Vascular System Pathology

Abdominal II

Abdominal aorta concerns

pulsatile abdominal mass

abdominal pain radiating into the lower back

abdominal bruit

hemodynamic compromise of lower extremitites

Bruit

weird sound where blood flow is disturbed

T or F: aneurysms are genetic

true

atheroma

fatty tumor (plaque)

Aortic ectasia

diffuse dilation of the aorta

Aortic ectasia looks like:

bulbous

“S” curved

tortuous or folded

Aortic ectasia is MOST COMMONLY SEEN in:

older patients due to shrinking

patients with bad posture or scoliosis/kyphosis

arteriosclerosis

causes rigidity and thickness in arterial walls, leading to the lack of organ perfusion or hypertension

Atherosclerosis

a specific form of arteriosclerosis in which fat and cholesterol builds up on the vessel walls

claudication

pain when walking or using a certain muscle group

Arteriosclerosis and atherosclerosis clinical findings

heart - chest pain

brain - stroke like symptoms

arms/legs - claudication

kidneys - HTN, renal failure

PAD

peripheral arterial disease

MOST COMMON cause of aneurysms

arteriosclerosis

Arteriosclerosis is usually seen in persons over _____ years of age with a ratio of ______ in men to women

50; 5:1

Aortic locations involved with arteriosclerosis

involvement of the abdominal aorta and/or common iliacs

sometimes involving the ascending and descending aorta

Abdominal aortic aneurysm (AAA)

a permanent localized dilation of an artery, with an increase in diameter of greater than 1.5 times its normal diameter; IT FAILS TO TAPER

MOST COMMON LOCATION FOR AN AAA

majority occur BELOW the kidneys (infrarenal)

Grey turner sign

slow aneurysmal leak; looks like a big bruise on the patient’s flanks

true aneurysm

aneurysm lined by all three layers of the aorta

False aneurysm - pseudoaneurysm

not lined by all three layers; blood escapes through a hole in the vessel wall and is contained within the surrounding tissue

pseudoaneurysms create what

hematomas

Classic ying - yang appearance

sign of a pseudoaneurysm

Shape of a true aneurysm

football shaped

Berry aneurysm

small spherical aneurysm of 1 - 1.5 cm

What does it mean if there is an abdominal aneurysm?

There is most likely another one somewhere else in the body

Berry aneurysms occur in the:

brain

Saccular aneurysms size

spherical and larger (5 - 10 cm)

saccular aneurysms are connected to vascular _____ by a mouth that may be as large as the ______

lumen; aneurysm

Saccular aneurysms tend to _____ quickly because of their shape

clot

MOST COMMON aneurysm

fusiform

fusiform aneurysm

gradual dilation of the vascular lumen

Aneurysm risk factors

tobacco

hypertension

vascular disease

chronic obstructive pulmonary disease (COPD)

family history of AAA

Causes of AAA

atherosclerosis

trauma

congenital defects

syphilis

mycosis

cystic medial necrosis

inflammation of the media and adventitia

HTN

abnormal volume load (pregnancy)

An aneurysm lacks this

normal tapering distally

Aneurysms measuring ______ are at the highest risk of rupture

6-7 cm

EVAR

endovascular aortic repair with a stent

Aortic rupture symptoms

excruciating abdominal pain

shock

expanding abdominal mass

A ________ is usually seen in ______ aneurysms as a high-amplitude linear echo “line”; ________ appears as thick, echogenic echoes sometimes with ______

thrombus; large; calcifications; shadowing

Aortic dissection

tear in the intima and/or media of the abdominal wall

Aortic dissection can lead to ____ formation and ______ length

clot; flap

Aortic dissection clinical findings

40 to 60 years

males > females

patients are hypertensive

Most dangerous type of dissection

type I

Type I aortic dissection

involves the ascending and aortic arch

begins at the root and may extend the entire length of the arch, descending aorta and into the abdominal

Which type of aortic dissection do we se 30% of?

type I

If a dissection spirals around the aorta, it cuts blood supply off to:

the coronary

carotid

brachiocephalic

subclavian

Type II aortic dissection is secondary to:

hypertension

cystic medial necrosis

Marfan’s syndrome

Marfan’s syndrome

progressive stretching disorder in all arterial vessels; usually long and lanky people

Type III aortic dissection

begins at the lower end of the descending aorta and extends into the abdominal aorta; inferior to the left subclavian artery

Which type of aortic dissection is the least severe?

type III

Type III aortic dissection can be critical if the _______ _______ are affected

renal arteries

If an aneurysm compresses on the CBD, it can result in

jaundice and stones (obstruction)

If an aneurysm compresses the renal arteries it can result in:

HTN

renal ischemia (kidneys dying off)

Aortic graft

surgical repair with a flexible graft material; MAN MADE synthetic material that produces bright echo reflections

Endoleak formation from an aortic graft

more blood is still flowing and entering the aneurysm

Other masses that can simulate a pulsatile abdominal mass

retroperitoneal tumor

fibroid mass

paraaortic nodes

In patients with right ventricular failure

IVC does not collapse with expiration

IVC dilation can occur as a result of

right ventricular heart failure

congestive heart disease

constrictive pericarditis

tricuspid disease

right heart obstructive tumors

MOST COMMON tumor seen in the IVC

renal cell carcinoma

Wilms’ tumor

childhood renal cancer with a good survival rate

ages 2-5

IVC thrombosis clinical signs

constipation

leg edema

low back pain

pelvic pain

gastrointestinal complaints

renal abnormalities

liver abnormalities

Tumor vs. blood clot

a tumor will have feeder vessels

a clot will have no blood flow

MOST COMMON origin of pulmonary emboli (PE)

DVT from lower extremities

What can be used to prevent recurrent embolization?

transvenous filters

Preferred location for a transvenous filter?

Iliac bifurcation (don’t want to block the kidneys)

Renal vein obstruction is seen in:

dehydrated or septic infants

Rein vein obstruction can be seen in adults who have

nephrotic syndrome

shock

renal tumor

kidney transplant

trauma

Clinical signs of renal vein obstruction

flank pain

gross hematuria

flank mass

proteinuria

associated with diabetes and HTN

Sonographic findings of renal vein obstruction

medium or clumps of echoes randomly scattered within the kidney with surrounding echo-free spaces

renal pattern progresses to atrophy (within 2 months)

late findings include increased parenchymal echoes and decreased renal size

Renal vein thrombosis can be diagnosed by:

direct visualization of the thrombi in the renal vein and IVC

demonstration of renal vein dilated proximal to the point of occlusion

loss of normal renal structure

increased renal size (acute phase)

doppler showing decreased or no flow

Clinical signs of renal vein thrombosis

pain

nephromegaly

hematuria

blood clots elsewhere in the body

What is important about portal venous hypertension

flow changes from hepatofugal to hepatopetal

Increased velocity or _______ may result from an _______ or aneurysmal _____

obstruction; atheroma; dilation

High resistant vessels (resistive)

don’t need a constant blood supply (face, arms, legs, etc.)

Low resistant vessels (non-resistive)

need constant blood supply (organs)

The celiac axis is _______ after eating

unchanged

The hepatic artery should have _______ broadening, and is crucial in ______ transplants

spectral; heart

The splenic artery is highly prone to an _______ in patients who have chronic pancreatitis and has a very _______ flow pattern

aneurysm; turbulent

The SMA ______ change with eating

DOES

The SMA is _______ resistive in a fasting patient

highly

The SMA is ______ resistive in a non-fasting patient

low

The renal artery is _____-resistive with spectral broadening in both ______ and _____

non; systole and diastole

If there is stenosis, what can happen?

collateral (accessory) vessels may form

Portal vein thrombosis is easily seen through:

loss of normal PV
dilation of SMV

dilation of splenic vein

Cavernous transformation of the portal vein

extrahepatic portal vein is not visualized

echogenic area is present in porta hepatis

periportal collateral vessels are present