Abdominal Vasculature Exam 2

A 60-year-old man presents to the sonography department for an aortic ultrasound. Based on this sonographic appearance what is the most likely diagnosis?

Fusiform Abdominal Aortic Aneurysm

A hypoechoic wedge shaped mass in the renal cortex with no blood flow demonstrated on Doppler exam is most likely the result of:

Focal Renal Infarction

A patient is sent to the ultrasound department to rule out Budd-Chiari syndrome. What anatomy needs to be examined carefully?

Hepatic veins & IVC

A patient presents with fatigue, nausea, jaundice, and increased ALT, AST, and bilirubin. The sonographic appearance of the liver appears hypoechoic and there is hepatosplenomegaly. What is the most likely diagnosis?

Acute hepatitis

A renal artery/aorta ratio of > 3.5 is indicated of what diagnosis?

Renal artery stenosis

A wedge-shaped lesion within the spleen most likely results from which of the following?

A. Splenic infarct

B. Splenic infection

C. Splenic hemangioma

D. Metastasis

A

A. In the image below, would this demonstrate direct or indirect evaluation of renal artery stenosis?

B. What is the sonographic descriptive term for this Doppler appearance of the renal artery?

A. Indirect

B. Parvus Tardus / crosstalk

All of the following can result from portal hypertension EXCEPT:

A. Ascites

B. Recanalization of the paraumbilical vein

C. Decreased diameter of the portal vein

D. Splenomegaly

C

Ascites is associated with impaired liver function because ___ decreases.

Albumin formation

What vessel demonstrates this type of Doppler waveform, because of its location in the liver?

Triphasic hepatic veins

Determine which image demonstrates a HEPATOPEDAL flow and which image demonstrates a HEPATOFUGAL flow.

HEPATOPEDAL: B

HEPATOFUGAL: A

During a renal artery Doppler exam, the following velocities are recorded:

Aorta 100cm/s

Right renal artery 200cm/s

Left renal artery 400 cm/s

What do these findings represent?

>60% stenosis in the left renal artery only

From what part of the heart does the aorta originate?

Left ventricle

From what do intraluminal tumors in the inferior vena cava most commonly arise?

Renal cell carcinoma

How many types of dissection are there according to the DeBakey model?

III

Identify which image demonstrates the aorta and which image demonstrates the IVC.

A. IVC

B. Aorta

If a tips shot is working properly, what type of flow should be seen in the right and left portal vein?

Hepatofugal

In a transverse view, which vessel can be imaged between the SMA and the aorta?

Left renal vein

In cases of portal hypertension, what embryo logic structure may become recanalized as a collateral?

Umbilical vein

In cases of renal vein thrombosis, you may visualize all of the following except?

A. Enlarged hypoechoic kidney

B. Abnormal Doppler flow pattern to the renal artery

C. Low-level echoes in the renal vein

D. normal Doppler flow pattern in the renal vein

D

In this image, what arterial pathology is being demonstrated?

Femoral artery pseudoaneurysm

Label the structures in the ultrasound image.

A. CBD

B. GDA

C. Splenic vein

D. SMV

E. IVC

F. Aorta

G. SMA

What divides and supplies the anterior and posterior portions of the right lobe of the liver?

Right portal vein

What divides the liver horizontally entering the porta hepatis?

Main portal vein

What branch is medial and lateral to supply the left lobe of the liver?

Left portal vein

What divides the liver longitudinally and has no valves?

Hepatic veins

What separates and drains the medial and lateral portions of the left lobe?

Left hepatic veins

What separates in drains the right lobe from the medial left lobe of the liver?

Middle hepatic vein

What separates and drains the anterior and posterior portions of the right lobe of the liver?

Right hepatic veins

Name two complications of tips? (Example how do you know it's not working)

Hepatopedal flow in RPV or LPV

Hepatofugal flow in MPV

Normal portal vein flow is __ and reverse portal vein flow is __.

Hepatopedal; hepatofugal

At what location do the renal arteries branch off from the lateral wall of the aorta?

Inferior to the SMA

The IVC courses superiorly and anteriorly to enter what part of the heart?

Right atrium

T/F

The SMV and splenic vein joint anterior to the neck of the pancreas to form the portal splenic confluence.

False

The __ is the anteriolateral border of the pancreas.

GDA

The __ passes through a groove posterior to the pancreatic head.

CBD

The abdominal aorta bifurcates into the __ arteries.

Right & left common iliac

At what point is the aorta consider the abdominal aorta?

It passes through the diaphragm

The gastroduodenal artery is a branch of what artery?

Common Hepatic artery

The head of the pancreas, the duodenum, and parts of the stomach are supplied by what artery?

GDA

The inferior phrenic artery supply what anatomy?

Diaphragm

The left renal vein courses:

Posterior to the SMA

The main Reno artery divides is it makes its way from the highland to the cortex. Identify these four branches of the renal artery.

Interlobular

Arcuate

Interlobar

Segmental

The normal AP portal vein measurement should be </=

1.3 cm

The normal aorta should __ in size as it courses inferiorly.

Decrease

The normal diameter of the aorta should measure less than or equal to:

3 cm

The right gonadal vein empties into the __; and the left gonadal vein empties into the __.

IVC; Left renal vein

Which of the following describes the location of the splenic artery?

Superior border of the pancreas

Which of the following describes the location of the splenic vein?

Posterior border of the pancreas

What vessel arises from the anterior aortic wall and runs parallel to the aorta to supply parts of the intestines?

SMA

The wall of the aorta has three layers, which layer is the thickest, allowing for elasticity?

Tunica media

This procedure is used for patients with portal hypertension. What does the acronym stand for?

Transjugular intrahepatic portosystemic shunt (TIPS)

What 2 main structures form the portal vein?

SMV & splenic vein

What 2 things are being measured in this image of a renal artery Doppler, using the systolic peak and end diastolic?

PSV & EDV

What are the first 2 branches that can be seen sonographically, branching anterior from the abdominal portion of the aorta?

A. Celiac axis

B. SMA

What can be inserted into the IVC to prevent thrombus from entering the heart, lungs, or brain?

Filter

What is the most common procedure used today to fix a pseudoaneurysm?

Inject thrombin under ultrasound guidance

What is the best definition of portal hypertension?

When the pressure in the portal vein measures 5 mmHg greater than the IVC pressure

What is being depicted in the following color in spectral Doppler image below?

Undulations and hepatopedal portal vein flow

What is the correct term for the “gold standard” to evaluate for renal artery stenosis?

Renal arteriography

What is the meaning of atherosclerosis?

Hardening of the arteries due to plaque

What is the most common pathology to occur within the IVC?

Thrombosis

What is the most common cause of abdominal aortic aneurysm?

Atherosclerosis

What is the most common cause of renal artery stenosis?

Atherosclerosis

What is the normal resistance index for the renal arteries?

0.7

What is the primary function of the IVC?

Carry deoxygenated blood to the heart

What is the purpose of a portosystemic shunt?

To shunt the portal vein blood to the hepatic vein, alleviating portal vein pressure

What type of pathology can result following a heart catheterization?

Pseudoaneurysm

What pathology is present when blood flows between the layers of the aorta creating a “flap” appearance?

Aortic dissection

What type of Doppler waveform would you expect to see at the neck/stalk of a pseudoaneurysm?

Bidirectional

What type of portal HTN develops when hepatopedal flow is impeded by thrombus or tumor invasion?

Extrahepatic

What vessel can be seen posterior to the IVC on a sagittal scan

Right renal artery

What vessel runs posterior to the neck of the pancreas and anterior to the uncinate process?

SMV

What vessels are demonstrated in the following image. And are part of the great vessels protocol?

Hepatic veins and IVC

When measuring the proximal portion of the aorta, where should the calipers be placed?

Above the celiac axis in SMA

Where do most abdominal aortic aneurysms occur?

Below the level of the renal arteries

Which of the following is the most common type of aneurysm?

Fusiform

Which of the following blood vessels provides the largest majority of blood to the liver?

Portal vein

Which of the following is an irreversible disease causing loss of liver function, portal HTN, ascites, splenomegaly, and a thinkened GB wall?

Cirrosis

Which of the following veins help to make up the main portal vein?

SMV

Which one of the following renal artery Doppler waveforms signifies a normal arterial flow and resistive index-RI? Also identify which wave has high resistance and which one has low resistance.

Normal: A

A: low resistance

B: high resistance

Which portosystemic Venus collateral can be fatal if hemorrhage occurs?

Gastroesophageal junction

When do patients typically experience abdominal pain, when suffering from chronic mesenteric ischemia

After eating

What landmark can be used to determine the end of the common iliac artery and the beginning of the external iliac artery?

Origin of the internal iliac artery

A 76-year-old female patient presents with left hip and buttocks claudication. During a sonographic evaluation, velocities in the common iliac artery are 72 cm/s. The velocity in the proximal external iliac artery is 302 cm/s. Which of the following has occurred?

External iliac artery stenosis

T/F:

Endovascular stent graft repair has been shown to decrease survival rates over open surgical repair of abdominal aortic aneurysm.

False

What is the goal of EVAR – endovascular stent graft repair?

Exclude the aneurysms sac from the general circulation

Which of the following sonographic appearances would confirm stability of an aneurysm sac after an EVAR procedure?

decrease in size of the aneurysm sac

What condition occurs when the left common iliac vein is compressed between the overlying right common iliac artery and underlying vertebral body?

May Thurner’s syndrome

Which of the following increases blood flow within the portal, splenic, and SMV?

Expiration and ingestion of food

What is the normal resistive index in the hepatic artery?

0.5 to 0.7

Which of the following can be a life-threatening complication of portal hypertension?

Bleeding from ruptured collaterals

Which of the following patient would be suspected of fibromuscular dysplasia of the renal artery?

32 year old female with uncontrolled hypertension

What term is used when there is transient compression of the celiac artery origin during exhalation, which is relieved by inhalation?

Medium arcuate ligament compression syndrome

What is persistent blood flow demonstrated outside a stent graft endovascular repair but within the aneurysms sac?

Endoleak

What is a tube-like structure placed inside a blood vessel to provide patency and support?

Stent

What is placement of a stink graft within an aortic aneurysms sac via catheter is a means of repair?

Endovascular aneurysm repair

What is occurring after a meal

Post prandial

What is a lack of blood flow to the viscera

Mesenteric ischemia

What is relating to additional blood vessels that aid or add to circulation?

Collateral flow