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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5760_Библиотеки_им_академика_М_И_Перельмана.pdf
Preface to the First German Edition
XI
Conventional and color duplex ultrasonography
has evolved into an indispensable tool for the diagnostic evaluation of vascular pathology. As a noninvasive test that can be repeated any time,
sonography is increasingly replacing conventional
diagnostic modalities that cause more discomfort
to the patient. e combination of gray-scale
sonographic information for evaluating topographic relationships and morphologic features of
vessels with the qualitative and quantitative data
obtained with the Doppler technique enables ne
diagnostic dierentiation of vascular disorders. In
particular, the hemodynamic Doppler information is a useful supplement to the ndings obtained
with radiologic modalities. Being noninvasive and
easy to perform any time, duplex sonography precedes more invasive, stressful, and expensive diagnostic tests in the step-by-step diagnostic workup
of patients with vascular disease. It provides crucial information for optimal therapy and will
replace invasive modalities such as angiography
and venography as examiners gain skills and experience and ultrasound equipment becomes more
sophisticated.
e signicance duplex ultrasonography has
gained in the hands of angiologists and vascular
surgeons is also reected in the further education
programs for these specialties. is book therefore aims at providing a detailed description of
the diagnostic information that can be obtained
by (color) duplex sonography in those vascular
territories that are relevant to angiologists and
vascular surgeons. Each of the main chapters
introduces beginners to the relevant vascular
anatomy and scanning technique while at the
same time oering detailed discussions of the
parameters involved and a thorough review of
the pertinent scientic literature to help experienced sonographers become more condent in
establishing their diagnoses.
e rst chapter presents the basic hemodynamic
concepts that are relevant to vascular sonography
and the fundamental physical and technical principles of vascular ultrasonography. is introductory chapter is intended to help readers grasp the
potential and limitations of the method.
e situation in Germany is dierent from that in
many other countries in that duplex sonography is
performed primarily by angiologists, internists,
and increasingly by vascular surgeons rather than
by radiologists. On the basis of a patient’s clinical
ndings, it is thus possible to specically address
therapeutically relevant questions in performing
the sonographic examination. Besides general
assessment of the vascular status, ultrasound can
thus serve to acquire additional diagnostic information important for therapeutic decisionmaking in general and for planning the surgical
procedure in particular. Duplex sonography in the
hands of the clinician who is also treating the
patient is seen as the continuation of the clinical
examination by technical means. at is why the
emphasis in this book is on the clinical and therapeutic role of ultrasound ndings, and the individual chapters are organized according to such
pragmatic aspects.
Each of the six main chapters deals with a specic
vascular territory and consists of a text section as
well as an atlas section with ample illustrations and
detailed descriptions of normal ndings, variants,
and abnormal ndings. Whenever considered
appropriate for better illustration of complex
pathology, the sonographic images have been supplemented with angiograms or CT scans. e
comparison also illustrates the advantages and disadvantages of the respective radiologic modalities.
As many rare vascular disorders are diagnosed at a
glance by an experienced sonographer, their
appearance is shown in numerous gures. Series of
ultrasound scans document the course of the
examination and complex hemodynamic changes
in vascular disorders as well as their clinical signicance and changes under therapy. e legends
provide detailed descriptions allowing the reader
to use the atlas sections independently for reference when looking for information on specic
vascular conditions.
Dierent ultrasound modes are described in detail
and their respective merits and shortcomings
are discussed for the benet of readers using different equipment. Gray-scale sonography alone
(compression ultrasound) is quite sucient for
the diagnostic assessment of thrombosis while
conventional duplex ultrasonography is a valid
modality for diagnosing therapeutically relevant
abnormal changes of the femoropopliteal territory. In most instances, color ow images are
shown together with the Doppler waveform but
occasionally “only” the conventional duplex scan
XII
Preface to the First German Edition
is presented to illustrate the fact that many abnormalities can be identied by conventional duplex
ultrasound alone. Despite the additional diagnostic information obtained with the color-coded
technique, quantitative evaluation relies on the
Doppler frequency spectrum. e color duplex
mode can facilitate the examination procedure
(identication of small vessels, recanalization,
dierential diagnosis) but the sonographer needs
some basic knowledge of the conventional Doppler technique for the proper interpretation of
color ow images.
My special thanks are due to Professor R.Eisele for
promoting the use of diagnostic ultrasound in the
department of vascular surgery at our hospital and
for his valuable advice. I thank Ms. G.Rieker and
Ms. E. Stieger and Mrs. B. Sihler for typing the
manuscript and Ms. R.Uhlig for the photographic
work in preparing the gures.
Finally I would like to express my thanks to the
publishers, Springer-Verlag, and in particular to
Ms. Zeck and Dr. Heilmann, for their excellent
cooperation and constructive support.
WilhelmSchäberle
Göppingen, Germany
December 1997
XIII
Contents
1 Fundamental Principles ............................................................................................................................................... 1
1.1 Technical Principles ofDiagnostic Ultrasound ...................................................................................................... 3
1.1.1 Gray-Scale Ultrasonography (B-Mode) ........................................................................................................................ 3
1.1.1.1 Historical Milestones ......................................................................................................................................................... 3
1.1.1.2 Sound Waves ........................................................................................................................................................................ 3
1.1.1.3 Generating Ultrasound Waves ........................................................................................................................................ 4
1.1.1.4 Physical Factors Aecting theUltrasound Scan ....................................................................................................... 4
1.1.1.4.1 Reection andRefraction ................................................................................................................................................ 4
1.1.1.4.2 Scattering andAttenuation............................................................................................................................................. 5
1.1.1.4.3 Interference .......................................................................................................................................................................... 6
1.1.1.4.4 Diraction ............................................................................................................................................................................. 6
1.1.1.4.5 Attenuation andAbsorption........................................................................................................................................... 6
1.1.1.5 Generating anUltrasound Image .................................................................................................................................. 6
1.1.1.5.1 Pulse-Echo Technique ....................................................................................................................................................... 6
1.1.1.5.2 Time Gain Compensation ................................................................................................................................................ 7
1.1.1.5.3 A-Mode .................................................................................................................................................................................. 7
1.1.1.5.4 B-Mode .................................................................................................................................................................................. 7
1.1.1.5.5 M-Mode ................................................................................................................................................................................. 7
1.1.1.6 Resolution ............................................................................................................................................................................. 8
1.1.1.7 Beam Focusing .................................................................................................................................................................... 9
1.1.1.8 Types ofTransducers ......................................................................................................................................................... 9
1.1.1.8.1 Principle ofOperation ....................................................................................................................................................... 9
1.1.1.8.2 Linear Arrays ........................................................................................................................................................................ 10
1.1.1.8.3 Curved or Convex Arrays .................................................................................................................................................. 10
1.1.1.8.4 Sector Scanners................................................................................................................................................................... 10
1.1.1.8.5 Phased Arrays ...................................................................................................................................................................... 10
1.1.1.8.6 Mechanical Sector Scanners ........................................................................................................................................... 10
1.1.1.8.7 Annular Phased Arrays ...................................................................................................................................................... 11
1.1.1.8.8 Disadvantages ofMechanical Transducers ................................................................................................................ 11
1.1.1.9 Ultrasound Artifacts .......................................................................................................................................................... 11
1.1.1.9.1 Posterior Shadowing ......................................................................................................................................................... 11
1.1.1.9.2 Acoustic Enhancement ..................................................................................................................................................... 11
1.1.1.9.3 Edge Eect ............................................................................................................................................................................ 12
1.1.1.9.4 Side Lobes ............................................................................................................................................................................. 12
1.1.1.9.5 Reverberation Artifact ...................................................................................................................................................... 12
1.1.1.9.6 Geometric Distortion ........................................................................................................................................................ 13
1.1.2 Basic Physics ofDoppler Ultrasound ............................................................................................................................ 13
1.1.2.1 Continuous Wave Doppler Ultrasound ........................................................................................................................ 15
1.1.2.2 Pulsed Wave Doppler Ultrasound/Duplex Ultrasound ........................................................................................... 15
1.1.2.3 Frequency Processing ....................................................................................................................................................... 16
1.1.2.4 Blood Flow Measurement ................................................................................................................................................ 17
1.1.3 Physical Principles ofColor-Coded Duplex Ultrasound ......................................................................................... 20
1.1.3.1 Velocity Mode ...................................................................................................................................................................... 20
1.1.3.2 Power Doppler Mode ........................................................................................................................................................ 23
1.1.3.3 B-Flow Mode (Brightness Flow) ..................................................................................................................................... 24
1.1.3.4 Intravascular Ultrasound .................................................................................................................................................. 25
1.1.3.5 Three-Dimensional/Four-Dimensional Ultrasound ................................................................................................. 26
1.1.4 Factors Aecting (Color) Duplex Imaging– Pitfalls ................................................................................................. 26
1.1.4.1 Scattering andAcoustic Shadowing ............................................................................................................................ 26
1.1.4.2 Mirror Artifact ...................................................................................................................................................................... 26
1.1.4.3 Maximum Flow Velocity Detectable– Pulse Repetition Frequency ................................................................... 26
1.1.4.4 Minimum Flow Velocity Detectable– Wall Filter, Frame Rate .............................................................................. 30
1.1.4.5 Transmit andReceive Gain .............................................................................................................................................. 30
1.1.4.6 Doppler Angle ..................................................................................................................................................................... 32
XIV
Contents
1.1.4.7 Physical Limitations ofColor Duplex Ultrasound ..................................................................................................... 32
1.1.5 Ultrasound Contrast Agents ........................................................................................................................................... 33
1.1.5.1 Approved Ultrasound Contrast Agents andUses .................................................................................................... 33
1.1.5.2 Mechanisms ofAction ...................................................................................................................................................... 34
1.1.5.3 Ultrasound Techniques Using Contrast Agents ........................................................................................................ 35
1.1.5.3.1 Contrast-Enhanced Duplex Ultrasound ...................................................................................................................... 35
1.1.5.3.2 Contrast Harmonic Imaging ............................................................................................................................................ 35
1.1.5.3.3 Stimulated Acoustic Emission Imaging ....................................................................................................................... 35
1.1.5.4 Summary ofTechnical Aspects andClinical Indications ........................................................................................ 35
1.1.6 Safety ofDiagnostic Ultrasound .................................................................................................................................... 36
1.1.6.1 Thermal Eects .................................................................................................................................................................... 36
1.1.6.2 Mechanical Eects ............................................................................................................................................................. 36
1.1.6.3 Specic Risks ofIndividual Ultrasound Techniques ................................................................................................ 36
1.1.6.3.1 B-Mode .................................................................................................................................................................................. 36
1.1.6.3.2 M-Mode ................................................................................................................................................................................. 36
1.1.6.3.3 CW Doppler .......................................................................................................................................................................... 36
1.1.6.3.4 PW Doppler .......................................................................................................................................................................... 37
1.1.6.3.5 Color Doppler ...................................................................................................................................................................... 37
1.1.6.4 Conclusion ............................................................................................................................................................................ 37
1.2 Hemodynamic Principles ............................................................................................................................................... 37
1.2.1 Laminar Flow........................................................................................................................................................................ 37
1.2.2 Flow Proles andPerfusion Regulation ....................................................................................................................... 40
1.2.2.1 Low-Resistance Flow ......................................................................................................................................................... 40
1.2.2.2 High-Resistance Flow ........................................................................................................................................................ 40
1.2.2.3 Perfusion Regulation ......................................................................................................................................................... 42
1.2.3 Stenosis Grading andBlood Flow Measurement ..................................................................................................... 42
1.2.3.1 Poststenotic Parameters ................................................................................................................................................... 47
1.2.3.1.1 Acceleration Time– Resistive Index ............................................................................................................................. 47
1.3 Machine Settings ............................................................................................................................................................... 47
Extremity Arteries ........................................................................................................................................................... 51
2
2.1 Pelvic andLeg Arteries .................................................................................................................................................... 53
2.1.1 Vascular Anatomy ............................................................................................................................................................... 53
2.1.1.1 Pelvic Arteries ...................................................................................................................................................................... 53
2.1.1.2 Leg Arteries .......................................................................................................................................................................... 53
2.1.2 Examination Protocol andTechnique .......................................................................................................................... 55
2.1.2.1 Pelvic Arteries ...................................................................................................................................................................... 55
2.1.2.2 Leg Arteries .......................................................................................................................................................................... 56
2.1.3 Specic Aspects oftheExamination fromthePerspective oftheAngiologist andVascular Surgeon ......... 61
2.1.4 Interpretation andDocumentation .............................................................................................................................. 64
2.1.5 Normal Duplex Ultrasound ofPelvic andLeg Arteries ........................................................................................... 64
2.1.6 Abnormal Findings ............................................................................................................................................................ 65
2.1.6.1 Atherosclerotic Occlusive Disease ................................................................................................................................ 65
2.1.6.1.1 Pelvic Arteries ...................................................................................................................................................................... 67
2.1.6.1.2 Time-Ecient Examination Based onWaveform Analysis .................................................................................... 68
2.1.6.1.3 Stenosis Grading ................................................................................................................................................................. 70
2.1.6.1.4 Leg Arteries .......................................................................................................................................................................... 71
2.1.6.1.5 Stenosis Grading: Ultrasound Versus Angiography ................................................................................................. 75
2.1.6.1.6 Role ofCollateralization inStenosis Grading ............................................................................................................ 77
2.1.6.1.7 Eects ofCollateralization onPre- andPostocclusive Spectral Doppler Waveforms ................................... 78
2.1.6.1.8 Plaque Conguration andStenosis Degree ............................................................................................................... 79
2.1.6.1.9 Profunda Femoris Artery .................................................................................................................................................. 81
2.1.6.1.10 Spectral Doppler Imaging below theKnee ................................................................................................................ 83
2.1.6.1.11 Role ofContrast-Enhanced Ultrasound ....................................................................................................................... 84
2.1.6.1.12 Identication ofPedal Target Artery forBypass Grafting ...................................................................................... 85
2.1.6.1.13 Multilevel Obstruction ...................................................................................................................................................... 85
2.1.6.1.14 Arterial Occlusion ............................................................................................................................................................... 85
2.1.6.2 Arterial Embolism ............................................................................................................................................................... 88
Contents
XV
2.1.6.3 Aneurysm ............................................................................................................................................................................ 89
2.1.6.3.1 True Aneurysm .................................................................................................................................................................. 89
2.1.6.3.2 Pseudoaneurysm .............................................................................................................................................................. 89
2.1.6.4 Rare Stenosing Arterial Diseases ofNonatherosclerotic Origin ........................................................................ 92
2.1.6.4.1 Adventitial Cystic Disease .............................................................................................................................................. 93
2.1.6.4.2 Popliteal Artery Entrapment Syndrome .................................................................................................................... 95
2.1.6.4.3 Raynaud’s Disease ............................................................................................................................................................ 98
2.1.6.4.4 Paraneoplastic Disturbance ofAcral Perfusion ....................................................................................................... 98
2.1.6.4.5 Buerger’s Disease .............................................................................................................................................................. 98
2.1.6.4.6 Vascular Inammatory Disease .................................................................................................................................... 99
2.1.6.4.7 Dissection ........................................................................................................................................................................... 100
2.1.6.4.8 Arteriovenous Fistulas .................................................................................................................................................... 100
2.1.6.4.9 Chronic Recurrent Compartment Syndrome oftheCalf ..................................................................................... 100
2.1.7 Follow-Up After Surgical andInterventional Treatment ...................................................................................... 102
2.1.7.1 Thromboendarterectomy .............................................................................................................................................. 102
2.1.7.2 Percutaneous Transluminal Angioplasty andStenting ........................................................................................ 102
2.1.7.3 Bypass Graft Surveillance ............................................................................................................................................... 104
2.1.7.3.1 Methodological Considerations andStenosis Criteria ......................................................................................... 105
2.1.7.3.2 Controversy About theBenet ofDuplex Bypass Graft Surveillance Programs .......................................... 107
2.1.7.4 Ultrasound Vein Mapping Prior toPeripheral Bypass Surgery ........................................................................... 110
2.1.8 Role of(Color) Duplex Ultrasound Compared withOther Modalities: Problems andPitfalls .................. 112
2.1.8.1 Comparison ofHemodynamic andMorphologic Imaging Modalities ............................................................ 114
2.2 Arm Arteries ...................................................................................................................................................................... 116
2.2.1 Vascular Anatomy ............................................................................................................................................................. 116
2.2.2 Examination Protocol andTechnique ........................................................................................................................ 117
2.2.3 Clinical Role ofDuplex Ultrasound ............................................................................................................................. 118
2.2.3.1 Atherosclerosis .................................................................................................................................................................. 118
2.2.3.2 Vascular Compression Syndromes .............................................................................................................................. 118
2.2.4 Documentation ................................................................................................................................................................. 119
2.2.5 Normal Findings ............................................................................................................................................................... 119
2.2.6 Abnormal Findings, Duplex Ultrasound Measurements, andClinical Role ................................................... 119
2.2.6.1 Atherosclerosis .................................................................................................................................................................. 119
2.2.6.2 Vascular Compression Syndromes .............................................................................................................................. 120
2.2.6.3 Vascular Inammatory Disease .................................................................................................................................... 122
2.2.6.4 Buerger’s Disease .............................................................................................................................................................. 122
2.2.6.5 Raynaud’s Disease ............................................................................................................................................................ 122
2.3 Atlas: Extremity Arteries ............................................................................................................................................... 124
Extremity Veins .............................................................................................................................................................. 167
3
3.1 Pelvic andLeg Veins ....................................................................................................................................................... 169
3.1.1 Vascular Anatomy ............................................................................................................................................................. 169
3.1.2 Examination Protocol ...................................................................................................................................................... 171
3.1.2.1 Thrombosis ......................................................................................................................................................................... 171
3.1.2.1.1 Equipment .......................................................................................................................................................................... 171
3.1.2.1.2 Patient Positioning ........................................................................................................................................................... 171
3.1.2.1.3 Examination Technique .................................................................................................................................................. 172
3.1.2.2 Chronic Venous Insuciency andVaricosis ............................................................................................................. 174
3.1.3 Normal Findings ............................................................................................................................................................... 176
3.1.4 Documentation ................................................................................................................................................................. 177
3.1.4.1 Deep Vein Thrombosis oftheLeg ............................................................................................................................... 177
3.1.4.2 Chronic Venous Insuciency andVaricosis ............................................................................................................. 178
3.1.5 Clinical Role ofDuplex Ultrasound ............................................................................................................................. 178
3.1.5.1 Thrombosis andPostthrombotic Syndrome............................................................................................................ 178
3.1.5.1.1 Leg Vein Thrombosis ....................................................................................................................................................... 178
3.1.5.1.2 Chronic Venous Insuciency/Postthrombotic Syndrome .................................................................................. 181
3.1.5.2 Varicosis ............................................................................................................................................................................... 182
3.1.6 Duplex Ultrasound: Diagnostic Criteria, Indications, andRole .......................................................................... 184
XVI
Contents
3.1.6.1 Thrombosis ......................................................................................................................................................................... 184
3.1.6.1.1 Controversy About theUltrasound Strategy inSuspected Deep Vein Thrombosis .................................... 192
3.1.6.1.2 Additional Examination oftheAsymptomatic Leg ............................................................................................... 194
3.1.6.1.3 Pulmonary Embolism ...................................................................................................................................................... 194
3.1.6.1.4 Diagnostic Tests Supplementing Compression Ultrasound ............................................................................... 195
3.1.6.1.5 Thrombus Age ................................................................................................................................................................... 198
3.1.6.1.6 Recurrent Thrombosis ..................................................................................................................................................... 198
3.1.6.2 Chronic Venous Insuciency........................................................................................................................................ 200
3.1.6.3 Varicosis ............................................................................................................................................................................... 204
3.1.6.3.1 Treatment Options ........................................................................................................................................................... 207
3.1.6.4 Varicophlebitis ................................................................................................................................................................... 208
3.1.7 Rare Venous Disorders .................................................................................................................................................... 210
3.1.7.1 Venous Aneurysm ............................................................................................................................................................ 210
3.1.7.1.1 Sonographic Workup....................................................................................................................................................... 210
3.1.7.1.2 Prevalence ofVenous Aneurysms inUltrasound Studies .................................................................................... 212
3.1.7.1.3 Therapeutic Relevance of Sonographically Detected Venous Aneurysms .................................................... 212
3.1.7.2 Tumors oftheVein Wall .................................................................................................................................................. 213
3.1.7.3 Venous Compression ....................................................................................................................................................... 213
3.1.7.4 Venous Adventitial Cystic Disease .............................................................................................................................. 213
3.1.7.5 Dierential Diagnosis: Lymphedema, Lipedema ................................................................................................... 214
3.1.8 Vein Mapping .................................................................................................................................................................... 215
3.1.9 Diagnostic Role ofUltrasound ..................................................................................................................................... 216
3.1.9.1 Deep Vein Thrombosis .................................................................................................................................................... 216
3.1.9.1.1 Ultrasound Versus Venography .................................................................................................................................... 217
3.1.9.1.2 Ultrasound forFollow-Up andTherapeutic Decision Making ............................................................................ 218
3.1.9.2 Chronic Venous Insuciency........................................................................................................................................ 219
3.1.9.3 Varicosis ............................................................................................................................................................................... 221
3.2 Arm Veins andJugular Vein ......................................................................................................................................... 221
3.2.1 Vascular Anatomy ............................................................................................................................................................. 221
3.2.2 Examination Protocol andTechnique ........................................................................................................................ 221
3.2.3 Normal Findings ............................................................................................................................................................... 222
3.2.4 Documentation ................................................................................................................................................................. 222
3.2.5 Clinical Role ........................................................................................................................................................................ 222
3.2.6 Duplex Ultrasound Findings andTheir Diagnostic Signicance ....................................................................... 223
3.2.7 Diagnostic Role ofDuplex Ultrasound Compared withOther Modalities ..................................................... 223
3.3 Atlas: Extremity Veins .................................................................................................................................................... 224
Arteriovenous Fistulas ................................................................................................................................................ 263
4
4.1 Clinical Role ofArteriovenous Fistula Evaluation ............................................................................................... 264
4.1.1 Background ........................................................................................................................................................................ 264
4.1.2 Diagnostic Evaluation ofPatients withAbnormal andSurgically Created Fistulas..................................... 264
4.1.2.1 Types ofAV Fistulas .......................................................................................................................................................... 264
4.1.2.2 Creation ofaHemodialysis Access .............................................................................................................................. 264
4.1.2.3 Indications forColor Duplex Ultrasound .................................................................................................................. 265
4.2 Examination Protocol, Technique, andDiagnostic Role................................................................................... 266
4.2.1 Congenital andAcquired Fistulas ............................................................................................................................... 266
4.2.2 Hemodialysis AV Fistula .................................................................................................................................................. 267
4.2.2.1 Time-Ecient Ultrasound Workup ofHemodialysis Access Problems ............................................................ 268
4.3 Doppler Waveform Changes Characteristic ofAV Fistulas .............................................................................. 269
4.4 Fistula Maturation andFlow Volume Measurement .......................................................................................... 269
4.5 Documentation ................................................................................................................................................................ 270
4.6 Vascular Mapping Prior toAV Fistula Creation .................................................................................................... 270
4.7 Hemodialysis Access Complications ........................................................................................................................ 271
4.7.1 Hemodialysis Access Stenosis ...................................................................................................................................... 271
4.7.1.1 Causes ofHemodialysis Access Stenosis ................................................................................................................... 271
4.7.1.2 Stenosis Detection andGrading .................................................................................................................................. 271
4.7.1.3 Proximal Feeding Artery Stenosis ............................................................................................................................... 273
4.7.2 Diagnostic Evaluation forSpecic Hemodialysis Access Problems .................................................................. 273
Contents
XVII
4.7.2.1 Peripheral Ischemia ......................................................................................................................................................... 273
4.7.2.2 Hemodialysis Access Aneurysm ................................................................................................................................... 275
4.7.2.3 Inadequate or Excessive Fistula Flow ......................................................................................................................... 275
4.7.2.4 Arm Swelling ...................................................................................................................................................................... 277
4.8 Diagnostic Role ofDuplex Ultrasound Compared withOther Modalities ................................................ 277
4.8.1 Therapeutic Decision-Making ...................................................................................................................................... 277
4.8.2 Surveillance Programs? .................................................................................................................................................. 278
4.9 Atlas: Arteriovenous Fistulas ...................................................................................................................................... 279
Extracranial Cerebral Arteries ................................................................................................................................. 291
5
5.1 Normal Vascular Anatomy andImportant Variants ........................................................................................... 293
5.1.1 Carotid Arteries ................................................................................................................................................................. 293
5.1.2 Vertebral Arteries ............................................................................................................................................................. 295
5.2 Examination Technique andProtocol ..................................................................................................................... 296
5.2.1 Carotid Arteries ................................................................................................................................................................. 296
5.2.2 Vertebral Arteries ............................................................................................................................................................. 299
5.3 Documentation ................................................................................................................................................................ 301
5.4 Normal Findings .............................................................................................................................................................. 301
5.4.1 Carotid Arteries ................................................................................................................................................................. 301
5.4.2 Vertebral Arteries ............................................................................................................................................................. 302
5.5 Clinical Role ofDuplex Ultrasound........................................................................................................................... 302
5.5.1 Carotid Arteries ................................................................................................................................................................. 302
5.5.1.1 Stenosis Grading ............................................................................................................................................................... 305
5.5.1.2 Plaque Morphology ......................................................................................................................................................... 307
5.5.2 Vertebral Arteries ............................................................................................................................................................. 309
5.6 Ultrasound Criteria, Measurement Parameters, andDiagnostic Role ........................................................ 309
5.6.1 Carotid Arteries ................................................................................................................................................................. 309
5.6.1.1 Plaque Evaluation andMorphology ........................................................................................................................... 309
5.6.1.1.1 Intima-Media Thickness .................................................................................................................................................. 309
5.6.1.1.2 Plaque Features ................................................................................................................................................................. 311
5.6.1.1.3 Plaque Dierentiation ..................................................................................................................................................... 312
5.6.1.1.4 Plaque Thickness .............................................................................................................................................................. 314
5.6.1.1.5 Plaque Morphology: Plaque Surface .......................................................................................................................... 314
5.6.1.1.6 Plaque Echogenicity: Inuencing Factors ................................................................................................................ 316
5.6.1.1.7 Gray-Scale Analysis: Potential andLimitations ....................................................................................................... 317
5.6.1.1.8 Carotid Plaque Characterization Using Contrast-Enhanced Ultrasound ........................................................ 318
5.6.1.2 Stenosis Quantication/Grading ................................................................................................................................. 319
5.6.1.2.1 Primary andSecondary Criteria forCarotid Stenosis Grading ........................................................................... 322
5.6.1.3 Occlusion ............................................................................................................................................................................ 332
5.6.1.3.1 Persistent Primitive Hypoglossal Artery .................................................................................................................... 333
5.6.1.4 Postoperative Follow-Up ................................................................................................................................................ 334
5.6.1.4.1 Carotid Endarterectomy (CEA) ..................................................................................................................................... 334
5.6.1.4.2 Carotid Artery Stenting (CAS) ....................................................................................................................................... 337
5.6.1.4.3 Scientic Discrepancies Regarding Restenosis Grading After CAS .................................................................. 337
5.6.1.4.4 Stenosis Grading Based onthe Continuity Equation ............................................................................................ 340
5.6.1.4.5 Stent Dislocation .............................................................................................................................................................. 342
5.6.2 Vertebral Arteries ............................................................................................................................................................. 343
5.6.2.1 Stenosis................................................................................................................................................................................ 343
5.6.2.2 Occlusion ............................................................................................................................................................................ 344
5.6.2.3 Dissection ........................................................................................................................................................................... 344
5.6.2.4 Subclavian Steal Syndrome ........................................................................................................................................... 345
5.7 Diagnosis ofBrain Death .............................................................................................................................................. 346
5.8 Rare (Nonatherosclerotic) Vascular Diseases oftheCarotid Territory ........................................................ 346
5.8.1 Dissection ........................................................................................................................................................................... 346
5.8.2 Vasculitis .............................................................................................................................................................................. 348
5.8.2.1 Ultrasound Findings inTakayasu’s Arteritis .............................................................................................................. 348
5.8.2.2 Ultrasound Findings inHorton’s Disease .................................................................................................................. 349
5.8.3 Fibromuscular Dysplasia ................................................................................................................................................ 350
XVIII
Contents
5.8.4 Aneurysm ............................................................................................................................................................................ 350
5.8.5 Arteriovenous Fistula ...................................................................................................................................................... 351
5.8.6 Idiopathic Carotidynia .................................................................................................................................................... 351
5.8.7 Vasospasm .......................................................................................................................................................................... 352
5.8.8 Compression by Tumor, Carotid Body Tumor .......................................................................................................... 352
5.9 Diagnostic Role ofDuplex Ultrasound inEvaluating theExtracranial Cerebral Arteries .................... 352
5.10 Atlas: Extracranial Cerebral Arteries ........................................................................................................................ 356
Visceral andRetroperitoneal Vessels .................................................................................................................. 389
6
6.1 Abdominal Aorta, Visceral andRenal Arteries ..................................................................................................... 391
6.1.1 Vascular Anatomy ............................................................................................................................................................. 391
6.1.1.1 Aorta ..................................................................................................................................................................................... 391
6.1.1.2 Visceral Arteries................................................................................................................................................................. 391
6.1.1.3 Renal Arteries..................................................................................................................................................................... 392
6.1.2 Examination Protocol andTechnique ........................................................................................................................ 392
6.1.2.1 Aorta ..................................................................................................................................................................................... 392
6.1.2.1.1 Protocol forUltrasound Examination oftheAbdominal Aorta andAortic Aneurysm ............................... 392
6.1.2.1.2 Protocol forUltrasound Follow-Up After Endovascular Aneurysm Repair (EVAR) ....................................... 392
6.1.2.2 Visceral Arteries................................................................................................................................................................. 393
6.1.2.3 Renal Arteries..................................................................................................................................................................... 395
6.1.2.3.1 Ultrasound Technique ..................................................................................................................................................... 397
6.1.3 Normal Findings ............................................................................................................................................................... 397
6.1.3.1 Aorta ..................................................................................................................................................................................... 397
6.1.3.2 Visceral Arteries................................................................................................................................................................. 397
6.1.3.3 Renal Arteries..................................................................................................................................................................... 398
6.1.4 Interpretation andDocumentation ............................................................................................................................ 399
6.1.5 Clinical Role ofDuplex Ultrasound ............................................................................................................................. 399
6.1.5.1 Aorta ..................................................................................................................................................................................... 399
6.1.5.1.1 Abdominal Aortic Aneurysm ........................................................................................................................................ 399
6.1.5.1.2 Inammatory andAtherosclerotic Conditions ....................................................................................................... 400
6.1.5.2 Visceral Arteries................................................................................................................................................................. 401
6.1.5.3 Renal Arteries..................................................................................................................................................................... 402
6.1.6 Measurement Parameters, Diagnostic Criteria, andRole ofUltrasound ........................................................ 405
6.1.6.1 Renal Arteries..................................................................................................................................................................... 405
6.1.6.1.1 Role ofColor Duplex Ultrasound in the Detection ofRenal Artery Stenosis ................................................ 406
6.1.6.1.2 Therapy-Oriented Stenosis Grading ........................................................................................................................... 408
6.1.6.1.3 Contrast-Enhanced Ultrasound (CEUS) ..................................................................................................................... 409
6.1.6.1.4 Ultrasound Follow-Up After Renal Artery Stenting ............................................................................................... 409
6.1.6.1.5 Diagnostic Algorithm ...................................................................................................................................................... 411
6.1.6.1.6 Renal Artery Occlusion ................................................................................................................................................... 412
6.1.6.1.7 Transplant Kidney ............................................................................................................................................................. 412
6.1.6.2 Visceral Arteries................................................................................................................................................................. 414
6.1.6.2.1 Celiac Trunk ........................................................................................................................................................................ 414
6.1.6.2.2 Visceral Artery Aneurysm............................................................................................................................................... 415
6.1.6.2.3 Dissection ........................................................................................................................................................................... 416
6.1.6.2.4 Superior Mesenteric Artery ........................................................................................................................................... 416
6.1.6.2.5 Acute Mesenteric Artery Occlusion ............................................................................................................................ 418
6.1.6.3 Aorta ..................................................................................................................................................................................... 422
6.1.6.3.1 Aortic Stenosis andThrombosis .................................................................................................................................. 422
6.1.6.3.2 Abdominal Aortic Aneurysm ........................................................................................................................................ 423
6.1.6.3.3 Specic Aspects oftheUltrasound Examination inAbdominal Aortic Aneurysm ...................................... 423
6.1.6.3.4 Comparison ofUltrasound andComputed Tomography .................................................................................... 426
6.1.6.3.5 Abdominal Aortic Aneurysm Screening: Rupture Risk ......................................................................................... 426
6.1.6.3.6 Aortic Dissection............................................................................................................................................................... 426
6.1.6.3.7 Follow-Up After Open Surgical andEndovascular Aneurysm Repair .............................................................. 427
6.1.6.3.8 Aortitis: Retroperitoneal Fibrosis– Inammatory Abdominal Aortic Aneurysm ......................................... 433
Contents
6.2 Visceral andRetroperitoneal Veins .......................................................................................................................... 435
6.2.1 Vascular Anatomy ............................................................................................................................................................. 435
6.2.1.1 Vena Cava ............................................................................................................................................................................ 435
6.2.1.2 Renal Veins .......................................................................................................................................................................... 436
6.2.1.3 Portal Venous System and Hepatic Veins .................................................................................................................. 436
6.2.2 Examination Technique .................................................................................................................................................. 436
6.2.2.1 Vena Cava ............................................................................................................................................................................ 436
6.2.2.2 Renal Veins .......................................................................................................................................................................... 437
6.2.2.3 Portal Vein andSuperior Mesenteric Vein ................................................................................................................ 438
6.2.3 Clinical Role ofDuplex Ultrasound ............................................................................................................................. 439
6.2.3.1 Renal Veins .......................................................................................................................................................................... 439
6.2.3.2 Portal Venous System ...................................................................................................................................................... 439
6.2.4 Normal Findings ............................................................................................................................................................... 439
6.2.4.1 Vena Cava andRenal Veins ............................................................................................................................................ 439
6.2.4.2 Portal Venous System ...................................................................................................................................................... 439
6.2.5 Documentation ................................................................................................................................................................. 440
6.2.6 Abnormal Ultrasound Findings, Measurement Parameters, andDiagnostic Role ...................................... 440
6.2.6.1 Vena Cava ............................................................................................................................................................................ 440
6.2.6.1.1 Membranous Vena Cava Obstruction ........................................................................................................................ 441
6.2.6.2 Renal Veins .......................................................................................................................................................................... 441
6.2.6.3 Superior Mesenteric Vein andSplenic Vein .............................................................................................................. 442
6.2.6.3.1 Splenic Vein Thrombosis ................................................................................................................................................ 443
6.2.6.4 Portal andHepatic Veins ................................................................................................................................................ 443
6.2.6.4.1 Portal Vein Thrombosis ................................................................................................................................................... 443
6.2.6.4.2 Portal Hypertension......................................................................................................................................................... 443
6.2.6.4.3 Hepatic Veins ..................................................................................................................................................................... 447
6.3 Atlas: Visceral andRetroperitoneal Vessels ........................................................................................................... 449
XIX
Penile andScrotal Vessels ......................................................................................................................................... 491
7
7.1 Vascular Anatomy ........................................................................................................................................................... 492
7.1.1 Penile Vessels ..................................................................................................................................................................... 492
7.1.2 Scrotal Vessels.................................................................................................................................................................... 493
7.2 Examination Technique ................................................................................................................................................ 493
7.2.1 Erectile Dysfunction ........................................................................................................................................................ 493
7.2.1.1 Ultrasound Examination ................................................................................................................................................ 493
7.2.2 Scrotal Vessels.................................................................................................................................................................... 494
7.3 Normal Findings .............................................................................................................................................................. 494
7.3.1 Penile Vessels ..................................................................................................................................................................... 494
7.3.2 Scrotal Vessels.................................................................................................................................................................... 494
7.4 Documentation ................................................................................................................................................................ 495
7.5 Clinical Role ofDuplex Ultrasound........................................................................................................................... 495
7.5.1 Erectile Dysfunction ........................................................................................................................................................ 495
7.5.1.1 Pathophysiology ofErectile Dysfunction ................................................................................................................. 495
7.5.2 Acute Scrotum ................................................................................................................................................................... 495
7.5.3 Varicocele ............................................................................................................................................................................ 496
7.6 Abnormal Findings: Role ofDuplex Ultrasound Parameters ......................................................................... 496
7.6.1 Erectile Dysfunction ........................................................................................................................................................ 496
7.6.2 Acute Scrotum ................................................................................................................................................................... 497
7.6.3 Varicocele ............................................................................................................................................................................ 498
7.7 Atlas: Penile andScrotal Vessels ................................................................................................................................ 499
Supplementary Information
References .......................................................................................................................................................................... 504
Subject Index ..................................................................................................................................................................... 537
Fundamental Principles
1.1 Technical Principles ofDiagnostic Ultrasound–3
1.1.1 Gray-Scale Ultrasonography (B-Mode)–3
1.1.1.1 Historical Milestones–3
1.1.1.2 Sound Waves–3
1.1.1.3 Generating Ultrasound Waves–4
1.1.1.4 Physical Factors Aecting theUltrasound Scan–4
1.1.1.4.1 Reection andRefraction–4
1.1.1.4.2 Scattering andAttenuation–5
1.1.1.4.3 Interference–6
1.1.1.4.4 Diraction–6
1.1.1.4.5 Attenuation andAbsorption–6
1.1.1.5 Generating anUltrasound Image–6
1.1.1.5.1 Pulse-Echo Technique–6
1.1.1.5.2 Time Gain Compensation–7
1.1.1.5.3 A-Mode–7
1.1.1.5.4 B-Mode–7
1.1.1.5.5 M-Mode–7
1.1.1.6 Resolution–8
1.1.1.7 Beam Focusing–9
1.1.1.8 Types ofTransducers–9
1.1.1.8.1 Principle ofOperation–9
1.1.1.8.2 Linear Arrays–10
1.1.1.8.3 Curved or Convex Arrays–10
1.1.1.8.4 Sector Scanners–10
1.1.1.8.5 Phased Arrays–10
1.1.1.8.6 Mechanical Sector Scanners–10
1.1.1.8.7 Annular Phased Arrays–11
1.1.1.8.8 Disadvantages ofMechanical Transducers–11
1.1.1.9 Ultrasound Artifacts–11
1.1.1.9.1 Posterior Shadowing–11
1.1.1.9.2 Acoustic Enhancement–11
1.1.1.9.3 Edge Eect–12
1.1.1.9.4 Side Lobes–12
1.1.1.9.5 Reverberation Artifact–12
1.1.1.9.6 Geometric Distortion–13
1.1.2 Basic Physics ofDoppler Ultrasound–13
1.1.2.1 Continuous Wave Doppler Ultrasound–15
1.1.2.2 Pulsed Wave Doppler Ultrasound/Duplex Ultrasound–15
1.1.2.3 Frequency Processing–16
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© Springer International Publishing AG, part of Springer Nature 2018
W. Schäberle, Ultrasonography in Vascular Diagnosis, https://doi.org/10.1007/978-3-319-64997-9_1