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dmst 265 vascular sonography 1 > Module 7 Liver Vasculature > Flashcards

Module 7 Liver Vasculature Flashcards

1
Q

The evaluation of the portal system is a common procedure often related to what?

A

Chronic liver disease and cirrhosis of the liver

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2
Q

Liver vasculature evaluation includes the evaluation of what?

A
  1. Hepatic veins
  2. Portal veins
  3. Hepatic Artery
  4. IVC
  5. Collaterals
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3
Q

Some of the vascular disorders we will look at are what?

A
  1. Portal hypertension
  2. Shunts/Stents
  3. Transplants
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4
Q

What are two types of portal hypertension?

A
  1. Portal vein thrombosis
  2. Hepatic vein thrombosis
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5
Q

How many major hepatic veins are there?

A

Three

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6
Q

Where do the MHV and the LHV typically join?

A

Before the IVC

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7
Q

Which Hepatic vein is typically duplicated?

A

Left hepatic veins

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8
Q

What do the hepatic veins drain into?

A

The IVC and become larger in diameter on their approach

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9
Q

What does Hepatic Vein waveforms look like typically?

A

Respirophasic and pulsatile

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10
Q

Why do we evaluate the hepatic veins?

A

We assess for patency or distension

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11
Q

What does this image demonstrate?

A

The hepatic veins draining into the IVC

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12
Q

What does the portal veins drain?

A

Blood from the bowel and spleen to the liver

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13
Q

How much blood does the portal veins supply to the liver?

A

Approximately 75%

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14
Q

The MPV is comprised of what?

A

Splenic and superior mesenteric veins

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15
Q

The MPV enters the liver through what?

A

The porta hepatis

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16
Q

When describing flow in the portals and hepatic veins we use what terms?

A
  1. Hepatopetal
  2. Hepatofugal
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17
Q

What does hepatopetal mean?

A

Towards the liver

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18
Q

What does hepatofugal mean?

A

Away from the liver

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19
Q

Portal veins have a low velocity normally, what is the range?

A

16-40 cm/s (variable- depends on source)

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20
Q

What is the flow relatively for portal veins post prandial?

A

Flow increase post prandial

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21
Q

The normal MPV diameter should be what?

A

Less than 13 mm

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22
Q

What does this image demonstrate?

A

MPV

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23
Q

What does this image demonstrate?

A

LPV

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24
Q

What does this image demonstrate?

A

RPV

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25
Q

How much blood does the hepatic artery supply to the liver?

A

25%

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26
Q

What kind of path does the Hepatic artery have?

A

tortous

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27
Q

Where is the proximal hepatic artery seen?

A

At the celiac axis

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28
Q

Where is the distal hepatic artery seen?

A
  1. Intercoastal
  2. MPV and RPV
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29
Q

Where is the distal hepatic artery seen?

A
  1. Intercoastal
  2. MPV and RPV
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30
Q

What is the resistance like in the hepatic artery?

A

Low resistance

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31
Q

Is there normally spectral broadening in the hepatic artery?

A

Yes, because the vessel is quite small

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32
Q

What is the velocities of the Hepatic artery?

A

Variable so RI is used to assess for pathology

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33
Q

What is the normal Resistive index?

A

0.5 - 0.7

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34
Q

What is the IVC formed from?

A

Iliac veins

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35
Q

Where is the IVC located?

A

Anterior to the spine and right of the aorta

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36
Q

What is the size of the IVC?

A

Variable, greater then 2.5 cm considered dilated

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37
Q

What does the IVC spectral trace look like?

A
  1. Spontaneous waveform?
  2. pulsatile proximal
  3. Phasic distally
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38
Q

What is the IVC spectral trace influenced by?

A

Heart and respiration

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39
Q

What categories can portal hypertension be categorized into?

A
  1. Pre- hepatic
  2. Intrahepatic (most common)
  3. Post hepatic
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40
Q

What is the leading cause of portal hypertension?

A

Cirrhosis

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41
Q

What is the leading cause of cirrhosis?

A

Hepatitis C followed by alcoholism

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42
Q

What are the signs and symptoms of portal hypertension?

A
  1. Jaundice
  2. Abnormal LFT
  3. Ascites (increased abdominal girth)
  4. Splenomegaly
  5. GI bleed
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43
Q

What are two types of GI bleeds?

A
  1. Hematemesis (vomiting blood)
  2. Melena (dark starry stools)
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44
Q

For a portal hypertension physical examination the patient can present with what?

A
  1. Caput medusae (dilated abdominal wall veins)
  2. Hepatic encephalopathy (confusion due to poor liver function)
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45
Q

What is Pre-hepatic obstructions?

A
  1. Pathology that occurs to blood flow before it enters the liver (inflow)
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46
Q

What are some examples of pre-hepatic obstruction?

A
  1. Portal or splenic vein thrombosis
  2. Portal or splenic vein invasion
  3. Extrinsic compression by tumor
  4. Inflammation of the pancreas (pancreatitis)
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47
Q

Portal vein thrombosis can be caused by what?

A
  1. Cirrhosis (20%)
  2. Malignancies (20%)
  3. Hypercoagulable states
  4. Intra- abdominal inflammation/ infection
  5. Trauma (From surgery)
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48
Q

Chronic PHT may be what?

A

Asymptomatic

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49
Q

What does Portal vein thrombosis look like sonographically?

A

Can appear enlarged (>15mm)

50
Q

How may the lumen echogenicity appear during portal vein thrombosis?

A
  1. Hyperechoic
  2. Hypoechoic
  3. Isoechoic
  4. Anechoic
51
Q

What might the portal vein thrombosis appear in spectral?

A

There may be an absence of flow with spectral, color, or power doppler

52
Q

What might portal vein thrombosis look like?

A
  1. Cavernous transformation
  2. HA enlarged/ increased flow
53
Q

Portal vein thrombosis tends to last how long?

A

It tends to be permanent leading to scarring

54
Q

What happens to the vessels during Portal vein thrombosis?

A

The vessel virtually disappears

55
Q

What are three pitfalls to be aware of for portal vein thrombosis?

A
  1. Undetected anechoic tumor/ thrombus
  2. Low velocity flow undetected
  3. Inadequate doppler angle
56
Q

What is the most common cause of portal hypertension?

A

Intrahepatic obstruction

57
Q

What are intrahepatic obstruction underlying diseases?

A
  1. Cirrhosis
  2. Hepatitis
  3. Hepatic fibrosis
  4. Nonalcoholic steatohepatitis (NASH)
58
Q

What is intrahepatic obstruction? And what does it lead to?

A

Inflammation of normal liver tissue which leads to death and fibrosis

59
Q

What does Intrahepatic obstructions lead to?

A
  1. Damage to liver, sinusoids and hepatocytes
  2. Increased resistance to blood flow at the sinusoid level
  3. Shunting of blood to collateral vessels
  4. Varicies develop
60
Q

Near the end stage of intrahepatic obstruction what happens to the liver and spleen?

A

The liver will decrease in size and the spleen will increase in size

61
Q

What is this an example of?

A

Liver cirrhosis

62
Q

What is poste hepatic obstruction?

A

When drainage of blood from liver (outflow) is compromised

63
Q

What is post-hepatic obstruction caused by?

A
  1. Chronic right sided heart failure
  2. Tricuspid regurgitation
  3. Budd chiari (thrombosis of the HV and IVC)
64
Q

If Post hepatic obstruction is acute, what does the liver do?

A

The liver enlarges and so does the spleen

65
Q

For post hepatic obstruction if there is increased right side heart pressure what can be the cause?

A

CHF or TR

66
Q

What is the the spectral of PV look like?

A

Pulsatile

67
Q

What is Budd chiari?

A

A rate condition that is most commonly caused by a hyper coagulable state like polycythemia

68
Q

What drugs can also lead to thrombosis somtimes?

A

Oral contraception

69
Q

What collaterals sometimes form during budd chiari?

A

They may form a caudate lobe which may help drain the liver

70
Q

What does this image demonstrate?

A

IVC obstruction

71
Q

What does the image demonstrate?

A

Hepatic vein obstruction

72
Q

What is the patency of MPV and branches? What are some questions we should ask?

A
  1. Presence or absences of thrombus
  2. Is there lack of flow?
  3. Are there collaterals?
73
Q

What are some questions we should ask when doing duplex documentation?

A
  1. What is the patency of MPV and branches
  2. What is the direction of flow
  3. What is the phasicity
  4. What is the MPV velocity
74
Q

What is MPV velocity?

A

16-40 cm/sec

75
Q

What are waveform changes?

A

When the waveform becomes either
1. Bi-phasic
2. Flow reversal

76
Q

What does waveform changes mean?

A
  1. If its bi-phasic - alternative antegrade/ retrograde flow
  2. If its flow reversal- severe PHT
77
Q

Why do collaterals flow?

A

In the event of portal hypertension is a key finding

78
Q

How many way can we take to return to the heart?

A

There are several natural collateral pathways

79
Q

What are alternative ways to bypass the liver and decompress the system?

A

Surgical intervention such as therapeutics shunts are used in severe cases to prevent GI bleeds and improve quality of life

80
Q

What are portosystemic collateral and shunts?

A
  1. Pre- existing vessels
  2. Normally drain into portal, splenic, and mesenteric vessels
81
Q

What are the three major congenital shunts?

A
  1. Portocaval
  2. Mesocaval
  3. Splenorenal
82
Q

What does the portocaval drain?

A

PV to IVC

83
Q

What does the mesocaval drain?

A

SMV to IVC

84
Q

What does the splenorenal drain?

A

SV to Lt. RV

85
Q

Why would we use portosystemic collaterals and shunts?

A

SO vessels develop or recanalize with portal hypertension to allow blood to circulate back to the IVC

86
Q

What does the portosystemic collaterals and shunts look after a while?

A

Seen as dilated vessels and appear as “too many tubes” or a “can of worms”

87
Q

A backup of blood flow ends up where in the portosystemic collaterals and shunts?

A

A backup of blood flow ends up in the organs they are draining and cause enlargement (splenomegaly)

88
Q

what is the most prevalent portosystemic collateral?

A

The coronary vein (left gastric)

89
Q

Increased pressure in the coronary vein may cause what?

A

Esophageal varices

90
Q

Why does increased pressure causes the coronary vein to cause esophageal varices?

A

These vessels are not made for the volume of blood they now receive

91
Q

Visualization implies an increase risk for what?

A

Hemorrhage which is life-threatening

92
Q

With PHT the remnant of the umbilical vein does what? What is the flow?

A
  1. Recanalizes in the ligamentum teres
  2. From the LPV to the umbilicus
  3. Flow is hepatofugal
93
Q

What kind of devices can decompress the portal system? How can it be inserted?

A

A surgical shunt, it can be placed surgically or with an endovascular technique

94
Q

The most common for PFT is what?

A

TIPS

95
Q

What does TIPS stand for?

A

Trans-jugular intrahepatic portosystemic shunt

96
Q

What is TIPS?

A

A metallic, expandable stent is placed in the liver tissue shunting blood from PV to HV

97
Q

What is the endovascular technique for placing TIPS?

A

Catheter passed down IJV into HV, Advancing through liver tissue into PV branch

98
Q

What is the success rate for TIPS?

A

100%

99
Q

What should we do to follow up for TIPS?

A

Assess with TIPS

100
Q

What does this image demonstrate?

A

TIPS

101
Q

Ultrasound is used to confirm what in terms of TIPS?

A

Patency and search for stenosis

102
Q

In a normal TIPS the velocity range is what?

A

90-190 cm/s

103
Q

Normal PV velocity is at least what?

A

30 cm/s

104
Q

What is the flow in TIPS?

A
  1. Flow is retrograde in the right and left portal
  2. Compensatory increased flow seen in HA
105
Q

What is early complication of TIPS?

A
  1. Usually due to thrombosis
  2. Will increase velocities in the stenosis (>190cms)
  3. Can decrease velocities in the MPV (<30 cms)
106
Q

What is late complications of TIPS?

A

Neo- intimal hyperplasia invades stent

107
Q

What is neo-intimal hyperplasia?

A

An over reaction of the bodies normal healing process

108
Q

If a stenosis is detected in TIPS what do we do?

A

Balloon angioplasty and thrombolysis can be done

109
Q

What is a liver transplant used for?

A

Treatment for end stage liver disease

110
Q

How much of a liver can be used for a liver transplant?

A

Whole or partial (typically right)

111
Q

what is used for pre and post operative assessment liver transplant patients?

A

Duplex ultrasound

112
Q

During post operative assessment what doe we look at to confirm patency, flow direction and size?

A
  1. HA
  2. PV
  3. IVC and HV
  4. Splenic and mesenteric veins
113
Q

What may be larger in the liver transplant patient? And what is the normal size?

A

The portal vein can be larger in the transplant patient with normal size up to 15 mm

114
Q

What are complications to transplant livers?

A
  1. Rejection
  2. Pseudo aneurysm
  3. Hepatic infarction
  4. Thrombosis of major liver vessels
  5. Stenosis may be observed at the surgical anastomosis sites in follow up exams
  6. Other concerns can be hematomas, abscess formation and AV fistulas
115
Q

What are some thrombosis’s that might be complications in liver transplants?

A
  1. HA thrombosis early post-op complications
  2. Stenosis of anastomosis sites
  3. PV thrombosis, air
116
Q

When is a ultrasound usually done after a liver transplant?

A

Typically done within 24 hours of the surgery and at regular intervals afterwards

117
Q

The HA should have what type of appearance in the post liver transplant?

A

Should have a rapid upstroke and an RI

118
Q

What should the RI be for a post transplant liver?

A

0.55 - 0.8

119
Q

What can we note about PSVs in the transplant liver?

A

PSV is variable and is not reliable

120
Q

HV’s can have what type of waveform post transplant?

A

Monophasic waveform immediately after the surgery but will normalize over time

dmst 265 vascular sonography 1 (19 decks)

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