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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
7.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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a b
Fig. 248a, b Upper abdominal longitudinal scan of the celiac trunk.
CT = celiac trunk, SMA = superior mesenteric artery, AO = aorta, L = liver
ab
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cd
Fig. 249a–d a, b Upper abdominal longitudinal scan of the aorta (AO), the celiac
trunk (TR), and the superior mesenteric artery (SMA) with the first jejunal branch
(arrow). Horizontal arrows: lower esophagus. D = shank of the muscular diaphragm
c, d Upper abdominal transverse scan of the celiac trank (TR), the common hepatic
artery (HA) and the splenic artery (SA), and the branch of the renal arteries (RA).
AO = aorta, LRV = left renal vein, crossing the aorta
tency, and its caliber can be seen to fluctuate with respirations. It contains no
internal echoes and shows typical double pulsations.
x
Portal vein (Figs. 250 and 251): The portal vein is formed by the confluence of
the visceral veins. It passes behind the head of the pancreas to the porta hepatis, where it divides into a right and left main branch that undergo further
arborization in a capillary system.
x
Venous confluence (Figs. 250 and 252): The venous confluence is located behind
the head of the pancreas, appearing sonographically as an elliptical expansion
of the vena cava. It is formed by the superior mesenteric vein, the inferior
189
7.1 Examination
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Fig. 250 Portal vein and its tributaries
ab
Fig. 251a, b Course of the portal vein. a Longitudinal scan: the portal vein in its
longitudinal axis (red) behind the common bile duct (CBD) and the hepatic artery
(red spot). VC = vena cava b Oblique scan: T-shaped division of the portal vein (VP)
into the right and left main branches. A = hepatic artery, VC = caval vein
mesenteric vein (which usually empties into the splenic vein), the left gastric
vein, and the splenic vein.
n
Scanning tips :
x
Look for respiration-dependent volume changes in the venous system (inspiratory collapse of the vena cava; end-inspiratory expansion of the portal vein
i2 mm or 50–100 %).
x
190
Compress and push aside overlying gas-filled loops of bowel.
7.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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ab
Fig. 252a, b Venous vessels in the upper abdomen. a Upper transverse scan. AO =
aorta, P = pancreas, SV = splenic vein, L = liver, VC = vena cava, LRV = left renal vein,
crossing the aorta b Upper abdominal oblique scan: right (R), middle (M), and left
(L) hepatic veins confluenting into the inferior caval vein (VC)
Peripheral Vessels
..............................................................................................................
n
Scan planes: The scan planes should conform to the anatomical course of the
imaged vessels.
n
Sonographic anatomy and normal findings:
x
As in the abdomen, typical differences are noted between the arteries and veins
of the peripheral vascular system (pulsations, caliber changes with respirations)
x
The anatomical relationships of the principal lower-extremity vessels are
shown in Fig.
x
The veins of the lower extremity generally run posterior to the arteries.
x
Arteries are almost incompressible, whereas veins are highly compressible in
253 and in Figs 286 and 287 on p. 210.
response to transducer pressure.
n
Scanning protocol:
x
Transducer: 3.5–7.5 MHz
x
Supine position: The lower leg veins are scanned with the leg hanging over the
edge of the table. The popliteal vessels are scanned in the prone position (where
the popliteal vein is closer to the transducer and the artery is farther away).
x
Begin the examination with transverse survey scans, then scan longitudinally in
planes that conform to the course of the vessels.
x
Standard scans may be supplemented by CDS (p. 7) to detect peripheral flow
(floating thrombi?), collateral channels, recanalization processes, or pelvic
venous thrombi.
n
Scanning tips :
x
Carefully controlled transducer pressure will reduce scattering artifacts.
x
Gentle transducer movements make it easier to detect arterial pulsations.
x
Slipping of the transducer under pressure leads to errors of interpretation; the
incompressible artery should therefore be defined along with the vein whenever possible.
x
The probe should be applied very carefully in the popliteal fossa because the
popliteal vein is subcutaneous and easily compressible, and cannot be visualized when in a normal state.
x
The vessels at the pelvic level are easier to define when the bladder is slightly
distended.
191
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7.1 Examination
Fig. 253 Vascular topography of the right upper leg
Overview of Findings, Classification
..............................................................................................................
n
Aorta and arteries: The intra- and retroperitoneal vessels provide important land-
marks for localization and anatomical orientation (just as the neck vessels aid in
examination of the thyroid gland and lymph nodes).
x
Changes due to atherosclerosis: Diseases of the aorta and arteries most commonly result from atherosclerosis, which leads to expansion, narrowing, and
occlusion of the affected vessel (see p. 197).
x
Hemodynamic changes:
– Detectable only by Doppler scanning or CDS (see p. 7). The B-mode image
reflects only morphological changes.
– Detection of stenoses: Stenotic lesions can be described morphologically by
spectral analysis and analyzed semiquantitatively by the measurement of
flow velocities (see Table
30 and Fig. 254).
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7.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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Table 30.Normal values for flow velocities and Doppler indices
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Vessel PI RI V
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Abdominal aorta
yyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
2–6
(cm/s) V
max
50–120
(cm/s)
min
yyyyyyyyyyyyyyyyyyyy
Common femoral artery 5–10 100
Popliteal artery 6–12
Renal artery 0.6–0.8 60–180 30
Celiac trunk 0.6–0.8 100–240
Superior mesenteric artery 0.75–0.9 120–220
Inferior mesenteric artery 0.8–0.9 100–150
PI = pulsatility index (for peripheral arteries), RI = resistance index (for parenchymal arteries,
e.g., the renal arteries)
Fig. 254 Pulsatility index (PI) and velocity waveform versus degree of stenosis
in normal and abnormal extremity waveforms. The PI is calculated by dividing
the difference between the maximum forward and reverse flow velocities (h)by
the mean value of the flow velocity (V
Gefässdiagnostik mit Ultraschall. Thieme, 1995)
) (from Neuerburg-Heusler D, Hennerici M.
m
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x
Classification of findings:
– By etiology : see Table
– By location : see Table
n
Vena cava and peripheral veins:
x
Veins are important sonographically both as landmarks for anatomical orienta-
31, p. 194.
32, p. 201.
tion and as potential sites of pathologic change. Thrombosis has the greatest
clinical significance.
x
Classification of findings: see Table 34, p. 208.
193
7.2 Aorta and Arteries
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7.2 Aorta and Arteries
Overview: Etiologic Classification of Changes (Table 31):
..............................................................................................................
Table 31.Classification of sonographic findings by etiology
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anomalies Traumatic and postoperative lesions
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyy
Arteries and Veins
Arteries and Veins
Arteries and Veins
Duplications
Arterial variants (p. 194) Arteriovenous fistula (p. 195)
Sequelae of hypertension and atherosclerosis Displacement, compression, infiltration
Aortic or arterial elongation (p. 197) Benign masses (p. 200)
Aortic ectasia (p. 197) Malignant masses (p. 200)
Aortic or arterial stenosis (p. 197)
Aneurysms (p. 198)
Anomalies
..............................................................................................................
n
Duplication anomalies: renal artery (Fig. 255), rarely the aorta
n
Arterial variants:
x
Renal arteries: course anterior (usually posterior) to the vena cava
– Left gastric artery arises from the superior mesenteric artery or from the
aorta (“hepatosplenic trunk”)
– Common origin of the superior mesenteric artery and celiac trunk (“celiaco-
mesenteric trunk,” Figs.
x
Aorta: may show an oblique or transverse course as a result of spinal scoliosis
256 and 257)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
False aneurysm (p. 195)
Arterial prosthesis (p. 195)
ab
Fig. 255a, b Duplicated renal artery. a Longitudinal scan: two arterial cross-sections (arrows) are visible behind the vena cava (VC). b Transverse scan through the
right upper abdomen. CDS demonstrates both renal arteries (A). The possibility of
duplication should always be considered when renal artery stenosis is suspected
194
Fig. 256 Variants of the celiac trunk (after Netter)
Schmidt, Ultrasound © 2007 Thieme
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Fig. 257 Atypical origin of the superior
mesenteric artery (SMA) from the celiac
trunk (TR): celiacomesenteric trunk.
V = superior mesenteric vein
7.2 Aorta and Arteries
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Traumatic and Postoperative Lesions
..............................................................................................................
n
Pseudoaneurysm (false aneurysm) (Fig. 258): most commonly results from
puncture of the femoral artery; arterial wall defect with pulsatile blood jets into
the adjacent tissue. CDS : systolic–diastolic “to and fro” pulsed Doppler waveform
x
Treatment: graded groin compression under CDS guidance is usually successful
in closing the leak (alternative: adhesive).
n
Arteriovenous fistula: Abnormal communication between a high-resistance
artery and a low-resistance vein without an intervening capillary bed (Figs
260).
n
Arterial prosthesis (see Fig. 279a), p. 205, and Fig. 281a, p. 206):
x
Smooth, straight echogenic structure (polyethylene), occasionally with a finely
meshed texture (Dacron)
x
Rare: periprosthetic infection or hematoma due to leakage. An irregular, hypoechoic structure can be seen around the prosthesis.
259,
195
7.2 Aorta and Arteries
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Fig. 258a, b Heavily thrombosed pseudoaneurysm (A) of the femoral artery (FA)
following percutaneous catheterization. a Residual flow (blue, arrows). b Arterial
Doppler signal (red). FV = thrombosed femoral vein
ab
Fig. 259a, b Arteriovenous fistula of the cubital artery and vein (A, V).
a B-mode image with spectral analysis demonstrates a fistulous connection
between the artery and vein. The sampled spectral waveform shows an arterial
signal at the fistula site.
b CDS directly defines the fistula (F) and shows a turbulent pattern in the vein
(blue–red)
196
7.2 Aorta and Arteries
Schmidt, Ultrasound © 2007 Thieme
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ab
Fig. 260a, b Arteriovenous fistula (F). a From the superficial femoral artery (SFA)
to the femoral vein (FV) following a shrapnel injury. The patient presented clinically
with signs of left heart failure, which resolved after closure of the fistula. b Between
the femoral artery (AF) and the greater saphenous vein (GSV) after catheterization
showing a turbulent yellow–blue–red pattern in the fistula. VF = femoral vein
Sequelae of Hypertension and Atherosclerosis
..............................................................................................................
n
Aortic or arterial elongation (Figs. 261 and 262): Tortuosity and kinking may
develop as an adaptive response to pressure.
n
Aortic ectasia (see Fig. 261) : dilatation of the aorta to 25–30 mm (often with an
associated aneurysm)
n
Aortic and arterial sclerosis (Fig. 263; see also Fig. 261):
x
Vascular stenosis resulting from lipid-containing atheromatous wall lesions
x
Complicated atherosclerotic plaques: protuberant, calcified sites of luminal
narrowing (see p. 201)
Fig. 261 Elongation, ectasia, and
sclerosis of the aorta. The aorta is
slightly elongated and presumably has
undergone marked lateral kinking
because its full length cannot be visualized (a similar pattern is seen with
spinal curvature). The aorta is markedly
ectatic (cursors) and shows echogenic
wall sclerosis with associated acoustic
shadows
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Fig. 262 Tortuosity of the aorta (AO)
secondary to hypertension and atherosclerosis. Arrows: atherosclerotic lesions
197
7.2 Aorta and Arteries
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cd
Fig. 263a–d Atherosclerosis and stenosis. a Protuberant plaque in the aorta (AO,
arrow) with luminal narrowing and atherosclerotic wall irregularities. b Iliac artery
stenosis. B-mode image shows high-grade narrowing of the proximal iliac artery
(arrow). c Iliac artery stenosis. CDS demonstrates the stenosis (arrow). Zones of
color reversal indicate turbulent flow. d Stenosis (arrow) of the femoral artery. CDS
shows prestenotic color change and turbulence. The high-grade luminal narrowing
is caused by a calcifying plaque with an associated acoustic shadow (S)
n
Aneurysms (Figs. 264–268; see also Figs. 276–278, p. 204):
x
Types of aneurysm (Fig. 264):
– Berry (pouch-)shaped
– Saccular
– Fusiform (spindle-shaped)
– Dissecting
Fig. 264 Types of arterial aneurysm. a True aneurysms, saccular or fusiform (2)
and berry (pouch-)shaped (1). b Dissecting aneurysm. c Pseudoaneurysm (or false
198
aneurysm)