  3. Identify pathologies affecting blood flow in the portal system.
  4. Describe a protocol to assess liver and IVC vasculature using duplex Doppler.
  5. Produce duplex Doppler images of liver vasculature.
  6. Analyze flow characteristics of liver vasculature.
  7. Correlate sonographic findings with other diagnostic tests.
37
Q

What vessels are evaluated for blood flow to and from the liver?

A

Hepatic veins, portal veins, hepatic artery, IVC, and collaterals.

38
Q

What is the typical number of major hepatic veins?

A

Typically, there are three major hepatic veins: right, middle, and left.

39
Q

What is the flow pattern of hepatic veins as seen in Doppler?

A

Hepatic veins demonstrate multiphasic flow, primarily retrograde to the transducer, termed hepatofugal.

40
Q

What is the role of portal veins?

A

Portal veins drain nutrient-rich blood from the bowel and spleen to the liver, accounting for 75% of blood to the liver.

41
Q

What is the normal flow direction in portal veins?

A

Normal flow is towards the liver, or hepatopedal.

42
Q

What is the velocity range for the main portal vein (MPV)?

A

The MPV velocity can range from 16-40 cm/s.

43
Q

What supplies the liver with the remaining blood flow?

A

The hepatic artery supplies the liver with the remaining 25% of blood flow.

44
Q

What is the typical resistive index range for the hepatic artery?

A

The resistive index of the hepatic artery is typically in the range of 0.5-0.7.

45
Q

What is considered a dilated IVC?

A

The IVC is considered dilated if the diameter exceeds 2.5 cm.

46
Q

What is portal hypertension?

A

Portal hypertension is an elevation of pressure in the portal venous system, impeding blood flow through the liver.

47
Q

What are common causes of portal hypertension?

A

Cirrhosis of the liver, hepatitis C, and alcoholism.

48
Q

What are the categories of portal hypertension?

A
  1. Pre-hepatic
  2. Intrahepatic (Most Common)
  3. Post-hepatic
49
Q

What is portal vein thrombosis?

A

A condition where the main portal vein is obstructed, often requiring Doppler evaluation.

50
Q

What are the most common causes of intrahepatic obstruction?

A

Cirrhosis, hepatitis, fibrosis, fatty infiltration, and inflammation.

51
Q

What can cause post-hepatic obstruction?

A

Congestive heart failure (CHF), tricuspid regurgitation, Budd Chiari, and thrombosis of the hepatic veins or IVC.

52
Q

What is the role of ultrasound in the liver duplex exam?

A

To determine flow direction in vessels and assess waveforms for normalcy.

53
Q

What are common collateral routes in portal hypertension?

A

Portocaval, mesocaval, and splenorenal.

54
Q

What is the most common collateral route?

A

The coronary vein (left gastric vein) takes blood from the portal vein to the gastroesophageal.

55
Q

What are the common collateral routes for blood flow in portal hypertension?

A

The most common collateral routes are:
- Portocaval
- Mesocaval
- Splenorenal

56
Q

What is the coronary vein’s role in portal hypertension?

A

The coronary vein is the most common collateral route, taking blood from the portal vein to the gastroesophageal collaterals. Reversed flow is seen in 80-90% of PHT cases.

57
Q

Where is the coronary vein located?

A

It is located posterior to the common hepatic artery or splenic artery and follows an oblique path, travelling superior to the left of the Porto-splenic confluence.

58
Q

What can the presence of the coronary vein lead to?

A

It can progress to esophageal varices, which implies an increased risk for variceal hemorrhage.

59
Q

What is the umbilical vein’s significance in portal hypertension?

A

The umbilical vein can recanalize, demonstrating hepatofugal flow from the tip of the LPV to the umbilicus, with varices potentially seen at the umbilicus.

60
Q

What does the splenorenal collateral route do?

A

The splenorenal collateral can shunt blood from the splenic hilum to the left renal vein, potentially leading to varices near the splenic hilum.

61
Q

What are surgical shunts used for in portal hypertension?

A

Surgical shunts are required to decompress the portal system in severe cases, effective for reducing ascites, preventing hemorrhage from gastroesophageal varices, and improving quality of life.

62
Q

What is TIPS?

A

TIPS stands for Trans-jugular Intrahepatic Portosystemic Shunt, a metallic expandable stent installed percutaneously to connect the IJV to a PV branch.

63
Q

What are the common complications of the TIPS procedure?

A

Early complications include stenosis or thrombosis, while late complications may involve neointimal hyperplasia invading the stent.

64
Q

What is the normal velocity range for TIPS?

A

In a normal TIPS, the velocity range is 90-190 cm/s, with pre-shunt PV PSV at least 30 cm/s.

65
Q

What is a potential complication of TIPS?

A

Hepatic Encephalopathy can develop post-procedure, characterized by confusion, disorientation, and alterations in quality of life due to bypassing the liver.

66
Q

What is the role of duplex ultrasound in liver transplant assessment?

A

Duplex ultrasound is used for pre and post-operative assessment, detecting vessel patency, tumors, and biliary tree status.

67
Q

What complications are assessed post-liver transplant?

A

Post-operative complications include rejection, pseudo aneurysm, hepatic infarction, and thrombosis of major liver vessels.

68
Q

What is the importance of the hepatic artery in post-transplant ultrasound?

A

The hepatic artery should demonstrate a sharp upstroke and a resistive index of 0.5 - 0.8, with an acceleration time of less than 0.08 seconds.

Sonocan Vasc Review (7 decks)

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