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Vascular > Module 6 : Liver Vasculature > Flashcards

Module 6 : Liver Vasculature Flashcards

1
Q

hepatic artery

A
  • primary blood supplier (30%)
  • tortuous
  • low resistance
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2
Q

proximal HA

A
  • best seen in transverse
  • at celiac axis
    + is celiac axis occluded then HA can still get flow from collaterals
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3
Q

distal HA

A
  • viewed intercostally
  • ## at level of main portal vein
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4
Q

spectral tracing of normal HA

A
  • low resistance
  • fill in of spectral window due to small artery diameter
  • variable viscosities due to tortuosity
  • RI 0.5-0.7
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5
Q

resistive index RI

A
  • EDV/PSV
  • EDV decreases = more resistive
  • stronger indicator of stenosis then velocity
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6
Q

inferior vena cava IVC

A
  • formed by union of the common iliac veins
  • anterior to the spine and to the right of the aorta
  • intercostal scans are best to visualize
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7
Q

IVC spectral waveform

A
  • spontaneous waveform (no provocative maneuver)
  • Proximal = more pulsatile closer to heart
  • distally = phasic (further from heart)
  • respiratory changes
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8
Q

IVC size

A
  • changes with size of patient
  • respiration
  • right atrial pressure CHF
  • > 3.7 dilated
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9
Q

hepatic veins

A
  • three major veins
  • accessory veins are common (more on right)
  • drain into IVC
  • hepatic veins enlarge as they approach the IVC
  • intersegmental
  • commonly left and middle come together first
  • with agenisis RHV usually absent followed by middle then left
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10
Q

right hepatic vein RHV

A
  • runs coronally between anterior and posterior segments of the right lobe
  • largest
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11
Q

middle hepatic vein MHV

A
  • lies between right and left lobes

- medial left lobe

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12
Q

left hepatic vein LHV

A
  • runs between the medial and lateral segment of the left lobe
  • commonly duplicated
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13
Q

caudate lobe

A
  • has its own drainage directly into IVC
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14
Q

spectral trace hepatic veins

A
  • multiphasic
  • pulsatile flow
  • flow away from transducer
  • if not showing this flow there may be an obstruction
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15
Q

walls of hepatic veins

A
  • less defined then PV

- no echogenic sheath

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16
Q

patency and distension hepatic veins

A
  • indications of Budd Chiari or CHF
  • BC = narrowed or absent
  • CHF = not phasic or pulsatile
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17
Q

hv scanning window for confluence

A
  • trans subxiphoid

- lots of color close to heart

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18
Q

hv scanning window RHV

A
  • right intercostal
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19
Q

hv scanning window MHV

A
  • midline subxiphoid

- intercostal

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20
Q

hv scanning window LHV

A
  • anterior subcostal

- angle heel toward left

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21
Q

portal veins

A
  • drains nutrient rich blood from bowel and spleen to the liver (70%)
  • formed by confluence of the splenic vein and SMV
    + IMV and coronary veins contribute
  • enters liver at porta hepatic
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22
Q

portal veins spectral trace

A 
- low velocity 
   \+ range = 15-40 cm/sec
   \+ mean = 15-18 cm/sec
- continuous signal
- subtle phasic variations (undulations)
- windstorm sound
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23
Q

portal veins flow

A
  • hepatopedal (toward flow)
  • increases post prandially
    + vessels dilate near bowel when you eat which increases flow
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24
Q

scanning window MPV

A
  • anterior subcostal
  • intercostal
  • always over ivc
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25
scanning window RPV
- intercostal | - coronal
26
scanning window LPV
- subxipoid | - intercostal
27
liver duplex exam - assessing
- flow direction - normal waveform - patency
28
liver duplex exam - routine vessels
- hepatic veins - portal vein - splenic vein - hepatic artery - collaterals
29
dopper assessment liver duplex
- assess flow quality | - only assessed during quiet respiration
30
patient positon
- supine
31
anterior window
``` - assess + LPV + LHV + SV + MPV ```
32
coronal intercostal
``` - assess + RHV + MHV + RPV and MPV + HA ```
33
color and spectral doppler of liver
- done in every picture - flow direction - quality of flow NOT QUANTITY - patency
34
hepatic veins assess
- hepatofugal (away from liver) flow | - multiphase waveform
35
portal veins assess
- hepatopedal | - subtle phasicity
36
MPV - protocal
``` - 2D (anterior subcostal) + measure AP + anterior to IVC + with quiet respiration + normal measurement less than 13mm - color and spectral trace (coronal intercostal) + sample MPV outside of liver + coronal intercostal = zero angle + anterior subcostal = 60 angle + measure peak velocity with generic calliper ```
37
normal range of peak velocity of MPV
- 15-40 cm/sec
38
splenic vein - protocol
- color and spectral (anterior subcostal) | - long axis
39
left hepatic - protocol
- color and spectral (anterior subcostal) | - long axis
40
left portal vein - protocol
- color and spectral - subxiphoid window - long axis - not doing velocity
41
right hepatic vein - protocol
- color and spectral - right intercostal window - long axis - closest to diaphragm
42
middle hepatic vein - protocol
- color and spectral - midline subxiphoid - intercostal - long axis
43
right portal vein - protocol
- color ade spectral - coronal intercostal + same as MPV - not doing velocity
44
hepatic artery - protocol
- color and spectral (coronal intercostal) - same window and area as MPV - measure PSV - patient may hold breath for this image only
45
splenic vein - protocol
- closer to heart | - more crazy waveform
46
IVC - protocol
- subxiphoid - long axis - close to diaphragm
47
flow tips - portal vs vein
- portal venous flow is slower than hepatic vein so adjust flow
48
sweep speed
- medium
49
portal vein baseline
- move down a little
50
hepatic vein baseline
- move up slightly
51
intercostal scanning tips
- rotate transducer to go between ribs | - point transducer indicator toward patient right scapula
52
portal hypertension
- elevated pressure in portal venous system | + impedes blood flow through the liver
53
portal hypertension - causes
- volume overload | - increased resistance to flow
54
three classifications of portal hypertension
- pre-hepatic - intrahepatic + most common - post hepatic
55
pre-hepatic portal hypertension - casues
- portal of splenic thrombosis - portal or splenic invasion - extrinsic compression by a tumor
56
intrahepatic portal hypertension - causes
- hepatocelluar disease + CIRRHOSIS + hepatitis + fatty infiltration
57
post hepatic portal hypertension - causes
- thrombosis of hepatic veins (Budd chiari) - thrombosis of IVC - congestive heart failure - right sided heart disease
58
risk factors of portal hypertension
- chronic liver diseases that precedes fibrosis or cirrhosis - heart disease resulting in increased right sided heart pressures
59
chronic liver disease that precedes fibrosis or cirrhosis
- viral hep (chronic hep B or C) - alcoholic liver disease - autoimmune disorder + primary biliary cirrhosis, primary sclerosing, cholangitis - metabolic and genetic disorders + hemochromatosis, Wilsons disease - schistosomiasis - non alcoholic steatohepatitis NASH - sarcoidosis
60
heart disease leading to increased right sided heart pressure s
- tricuspid regurge - congestive heart failure - constrictive pericarditis
61
patient clinical signs - portal hypertension
- ascites (abdominal distention) - splenomegaly - GI bleed - JAUNDICE (COMMON SIGN OF CIRRHOSIS) - abnormal LFTs
62
can patients be asymptomatic with portal hypertension
- yes
63
manifestations of signs and symptoms associated with underlying disease - portal hypertension
- pancreatitis | - liver diseases
64
patient history - portal hypertension
- could have variceal hemorrhage (hematemesis and melena) | - bacterial peritonitis
65
physical exam of patient would see - portal hypertension
- jaundice (if liver sufficiently impaired) - splenomegaly (could lead to low platelet counts) - dilated abdominal wall veins - hepatic encephalopathy (confusion due to poor liver function)
66
ultrasound evaluation would document - portal hypertension
- portal vein diameter > 13mm - cavernous transformation (intraabdominal collaterals) - portocaval anastomoses - dilation/ recannalization of umbilical vein - splenomegaly > 13cm
67
duplex eval - patency of vessels (collaterals too)
- color doppler + flow or lack of flow - power doppler + tortuous vessels and collaterals
68
duplex eval - direction of flow
- color and spectral | - possibility of reversed flow in portal/splenic veins
69
duplex eval - loss of phasic variation
- special tracing - in response to respiration - Changs to biphasic with progression to flow reversal + increased pressures
70
duplex eval - presence or absence of thrombosis
- 2D - color + decease or absent of flow + not indicative of hypertension in patients with chronic liver disease
71
duplex eval - PV velocity
mean velocity 15-18 cm/s
72
pulsatile and dilated IVC mean what
congestive heart failure
73
portal vein thrombosis - primary condition
``` - can be found in patients with + liver disease + hypercoagulable states + intestinal inflammation = appendicitis, diverticulitis, - causes increased resistance in portal venous circulation ```
74
ultrasound findings - portal vein thrombosis
- enlarged PV - lack of flow or decreased flow - collateral flow - enlarged hepatic artery and increased flow - tumor - portal vein occlusion
75
PVT - enlarged PV
- look for thrombus in lumen | + variable echogenicity
76
PVT - lack of flow or decreased flow
- spectral color or power doppler
77
PVT - collateral flow
- chronic PV thrombosis | - cavernous transformation/shunts
78
PVT -tumor
- invasion of portal vein - typically hepatocellular and pancreatic carcinoma - presence of arterial flow within thrombosis - partial blockage + at site of obstruction = increase speed and disturbed flow patterns + distal to obstruction = continuous flow no respiratory changes
79
PVT - portal vein occlusions
- usually permanent | - fibrotic changes cause vessel to virtually disappear
80
three pitfalls of scanning for PVT
1) undetected anechoic thrombus/tumor 2) low velocity flow undetected 3) inadequate doppler angle precluding detection of flow
81
hepatic vein occlusion (budd chiari syndrome) - causes
* post hepatic portal hypertension - thrombosis + increases hypercoagulability = oral contraceptives, polycythemia, hemoglobinuria - compression - tumor invasion - cirrhosis - membraneous obstruction of IVC
82
hepatic vein occlusion - signs and symptoms
- hepatomegaly - abdominal pain - acute development of ascites - abnormal liver function tests - splenomegaly and collaterals may be evident in chronic cases
83
hepatic vein occlusion - ultrasound findings
- hepatomegaly - caudate lobe hypertrophy - thrombus or tumor in HV or IVC - ABSENCE OF FLOW - if veins are narrow + focal elevation of velocity + turbulence - deep liver + segmental lack of flow and bicolor - collaterals + connecting patent HV with the portal system + bypasses the occluded segment - IVC should be evaluated to rule out thrombus or tumor causing secondary obstruction to hepatic veins
84
normal portal vein - ultrasound
- low velocity (15-30cm/s) = hepatopedal flow - respiratory variations
85
hepatic artery - ultrasouns
- low resistance flow | - PSV 70-150 cm/s
86
hepatic vein - ultrasound
- multiphase flow
87
right sided heart failure/tricuspid regurge - ultrasound
- increase HV pulsatility | - pulsatile PV and IVC
88
portosystemic collaterals and shunts
- obstruction of major vessels forces blood to take a secondary route - flow directed toward mesenteric, splenic and portal veins
89
collaterals
- preexisting vessels - blood flow completes circulation back to IVC - secondary vessels dilate - high risk rupturing
90
most common collateral routes
- at esophagus + near the stomach + under the left lobe of the liver + near the spleen
91
coronary vein (left gastric vein)
- > 7mm - most common collateral + reversed flow in 80-90% of PH cases - can progress to esophageal varices - presence clinically important + implies increased risk for variceal hemorrhage
92
coronary vein - location
- anterior to CA bifurcation - posterior to common hepatic artery or splenic artery - follows oblique path travelling superior to the left of portosplenic confluence
93
umbilical vein
- remnant of the umbilical vein + located in the lig teres - from the umbilicus to the tip left portal vein - hepatofugal flow - normally measure less than 3mm no blood flow
94
most common collaterals
- coronary vein - umbilical vein - splenorenal vein
95
surgical shunts
- decompress the portal system - surgical or endovascular - in severe cases of portal hypertension or cirrhosis
96
surgical shunts effective for
- reducing ascites - preventing hemorrhage from gastroesophageal varices - improving quality of life of patio nest with severe cirrhosis
97
trans jugular intrahepatic portosystemic shunt TIPS
- most common - metallic expandable stent + installed percutaneously + IJV into HV through liver tissue to PV + duplex US to assess - success 90% - subject to high rate of stenosis or occlusion - compensatory increased flow seen in HA
98
TIPS - early complication
- stenosis or thrombosis | - first few weeks of stent placement usually due to thrombosis
99
TIPS - late complication
- neointimal hyperplasia invading stent
100
TIPS - most common site of stenosis
- hepatic vein end
101
post surgery
- baseline study | - regular follow up
102
TIPS - normal ultrasound
- patent TIPS - TIPS velocity range 90-190cm.s - PV peak velocity 30cm/s - similar velocities at each end - pulsatile wave form - MPV caliber up to 15mm - PV and Sv - hepatofugal flow - RPV/LPV flow towards stent
103
TIPS - abnormal ultrasound
- no flow - focal area narrowing - velocity gradient > 100cm/s at stenosis - TIPS velocity < 50cm/s - PV velocity <30cm/s - continuous flow - RPV?LPV flow away from stent
104
transplant liver
- treatment for end stage liver disease | - duplex US used inure and post op assessment of patient s
105
pre op liver transplant scan
``` - assessment for patency of + portal vien + hepatic artery + hepatic vein + IVC - detect tumors in liver or surrounding tissue - biliary tree status ```
106
post op liver transplant scan - performed
- within 24 hours post op | - follow up at 1 6 and 12 month
107
post op liver transplant scan - color and spectral
``` - confirms patency of all major vessels + hepatic artery (most important) = RI : 0.5-0.8 = PSV : < 200 cm/s = acceleration time : < 0.08 sec - assess anastomosis sites - flow direction and vessel size + portal vein normal up to 15mm ```
108
post op liver transplant scan - 2D
- liver parenchyma - biliary tree - perihepatic spaces
109
post transplant complications
- HA thrombosis - stenosis - viability of liver is critical to hepatic artery inflow - hematoma - abscess formation - AV fistulas
110
HA thrombosis - liver transplant
- MOST COMMN - within first 6 weeks + absence of flow + dampening of PSV + decreasing diastolic flow - stenosis of anastomosis sites - PV thrombosis, air (PV larger up to 15mm)
111
stenosis - liver transplant
- at surgical anastomosis
112
post op liver scan - doppler
- appropriate doppler angle critical + HA tortuous + sample along artery starting at celiac axis
113
portal hypertension sonographic signs
- ascites - MPV diameter > 13mm - splenic vein diameter > 10mm - patent umbilical vien - paraumbilical vein > 2.5. mm - splenic length > 13mm - portal vein thrombosis - +/- cavernous transformation of MPV - slow PV flow - alternating retrograde/antergrade PV flow - hepatofugal flow in portal/splenic vessels - coronary vein retrograde flow - esophageal varices
114
budd chiari (hepatic vein occlusion) - sonographic signs
- hepatomegaly - caudate lobe hypertrophy - decreased absent or reversed flow in any HV - narrowed IVC - thrombus in IVC or HV - dampened HV spectral trace - collaterals within liver tissue
115
congestive heart failure
- increased right heart pressure - PV pulsatile - HV increased pressure + W PATTERN - dilated IVC

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