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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
Q

scanning window RPV

A
  • intercostal

- coronal

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26
Q

scanning window LPV

A
  • subxipoid

- intercostal

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27
Q

liver duplex exam - assessing

A
  • flow direction
  • normal waveform
  • patency
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28
Q

liver duplex exam - routine vessels

A
  • hepatic veins
  • portal vein
  • splenic vein
  • hepatic artery
  • collaterals
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29
Q

dopper assessment liver duplex

A
  • assess flow quality

- only assessed during quiet respiration

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30
Q

patient positon

A
  • supine
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31
Q

anterior window

A 
- assess
  \+ LPV
  \+ LHV
  \+ SV
  \+ MPV
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32
Q

coronal intercostal

A 
- assess
   \+ RHV
   \+ MHV
   \+ RPV and MPV
   \+ HA
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33
Q

color and spectral doppler of liver

A
  • done in every picture
  • flow direction
  • quality of flow NOT QUANTITY
  • patency
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34
Q

hepatic veins assess

A
  • hepatofugal (away from liver) flow

- multiphase waveform

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35
Q

portal veins assess

A
  • hepatopedal

- subtle phasicity

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36
Q

MPV - protocal

A 
- 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
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37
Q

normal range of peak velocity of MPV

A
  • 15-40 cm/sec
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38
Q

splenic vein - protocol

A
  • color and spectral (anterior subcostal)

- long axis

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39
Q

left hepatic - protocol

A
  • color and spectral (anterior subcostal)

- long axis

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40
Q

left portal vein - protocol

A
  • color and spectral
  • subxiphoid window
  • long axis
  • not doing velocity
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41
Q

right hepatic vein - protocol

A
  • color and spectral
  • right intercostal window
  • long axis
  • closest to diaphragm
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42
Q

middle hepatic vein - protocol

A
  • color and spectral
  • midline subxiphoid
  • intercostal
  • long axis
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43
Q

right portal vein - protocol

A
  • color ade spectral
  • coronal intercostal
    + same as MPV
  • not doing velocity
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44
Q

hepatic artery - protocol

A
  • color and spectral (coronal intercostal)
  • same window and area as MPV
  • measure PSV
  • patient may hold breath for this image only
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45
Q

splenic vein - protocol

A
  • closer to heart

- more crazy waveform

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46
Q

IVC - protocol

A
  • subxiphoid
  • long axis
  • close to diaphragm
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47
Q

flow tips - portal vs vein

A
  • portal venous flow is slower than hepatic vein so adjust flow
48
Q

sweep speed

A
  • medium
49
Q

portal vein baseline

A
  • move down a little
50
Q

hepatic vein baseline

A
  • move up slightly
51
Q

intercostal scanning tips

A
  • rotate transducer to go between ribs

- point transducer indicator toward patient right scapula

52
Q

portal hypertension

A
  • elevated pressure in portal venous system

+ impedes blood flow through the liver

53
Q

portal hypertension - causes

A
  • volume overload

- increased resistance to flow

54
Q

three classifications of portal hypertension

A
  • pre-hepatic
  • intrahepatic
    + most common
  • post hepatic
55
Q

pre-hepatic portal hypertension - casues

A
  • portal of splenic thrombosis
  • portal or splenic invasion
  • extrinsic compression by a tumor
56
Q

intrahepatic portal hypertension - causes

A
  • hepatocelluar disease
    + CIRRHOSIS
    + hepatitis
    + fatty infiltration
57
Q

post hepatic portal hypertension - causes

A
  • thrombosis of hepatic veins (Budd chiari)
  • thrombosis of IVC
  • congestive heart failure
  • right sided heart disease
58
Q

risk factors of portal hypertension

A
  • chronic liver diseases that precedes fibrosis or cirrhosis
  • heart disease resulting in increased right sided heart pressures
59
Q

chronic liver disease that precedes fibrosis or cirrhosis

A
  • 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
Q

heart disease leading to increased right sided heart pressure s

A
  • tricuspid regurge
  • congestive heart failure
  • constrictive pericarditis
61
Q

patient clinical signs - portal hypertension

A
  • ascites (abdominal distention)
  • splenomegaly
  • GI bleed
  • JAUNDICE (COMMON SIGN OF CIRRHOSIS)
  • abnormal LFTs
62
Q

can patients be asymptomatic with portal hypertension

A
  • yes
63
Q

manifestations of signs and symptoms associated with underlying disease - portal hypertension

A
  • pancreatitis

- liver diseases

64
Q

patient history - portal hypertension

A
  • could have variceal hemorrhage (hematemesis and melena)

- bacterial peritonitis

65
Q

physical exam of patient would see - portal hypertension

A
  • 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
Q

ultrasound evaluation would document - portal hypertension

A
  • portal vein diameter > 13mm
  • cavernous transformation (intraabdominal collaterals)
  • portocaval anastomoses
  • dilation/ recannalization of umbilical vein
  • splenomegaly > 13cm
67
Q

duplex eval - patency of vessels (collaterals too)

A
  • color doppler
    + flow or lack of flow
  • power doppler
    + tortuous vessels and collaterals
68
Q

duplex eval - direction of flow

A
  • color and spectral

- possibility of reversed flow in portal/splenic veins

69
Q

duplex eval - loss of phasic variation

A
  • special tracing
  • in response to respiration
  • Changs to biphasic with progression to flow reversal
    + increased pressures
70
Q

duplex eval - presence or absence of thrombosis

A
  • 2D
  • color
    + decease or absent of flow
    + not indicative of hypertension in patients with chronic liver disease
71
Q

duplex eval - PV velocity

A

mean velocity 15-18 cm/s

72
Q

pulsatile and dilated IVC mean what

A

congestive heart failure

73
Q

portal vein thrombosis - primary condition

A 
- can be found in patients with 
   \+ liver disease
   \+ hypercoagulable states
   \+ intestinal inflammation 
       = appendicitis, diverticulitis, 
- causes increased resistance in portal venous circulation
74
Q

ultrasound findings - portal vein thrombosis

A
  • enlarged PV
  • lack of flow or decreased flow
  • collateral flow
  • enlarged hepatic artery and increased flow
  • tumor
  • portal vein occlusion
75
Q

PVT - enlarged PV

A
  • look for thrombus in lumen

+ variable echogenicity

76
Q

PVT - lack of flow or decreased flow

A
  • spectral color or power doppler
77
Q

PVT - collateral flow

A
  • chronic PV thrombosis

- cavernous transformation/shunts

78
Q

PVT -tumor

A
  • 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
Q

PVT - portal vein occlusions

A
  • usually permanent

- fibrotic changes cause vessel to virtually disappear

80
Q

three pitfalls of scanning for PVT

A

1) undetected anechoic thrombus/tumor
2) low velocity flow undetected
3) inadequate doppler angle precluding detection of flow

81
Q

hepatic vein occlusion (budd chiari syndrome) - causes

A
  • post hepatic portal hypertension
  • thrombosis
    + increases hypercoagulability
    = oral contraceptives, polycythemia, hemoglobinuria
  • compression
  • tumor invasion
  • cirrhosis
  • membraneous obstruction of IVC
82
Q

hepatic vein occlusion - signs and symptoms

A
  • hepatomegaly
  • abdominal pain
  • acute development of ascites
  • abnormal liver function tests
  • splenomegaly and collaterals may be evident in chronic cases
83
Q

hepatic vein occlusion - ultrasound findings

A
  • 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
Q

normal portal vein - ultrasound

A
  • low velocity (15-30cm/s)
    = hepatopedal flow
  • respiratory variations
85
Q

hepatic artery - ultrasouns

A
  • low resistance flow

- PSV 70-150 cm/s

86
Q

hepatic vein - ultrasound

A
  • multiphase flow
87
Q

right sided heart failure/tricuspid regurge - ultrasound

A
  • increase HV pulsatility

- pulsatile PV and IVC

88
Q

portosystemic collaterals and shunts

A
  • obstruction of major vessels forces blood to take a secondary route
  • flow directed toward mesenteric, splenic and portal veins
89
Q

collaterals

A
  • preexisting vessels
  • blood flow completes circulation back to IVC
  • secondary vessels dilate
  • high risk rupturing
90
Q

most common collateral routes

A
  • at esophagus
    + near the stomach
    + under the left lobe of the liver
    + near the spleen
91
Q

coronary vein (left gastric vein)

A
  • > 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
Q

coronary vein - location

A
  • anterior to CA bifurcation
  • posterior to common hepatic artery or splenic artery
  • follows oblique path travelling superior to the left of portosplenic confluence
93
Q

umbilical vein

A
  • 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
Q

most common collaterals

A
  • coronary vein
  • umbilical vein
  • splenorenal vein
95
Q

surgical shunts

A
  • decompress the portal system
  • surgical or endovascular
  • in severe cases of portal hypertension or cirrhosis
96
Q

surgical shunts effective for

A
  • reducing ascites
  • preventing hemorrhage from gastroesophageal varices
  • improving quality of life of patio nest with severe cirrhosis
97
Q

trans jugular intrahepatic portosystemic shunt TIPS

A
  • 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
Q

TIPS - early complication

A
  • stenosis or thrombosis

- first few weeks of stent placement usually due to thrombosis

99
Q

TIPS - late complication

A
  • neointimal hyperplasia invading stent
100
Q

TIPS - most common site of stenosis

A
  • hepatic vein end
101
Q

post surgery

A
  • baseline study

- regular follow up

102
Q

TIPS - normal ultrasound

A
  • 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
Q

TIPS - abnormal ultrasound

A
  • 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
Q

transplant liver

A
  • treatment for end stage liver disease

- duplex US used inure and post op assessment of patient s

105
Q

pre op liver transplant scan

A 
- assessment for patency of 
   \+ portal vien 
   \+ hepatic artery
   \+ hepatic vein 
   \+ IVC
- detect tumors in liver or surrounding tissue
- biliary tree status
106
Q

post op liver transplant scan - performed

A
  • within 24 hours post op

- follow up at 1 6 and 12 month

107
Q

post op liver transplant scan - color and spectral

A 
- 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
Q

post op liver transplant scan - 2D

A
  • liver parenchyma
  • biliary tree
  • perihepatic spaces
109
Q

post transplant complications

A
  • HA thrombosis
  • stenosis
  • viability of liver is critical to hepatic artery inflow
  • hematoma
  • abscess formation
  • AV fistulas
110
Q

HA thrombosis - liver transplant

A
  • 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
Q

stenosis - liver transplant

A
  • at surgical anastomosis
112
Q

post op liver scan - doppler

A
  • appropriate doppler angle critical
    + HA tortuous
    + sample along artery starting at celiac axis
113
Q

portal hypertension sonographic signs

A
  • 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
Q

budd chiari (hepatic vein occlusion) - sonographic signs

A
  • 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
Q

congestive heart failure

A
  • increased right heart pressure
  • PV pulsatile
  • HV increased pressure
    + W PATTERN
  • dilated IVC

Vascular (7 decks)

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